Exhibit 10.22

Employee Group Benefits

UNDERWRITTEN BY

SUN LIFE ASSURANCE COMPANY OF CANADA

 

LOGO [g475296g05b35.jpg]

THE INSURANCE POLICY UNDER WHICH THIS CERTIFICATE IS ISSUED IS NOT A POLICY OF
WORKERS’ COMPENSATION INSURANCE. YOU SHOULD CONSULT YOUR EMPLOYER TO DETERMINE
WHETHER YOUR EMPLOYER IS A SUBSCRIBER TO THE WORKERS’ COMPENSATION SYSTEM.

All Non-Hawaii and Non-Distribution Center Employees

GROUP POLICY NUMBER—65955—001

POLICY EFFECTIVE DATE—April 1, 2001

POLICY AMENDMENT DATE—June 1, 2012

 

 

93C-LH-TX

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Exhibit 10.22

Welcome to Sun Life Assurance Company of Canada (Sun Life). Sun Life is pleased
to be your Employer’s insurance carrier for the benefits provided in the Group
Policy. The description of Eligible Classes in the Benefit Highlights will help
you determine what benefits apply to you.

The booklet is intended to provide a summarized explanation of the current Group
Policy Benefits. However, the Group Policy is the document which forms Sun
Life’s contract to provide benefits. If the terms of the booklet and the Group
Policy differ, the Group Policy will govern. A complete copy of the Group Policy
is in the possession of your Employer and is available for your review. In the
event of any changes in benefits or Group Policy provisions, you will be
provided with a new booklet or a supplement which describes any changes.

Possession of this booklet does not necessarily mean you are insured under the
Group Policy. The requirements for becoming eligible for insurance and the dates
your insurance begins or ceases are explained within this booklet.

This booklet uses insurance terms and phrases that are listed in the Definitions
Section.

For information, call the Sun Life Group Customer Service Center toll free at
1-800-247-6875.

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Exhibit 10.22

NOTE: DEATH BENEFITS WILL BE REDUCED IF AN ACCELERATED BENEFIT IS PAID.

THE ACCELERATED BENEFITS OFFERED UNDER THE GROUP POLICY MAY OR MAY NOT QUALIFY
FOR FAVORABLE TAX TREATMENT UNDER THE INTERNAL REVENUE CODE OF 1986. WHETHER
SUCH BENEFITS QUALIFY DEPENDS ON FACTORS SUCH AS YOUR LIFE EXPECTANCY AT THE
TIME BENEFITS ARE ACCELERATED OR WHETHER YOU USE THE BENEFITS TO PAY FOR
NECESSARY LONG TERM CARE EXPENSES, SUCH AS NURSING HOME CARE. IF THE ACCELERATED
BENEFITS QUALIFY FOR FAVORABLE TAX TREATMENT, THE BENEFITS WILL BE EXCLUDABLE
FROM YOUR INCOME AND NOT SUBJECT TO FEDERAL TAXATION. TAX LAWS RELATING TO
ACCELERATED BENEFITS ARE COMPLEX. YOU ARE ADVISED TO CONSULT WITH A QUALIFIED
TAX ADVISOR ABOUT CIRCUMSTANCES UNDER WHICH YOU COULD RECEIVE ACCELERATED
BENEFITS EXCLUDABLE FROM INCOME UNDER FEDERAL TAX LAW.

RECEIPT OF ACCELERATED BENEFITS MAY AFFECT YOU, YOUR SPOUSE OR YOUR FAMILY’S
ELIGIBILITY FOR PUBLIC ASSISTANCE PROGRAMS SUCH AS MEDICAL ASSISTANCE (MEDICAID)
AID TO FAMILIES WITH DEPENDENT CHILDREN (AFDC), SUPPLEMENTARY SOCIAL SECURITY
INCOME (SSI) AND DRUG ASSISTANCE PROGRAMS. YOU ARE ADVISED TO CONSULT WITH A
QUALIFIED TAX ADVISOR AND WITH SOCIAL SERVICE AGENCIES CONCERNING HOW RECEIPT OF
SUCH A PAYMENT WILL AFFECT YOU, YOUR SPOUSE AND YOUR FAMILY’S ELIGIBILITY FOR
PUBLIC ASSISTANCE.

IF YOU RECEIVE ACCELERATED BENEFITS, WE WILL PROVIDE ANNUAL STATEMENTS
SPECIFYING THE BENEFIT AMOUNT PAID AND THE AMOUNT OF DEATH BENEFIT REMAINING.

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Exhibit 10.22

(Applicable to Texas Residents)

IMPORTANT NOTICE

To obtain information or to make a complaint:

You may call Sun Life’s toll-free telephone number for information or to make a
complaint at:

1-800-247-6875

You may also write to Sun Life at:

Sun Life Assurance Company Of Canada

Group Customer Service Center SC 1219

1 Sun Life Executive Park

Wellesley Hills, MA 02481

You may contact the Texas Department of Insurance to obtain information on
companies, coverages, rights or complaints at:

1-800-252-3439

You may write the Texas Department of Insurance

P.O. Box 149104

Austin, TX 78714-9104

FAX# (512) 475-1771

Web: http://www.tdi.state.tx.us

E-mail: ConsumerProtection@tdi.state.tx.us

PREMIUM OR CLAIM DISPUTES:

Should you have a dispute concerning your premium or about a claim, you should
contact Sun Life first. If the dispute is not resolved, you may contact the
Texas Department of Insurance.

ATTACH THIS NOTICE TO YOUR POLICY:

This notice is for information only and does not become a part or condition of
the attached document.

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Exhibit 10.22

AVISO IMPORTANTE

Para obtener informacion o para someter una queja:

Usted puede llamar al numero de telefono gratis de Sun Life’s para informacion o
para someter una queja al:

1-800-247-6875

Usted tambien puede escribir a Sun Life:

Sun Life Assurance Company Of Canada Group

Customer Service Center SC 1219

1 Sun Life Executive Park

Wellesley Hills, MA 02481

Puede comunicarse con el Departamento de Seguros de Texas para obtener
informacion acerca de companias, coberturas, derechos o quejas al:

1-800-252-3439

Puede escribir al Departamento de Seguros de Texas

P.O. Box 149104

Austin, TX 78714-9104

FAX# (512) 475-1771

Web: http://www.tdi.state.tx.us

E- mail: ConsumerProtection@tdi.state.tx.us

DISPUTAS SOBRE PRIMAS O RECLAMOS:

Si tiene una disputa concerniente a su prima o a un reclamo, debe comunicarse
con el Sun Life primero. Si no se resuelve la disputa, puede entonces
comunicarse con el departmento (TDI).

UNA ESTE AVISO A SU POLIZA:

Este aviso es solo para proposito de informacion y no se convierte en parte o
condicion del documento adjunto.

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Exhibit 10.22

TABLE OF CONTENTS

 

     Page  

Benefit Highlights

  

Employee Life and Accidental Death and Dismemberment Insurance

     7   

Dependent Optional Life Insurance

     10   

Eligibility and Effective Dates

     13   

Termination of Insurance

  

Employee

     16   

Dependent

     17   

Benefit Provisions

  

Life Insurance

  

Employee

     18   

Dependent

     25   

Accidental Death and Dismemberment Insurance (AD&D)

     28   

Claim Provisions

  

Notice of Claim

     31   

Proof of Claim

     31   

Payment of Claims

     32   

Change of Beneficiary

     33   

General Provisions

     34   

Definitions

  

General

     35   

Employee Life

     37   

Dependent Optional Life

     38   

Accidental Death and Dismemberment

     39  

 

93C-LH-TAB    Page No. 6   

Table of Contents

June 1, 2012

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BENEFIT HIGHLIGHTS

EMPLOYEE LIFE AND ACCIDENTAL DEATH AND DISMEMBERMENT INSURANCE

ELIGIBLE CLASSES

Initial Associate Qualifying Period

A qualifying period of eight weeks of continuous employment where an active
regular status Employee has averaged at least 32 hours per week.

Ongoing Associate Eligibility

An active regular status Employee’s hours are recalculated semi-annually in
March and September. An Employee must average 32 hours per week for the previous
six month period, in order to retain coverage.

However, if an Employee was insured prior to January 1, 1991 and averaged at
least 20 hours per week, Ongoing Eligibility will be based on 20 hours per week
average. If the average drops below 20 hours per week, the Employee will need to
meet the Ongoing Eligibility of 32 hours average thereafter.

BASIC INSURANCE

CLASSIFICATION

 

1 All Eligible Executives

 

2 All Other Eligible Employees

 

CLASS    LIFE    AD&D 1   

1.5 times your Basic

Annual Earnings*

   An amount equal to your amount of Basic Life Insurance in force 2    1 times
your Basic Annual Earnings*    An amount equal to your amount of Basic Life
Insurance in force

 

93C-LH-SCHED    Page No. 7   

Benefit Highlights

June 1, 2012

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BENEFIT HIGHLIGHTS

OPTIONAL LIFE INSURANCE

CLASSIFICATION

All Eligible Employees

You may elect one of the following Options:

 

Option I

   $ 25,000   

Option II

   $ 50,000   

Option III

   $ 75,000   

Option IV

   $ 100,000   

Option V

   $ 150,000   

Option VI

   $ 200,000   

Option VII

   $ 250,000   

Option VIII

   $ 300,000   

Option IX

   $ 350,000   

Option X

   $ 400,000   

Option XI

   $ 450,000   

Option XII

   $ 500,000   

Option XIII

   $ 550,000   

Option XIV

   $ 600,000   

Option XV

   $ 650,000   

Option XVI

   $ 700,000   

Option XVII

   $ 750,000   

Option XVIII

   $ 1,000,000   

 

* rounded to the next higher $1,000, if not already a multiple of $1,000

 

The Basic Maximum Benefit for Class 1 is $500,000.

The Basic Maximum Benefit for Class 2 is $100,000.

(Applicable if you were hired on or after April 1, 2001 but prior to April 1,
2004)

The Guaranteed Issue Amounts for Optional Life Insurance are as follows:

 

AGE

   GUARANTEED
ISSUE
AMOUNT  

Under age 70

   $ 100,000   

Ages 70 to 74

   $ 45,000   

Ages 75 to 79

   $ 30,000   

Ages 80 to 84

   $ 20,000   

Ages 85 to 89

   $ 15,000   

Age 90 or over

   $ 10,000   

 

93C-LH-SCHED    Page No. 8   

Benefit Highlights

June 1, 2012

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BENEFIT HIGHLIGHTS

(Applicable if you were hired on or after April 1, 2004)

The Guaranteed Issue Amounts for Optional Life Insurance are as follows:

 

AGE

   GUARANTEED
ISSUE
AMOUNT  

Under age 70

   $ 500,000   

Ages 70 to 74

   $ 50,000   

Ages 75 to 79

   $ 30,000   

Ages 80 to 84

   $ 20,000   

Ages 85 to 89

   $ 15,000   

Age 90 or over

   $ 10,000   

(Applicable if you were insured for Optional Life Insurance on March 31, 2001)

The Guaranteed Issue Amount for Optional Life Insurance is the amount of
Optional Life Insurance you had in force on March 31, 2001.

Your amount of Basic and Optional Life and Basic Accidental Death and
Dismemberment Insurance reduces to 45% when you reach age 70, to 30% when you
reach age 75, to 20% when you reach age 80, to 15% when you reach age 85 and to
10% when you reach age 90.

Your Basic and Optional Life and Basic Accidental Death and Dismemberment
Insurance cancels at your retirement.

Evidence of Insurability, satisfactory to Sun Life, will be required for any of
the following reasons:

 

  •  

you elect an increase in your amount of Optional Life Insurance in excess of one
option; or

 

  •  

your amount of Life Insurance is in excess of the Guaranteed Issue Amount.

Basic Annual Earnings

Your current salary or wage from your Employer. Basic Annual Earnings does not
include commissions, bonuses, overtime pay or any other extra compensation.

 

93C-LH-SCHED    Page No. 9   

Benefit Highlights

June 1, 2012

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BENEFIT HIGHLIGHTS

DEPENDENT OPTIONAL LIFE INSURANCE

ELIGIBLE CLASSES

CLASSIFICATION

 

1 Employees hired prior to April 1, 2006 who were insured for Dependent Optional
Life Insurance on March 31, 2006 and who elect to remain in their current plan
option

 

2 Employees hired on or after April 1, 2006, Employees hired prior to April 1,
2006 who newly elect Dependent Optional Life Insurance and Employees who are
enrolled in Dependent Optional Life Insurance on March 31, 2006 who elect to
change their amount of Dependent Optional Life Insurance

 

CLASS    Spouse    Child under age 25 1    The amount of Dependent Spouse
Optional Life Insurance you had in force on March 31, 2006    The amount of
Dependent Child Optional Life Insurance you had in force on March 31, 2006

An Employee in Class 1 who elects a change in their amount of Dependent Optional
Life Insurance must enroll in Class 2.

 

CLASS         Spouse           Child under age 25  

2

You may elect one of the following Options:

               Option I    $ 25,000       Option I    $ 2,500 *     Option II   
$ 50,000       Option II    $ 5,000 *     Option III    $ 75,000       Option
III    $ 7,500 *     Option IV    $ 100,000       Option IV    $ 10,000 *    
Option V    $ 150,000       Option V    $ 12,500 *     Option VI    $ 200,000   
   Option VI    $ 15,000 *     Option VII    $ 250,000         

 

* the amount of Dependent Optional Life Insurance for your child under 14 days
is None.

* the amount of Dependent Optional Life Insurance for your child age 14 days but
under 6 months is $500.

 

(Your amount of Dependent Spouse Optional Life Insurance cannot exceed 50% of
your amount of Optional Life Insurance)

(Your amount of Dependent Child Optional Life Insurance cannot exceed 10% of
your amount of Optional Life Insurance)

 

93C-LH-SCHED    Page No. 10   

Benefit Highlights

June 1, 2012

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BENEFIT HIGHLIGHTS

(Applicable if you were hired prior to April 1, 2004)

The Guaranteed Issue Amounts for Dependent Spouse Optional Life Insurance are as
follows:

 

 

AGE

   GUARANTEED
ISSUE
AMOUNT  

Under age 70

   $ 100,000   

Ages 70 to 74

   $ 25,000   

Ages 75 to 79

   $ 15,000   

Ages 80 to 84

   $ 10,000   

Ages 85 to 89

   $ 7,500   

Age 90 or over

   $ 5,000   

Your amount of Dependent Spouse Optional Life reduces to 45% when your Dependent
Spouse reaches age 70, to 30% when your Dependent Spouse reaches age 75, to 20%
when your Dependent Spouse reaches age 80, to 15% when your Dependent Spouse
reaches age 85, and to 10% when your Dependent Spouse reaches age 90.

Evidence of Insurability, satisfactory to Sun Life, will be required for your
Dependent for any of the following reasons:

 

  •  

you elect an amount of Life Insurance for your Dependent in excess of the
Guaranteed Issue Amount; or

 

  •  

you elect an increase in your amount of Dependent Spouse Optional Life Insurance
in excess of one option; or

 

  •  

you elect an increase in your amount of Dependent Child Optional Life Insurance
in excess of one option.

 

93C-LH-SCHED    Page No. 11   

Benefit Highlights

June 1, 2012

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BENEFIT HIGHLIGHTS

WAITING PERIOD

(The period of time you must be employed in an Eligible Class before you can
apply for benefits)

Once you have met your Initial Associate Qualifying Period, coverage may become
effective on the first day of the month coincident with or next following the
completion of an additional 30 day Waiting Period. (See Eligibility and
Effective Dates, When does my insurance start?)

CONTRIBUTIONS

The cost of your Employee Basic Life and Employee Basic Accidental Death and
Dismemberment Insurance is paid for entirely by your Employer. This is your
non-contributory insurance.

The cost of your Employee Optional Life and Dependent Optional Life Insurance is
paid for by you. This is your contributory insurance.

The following Questions and Answers will help you to better understand your
benefits.

Please read them carefully and refer any questions to your Employer or call the
Sun Life Group Customer Service Center toll free at 1-800-247-6875.

 

93C-LH-SCHED    Page No. 12   

Benefit Highlights

June 1, 2012

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ELIGIBILITY AND EFFECTIVE DATES OF INSURANCE

When am I eligible for insurance?

If you are in an Eligible Class shown in the Benefit Highlights, you are
eligible on the later of:

 

  •  

April 1, 2001; or

 

  •  

the first day of the month coincident with or next following the date you
complete your Waiting Period.

 

  •  

the day after you complete your Waiting Period

If you are in an Eligible Class shown in the Benefit Highlights and you have a
Dependent, you are eligible for Dependent Optional Life Insurance on the latest
of:

 

  •  

the date you are insured for Employee Optional Life Insurance; or

 

  •  

April 1, 2001; or

 

  •  

the date you first acquire a Dependent.

When must I apply for insurance?

You must apply for insurance during your Initial Enrollment Period.

When is my Initial Enrollment Period?

If you are eligible for insurance on April 1, 2001, your Initial Enrollment
Period is the period from December 1, 2001 through December 31, 2001 as
designated by your Employer.

If you first become eligible for insurance after April 1, 2001, your Initial
Enrollment Period is the period of time between your Initial Associate
Qualifying Period and your effective date of coverage.

When does my insurance start?

For Non-Contributory Insurance:

Your insurance starts on the date you are eligible if you are actively at work
on that date.

For Contributory Insurance:

Your insurance starts on the date you are eligible on or after the date you
apply for your insurance, if:

 

  •  

you are Actively at Work on that date; and

 

  •  

Evidence of Insurability is not required.

If Evidence of Insurability is required for any amount of insurance, your
insurance will not start until Sun Life approves your insurance, but you need to
be Actively at Work on that date.

What if I am not Actively at Work on the date my insurance starts?

If you are not Actively at Work on the date your insurance would normally start,
your insurance will not start until you are Actively at Work.

What happens if I do not apply during the Initial Enrollment Period?

If you do not apply for insurance during your Initial Enrollment Period, you
will be insured for basic coverage only.

 

93C-LH-ENROLL    Page No. 13   

Eligibility and Effective

Dates of Insurance

June 1, 2012

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ELIGIBILITY AND EFFECTIVE DATES OF INSURANCE

When does my Dependent’s insurance start?

Your Dependent’s insurance starts on the latest of:

 

  •  

the date you are Eligible for Dependent Optional Life Insurance; or

 

  •  

the date you apply for Dependent Optional Life Insurance; or

 

  •  

the date Sun Life approves your Dependent’s Evidence of Insurability (if
required); as long as your Dependent is not hospital confined on that date.

If your Dependent is hospital confined on the date your Dependent’s insurance
would normally start, your Dependent’s insurance will not start until the
Dependent is no longer hospital confined.

If you do not apply for Dependent Optional Life Insurance during your Initial
Enrollment Period, your Dependent will not be insured.

Can I make any changes in my Plan Options?

No change can be made to your Plan Options until:

 

  •  

the Annual Enrollment Period; or

 

  •  

you have a Family Status Change.

When is the Annual Enrollment Period?

The Annual Enrollment Period is the period during the month of April of each
year as designated by your Employer. During this period of time you may make
changes to your Plan Options.

When do changes to my Plan Options start?

If you have increased your amount of insurance, the increase starts on the later
of:

 

  •  

the April 1st following the change in your Plan Options; or

 

  •  

the date Sun Life approves your Evidence of Insurability (if required); as long
as you are Actively at Work on that date.

If you are not Actively at Work on the date your insurance would normally
increase, the increase in your insurance will not start until you are Actively
at Work.

If you have increased your Dependent’s amount of insurance, the increase starts
on the later of:

 

  •  

the April 1st following the change in your Plan Options; or

 

  •  

the date Sun Life approves your Dependent’s Evidence of Insurability (if
required); as long as your Dependent is not hospital confined.

If your Dependent is hospital confined on the date an increase in your
Dependent’s insurance would normally start, the increase in your Dependent’s
insurance will not start until the Dependent is no longer hospital confined.

Decreases in any amount of insurance will start on the April 1st following the
change in your Plan Options.

 

 

93C-LH-ENROLL    Page No. 14   

Eligibility and Effective

Dates of Insurance

June 1, 2012

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ELIGIBILITY AND EFFECTIVE DATES OF INSURANCE

What if I do not make any changes during the Annual Enrollment Period?

If you do not make any changes during the Annual Enrollment Period you will
continue to be insured for the same Plan Option previously selected.

No change in your Plan Options can be made until the next Annual Enrollment
Period unless you have a Family Status Change.

What is considered a Family Status Change?

A Family Status Change is one of the following events:

 

  •  

your marriage or divorce;

 

  •  

the birth of your child;

 

  •  

the adoption of a child by you;

 

  •  

the death of your spouse or child;

 

  •  

the commencement or termination of employment of your spouse;

 

  •  

the change from part-time to full-time employment by you or your spouse;

 

  •  

the change from full-time to part-time employment by you or your spouse;

 

  •  

the taking of an unpaid leave of absence by you or your spouse;

 

  •  

a significant change in your health coverage or your spouse’s health coverage as
a result of your spouse’s employment.

These changes must be made within 31 days of the change in your Family Status
and be necessary or appropriate as a result of the Family Status Change.

When does insurance due to Family Status Changes start?

If you have increased your amount of insurance, the increase starts on the
latest of:

 

  •  

the date you apply for a change in your Plan Options; or

 

  •  

the date your Family Status changes; or

 

  •  

the date Sun Life approves your Evidence of Insurability (if required); as long
as you are Actively at Work on that date.

If you are not Actively at Work on the date your insurance would normally
increase, the increase in your insurance will not start until you are Actively
at Work.

If you have increased your Dependent’s amount of insurance, the increase starts
on the latest of:

 

  •  

the date you apply for a change in your Plan Options; or

 

  •  

the date your Family Status changes; or

 

  •  

the date Sun Life approves your Dependent’s Evidence of Insurability (if
required); as long as your Dependent is not hospital confined on that date.

If your Dependent is hospital confined on the date an increase in your
Dependent’s insurance would normally start, the increase in your Dependent’s
insurance will not start until the Dependent is no longer hospital confined.

If due to the Family Status change you decrease any amount of insurance, the
decrease will start on the date you apply for the change in your Plan Options.

 

 

93C-LH-ENROLL    Page No. 15   

Eligibility and Effective

Dates of Insurance

June 1, 2012

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TERMINATION OF EMPLOYEE INSURANCE

When does my insurance cease?

Your insurance ceases on the earliest of:

 

  •  

the date the Group Policy terminates.

 

  •  

the date you are no longer in an Eligible Class.

 

  •  

the date your class is no longer included for insurance.

 

  •  

the last day for which any required premium has been paid for your insurance.

 

  •  

the date you are approved as a Limited Status Employee.

 

  •  

the date you retire.

 

  •  

the date you request in writing to terminate your insurance.

 

  •  

the date you enter active duty in any armed service during a time of war
(declared or undeclared).

 

  •  

the date your employment terminates.

 

  •  

the date you cease to be Actively at Work.

Are there any conditions under which my insurance can continue?

Yes.

Your insurance will continue during any period the premium for your insurance is
waived under the Group Policy.

If you are on temporary layoff, leave of absence or vacation, your Employer may
continue your insurance by paying the required premium for the length of time
specified below.

Layoff—for up to 6 months

Leave of Absence (including the Family and Medical Leave of Absence)—for up to 6
months Vacation—for up to 3 months

If you are absent from work due to an injury or sickness, your Employer may
continue your Life insurance, by paying the required premium, for up to 12
months.

If you are “Totally Disabled” you may be eligible for a longer continuation of
Life Insurance. Refer to “What is the Waiver of Premium Provision” in the Life
Benefit Section. Please note you need to apply for continued benefits under the
Waiver of Premium Provision within 12 months after you cease to be Actively at
Work.

If your coverage terminates and you are not eligible for any of the described
continuations, you may be eligible for a Conversion Privilege. Refer to the
“Conversion Privilege” in the Life Benefit section. Please note that you need to
apply for the conversion and pay the required premium within 31 days following
your termination of insurance.

You may be eligible to continue your insurance coverage pursuant to the Family
and Medical Leave Act of 1993, as amended or continue coverage pursuant to a
state required continuation period (if any). You should contact your Employer
for more details.

You may be eligible to continue your insurance coverage pursuant to the
Uniformed Services Employment and Reemployment Rights Act (USERRA). You should
contact your Employer for more details.

 

93C-LH-ETERM.1    Page No. 16   

Termination of

Employee Insurance

June 1, 2012

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TERMINATION OF DEPENDENT INSURANCE

When does my Dependent’s insurance cease?

Your Dependent’s insurance ceases on the earliest of:

 

  •  

the date the Group Policy terminates.

 

  •  

the date you cease to be insured.

 

  •  

the date you are no longer in an Eligible Class for Dependent Insurance.

 

  •  

the date the Dependent does not qualify as a Dependent.

 

  •  

the last day for which any required premium has been paid for your Dependent’s
insurance.

 

  •  

the date you request in writing to terminate your Dependent’s insurance.

 

  •  

the date your Dependent enters active duty in any armed service during a time of
war (declared or undeclared).

 

  •  

the date you are approved as a Limited Status Employee.

 

  •  

the date you retire.

 

  •  

the date you die.

Are there any conditions under which my Dependent’s insurance can continue?

Yes.

If your Dependent’s coverage terminates, your Dependent may be eligible for a
Conversion Privilege. Refer to the “Conversion Privilege” of the Dependent
Optional Life Benefit section. Please note that you or your Dependent need to
apply for the conversion and pay the required premium within 31 days following
termination of the Dependent’s insurance.

 

 

93C-LH-DTERM    Page No. 17   

Termination of

Dependent Insurance

June 1, 2012

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BENEFIT PROVISIONS

EMPLOYEE LIFE INSURANCE

What is the Life Insurance Benefit?

If you die while insured, your Beneficiary will receive the amount of your Life
Insurance in force when Sun Life receives written Notice and Proof of Claim.

What is the amount of my Life Insurance?

Basic Life Insurance

The amount of your Basic Life Insurance is the Basic amount of insurance as
determined in the Benefit Highlights.

Your Basic Life Insurance cannot exceed the Basic Maximum Benefit shown in the
Benefit Highlights.

Your amount of Basic Life Insurance is subject to any age reductions or
terminations shown in the Benefit Highlights.

Optional Life Insurance

The amount of your Optional Life Insurance is the lesser of:

 

1. your Optional amount of insurance elected as determined in the Benefit
Highlights; or

 

2. the Optional Guaranteed Issue Amount shown in the Benefit Highlights, plus
any amount of insurance over your Optional Guaranteed Issue Amount that Sun Life
has approved your Evidence of Insurability.

Your amount of Optional Life Insurance is subject to the Exclusions shown below
and any Evidence of Insurability requirements, age reductions or terminations
shown in the Benefit Highlights.

What are the Exclusions?

If your cause of death is suicide:

 

  •  

No amount of Optional Life Insurance is payable if the suicide occurs within 24
months after your Optional Life Insurance starts. Any period of time you were
insured for the same amount of Optional Life Insurance under your Employer’s
prior group Life policy will count towards your completion of the 24 months.

 

  •  

No increased or additional amount of your Optional Life Insurance is payable if
the suicide occurs within 24 months after the increased or additional amount of
your Optional Life Insurance starts.

 

  •  

No amount of your Optional Life Insurance over your Guaranteed Issue Amount is
payable if the suicide occurs within 24 months after the amount over your
Guaranteed Issue Amount starts.

 

93C-LH-LIFE.2    Page No. 18   

Employee Life Insurance

June 1, 2012

--------------------------------------------------------------------------------

BENEFIT PROVISIONS

EMPLOYEE LIFE INSURANCE

What is the Waiver of Premium Provision?

If you become Totally Disabled while insured, the Waiver of Premium Provision
may continue your Life Insurance without any further payment of premiums by you
or your Employer.

When am I eligible for the Waiver of Premium Provision?

You are eligible if Sun Life receives Notice and Proof of Claim that you became
Totally Disabled:

 

  •  

while insured; and

 

  •  

before your 60th birthday; and

 

  •  

before you retire.

What is the amount of Life Insurance that is continued under the Waiver of
Premium Provision?

Sun Life will continue the amount of your Life Insurance in force on the last
day you were Actively at Work. This amount is subject to the same reductions or
terminations that would have been applicable had you not become Totally
Disabled.

If you have converted your Life Insurance to an individual policy, the continued
insurance will be reduced by that converted amount unless you exchange that
individual policy for a full refund of premiums paid.

When does my Waiver of Premium cease?

Your Waiver of Premium ceases on the earliest of:

 

  •  

the date you are no longer Totally Disabled.

 

  •  

the date you do not provide Proof that you continue to be Totally Disabled.

 

  •  

the date you do not submit to an examination by a Physician of Sun Life’s
choice.

 

  •  

the date you are no longer under the regular and continuing care of a Physician
providing appropriate treatment by means of examination and testing in
accordance with your disabling condition.

 

  •  

the date you reach age 70 .

 

  •  

the date you retire.

For the purposes of this Waiver of Premium Provision, you are considered retired
when you receive any compensation from a Retirement Plan of your Employer, or
when you reach age 70, whichever is earlier.

If your Waiver of Premium ceases and you do not return to work with your
Employer, your Life Insurance will terminate. You may be eligible to convert
your Life Insurance under the Conversion Privilege.

 

93C-LH-LIFE.2    Page No. 19   

Employee Life Insurance

June 1, 2012

--------------------------------------------------------------------------------

BENEFIT PROVISIONS

EMPLOYEE LIFE INSURANCE

Note: Death Benefits will be reduced if an Accelerated Benefit is paid.

What is the Accelerated Benefit?

If Sun Life receives satisfactory proof that you are Terminally Ill, part of
your Life Insurance may be payable to you while you are still living.

When am I eligible for an Accelerated Benefit?

(Applicable if you were hired on or before April 1, 2001)

You are eligible if:

 

  •  

you were Actively at Work on April 1, 2001 and have been insured for Life
Insurance for at least 60 days. (This includes any period of time you were
insured under the prior insurer’s group life policy); and

(Applicable if you were hired after April 1, 2001)

You are eligible if:

 

  •  

you have been insured for Life Insurance for at least 60 days; and

(Applicable to All Employees)

 

  •  

you are certified as Terminally Ill with a life expectancy of 12 months or less;
and

 

  •  

you are insured for at least $10,000 of Life Insurance.

How do I receive an Accelerated Benefit?

You need to submit a written request to Sun Life.

If you have assigned your Life Insurance, named an irrevocable Beneficiary or
have a former spouse named as Beneficiary as part of a divorce decree, you must
have a signed agreement from those parties.

What is the amount of Accelerated Benefit?

You can request up to 75% of the amount of your Life Insurance currently in
force. The maximum amount you can request is $82,500. The minimum amount you may
request is $5,000.

If you have received an Accelerated Benefit under the prior insurer’s group life
policy, you can request up to 75% of your Life Insurance currently in force
reduced by the amount of the Accelerated Benefit you have previously received.

How is the Accelerated Benefit paid?

The Accelerated Benefit is paid in a single lump sum amount.

Can I receive more than one Accelerated Benefit?

You may request the Accelerated Benefit only once under Sun Life’s Group Policy.

 

93C-LH-LIFE.2    Page No. 20   

Employee Life Insurance

June 1, 2012

--------------------------------------------------------------------------------

BENEFIT PROVISIONS

EMPLOYEE LIFE INSURANCE

Are there any charges if I request an Accelerated Benefit?

No.

What happens to my Life Insurance if I receive an Accelerated Benefit?

If you have received an Accelerated Benefit from Sun Life or the prior insurer’s
group life policy, your Life Insurance will be reduced by the amount of the
Accelerated Benefit requested. Annual statements will be provided showing the
amount paid and the remaining death benefit. The remaining amount of Life
Insurance will be paid to your Beneficiary upon your death.

Some Important Notes about your Accelerated Benefit

Your Accelerated Benefit is not a long term care policy. The amount your
Accelerated Benefit would pay may not be enough to cover nursing home expenses
or other bills. You may use the money received from the Accelerated Benefit for
any purpose.

Receipt of your Accelerated Benefit may affect your Medicaid eligibility.

Benefits payable under this provision MAY be taxable. You should consult your
tax advisor. Sun Life does not give tax or legal advice.

What is the Portability Privilege?

If, prior to age 65, your Optional Life insurance ceases because you terminate
employment, you may apply for portable coverage, instead of converting to an
individual policy.

How does this differ from the Conversion Privilege?

Portable coverage is group term life insurance. This benefit may be continued
only for 10 years, to age 65, whichever comes first. At the end of that time,
you may convert the coverage then in force to an individual permanent life
policy under a Conversion Privilege.

Also, you must provide a statement of good health in order to qualify for
portable coverage.

What amounts of insurance are portable?

You may apply for portable coverage up to the amount of Optional Life coverage
that ceased, to a maximum of $500,000. If you port your Optional Life coverage,
you may also port any Dependent Optional Life Insurance that ceased due to your
termination of employment.

When does my portable coverage start?

If your application is approved and the first premium is paid when due, your
coverage will start on the day after the 31 day conversion period. If your
application is declined, you will be given a 31 day period to apply for an
individual permanent life policy under the conversion privilege.

 

93C-LH-LIFE.2    Page No. 21   

Employee Life Insurance

June 1, 2012

--------------------------------------------------------------------------------

BENEFIT PROVISIONS

EMPLOYEE LIFE INSURANCE

How do I apply for portable coverage?

You must complete an application for portable coverage, which contains a short
medical questionnaire, and send it, with payment of the first premium, to Sun
Life within 60 days of the date your Optional Life Insurance terminates.

The application contains a table to calculate the applicable premium, based on
your age and the amount of coverage elected.

The application is available from your Employer.

What is the Conversion Privilege?

If your Life Insurance ceases, you may be able to convert your Life Insurance to
an individual policy. You need to apply for the Conversion Privilege within 31
days. See question “How do I convert my Life Insurance?”.

When can I convert my Life Insurance?

 

1. You can convert if all or part of your Life Insurance ceases or reduces due
to:

 

  •  

termination of your employment;

 

  •  

termination of your membership in an Eligible Class;

 

  •  

your retirement;

 

  •  

your reaching a specified age; or

 

  •  

your changing to a different Eligible Class; or

 

  •  

termination of your Waiver of Premium continuation; or

 

  •  

your continuation period ending during your layoff or leave of absence.

 

2. You can convert if you have been continuously insured for 5 or more years
under Sun Life’s Group Life Policy and all or part of your Life Insurance ceases
or reduces due to:

 

  •  

termination of the Life Insurance Benefit Provision;

 

  •  

termination of the Group Policy;

 

  •  

an amendment to the Group Policy to reduce the amount of Life Insurance in your
Eligible Class; or

 

  •  

an amendment to the Group Policy to terminate your Eligible Class.

What amount of Life Insurance can I convert?

The amount of Life Insurance you can convert depends on the reason your Life
Insurance ceases.

If your amount of Life Insurance ceased or reduced for the reasons stated in #1
“When can I convert my Life Insurance?”, you can convert up to the amount that
ceased or reduced. If your amount of Life Insurance that ceased is $10,000 or
more, the minimum amount of your individual policy must be $10,000.

If your amount of Life Insurance ceased or reduced for the reasons stated in #2
“When can I convert my Life Insurance?”, you can convert up to the lesser of:

 

  •  

$2,000; or

 

  •  

the amount that ceased or reduced less any amount of group life insurance you
may become eligible for within 31 days after your Life Insurance ceased or
reduced.

 

93C-LH-LIFE.2    Page No. 22   

Employee Life Insurance

June 1, 2012

--------------------------------------------------------------------------------

BENEFIT PROVISIONS

EMPLOYEE LIFE INSURANCE

How do I convert my Life Insurance?

You convert by applying to Sun Life for an individual policy along with sending
payment of the first premium within 31 days after any part of your Life
Insurance ceases or reduces. This is your 31 day conversion period. However, if
you are not notified by your Employer of this conversion privilege, you will
have an additional 15 days to exercise this conversion privilege. In no event
will this conversion privilege be extended beyond 30 days following your 31 day
conversion period.

What type of individual policy is available?

You can convert to any plan of permanent life insurance available by Sun Life
for conversion. The individual policy will not include any additional benefits
such as disability benefits or accidental death and dismemberment benefits.

You do not have to submit Evidence of Insurability to convert to an individual
policy.

When does my individual policy start?

If your application for the individual policy is received and the first premium
is paid when due, your individual policy starts on the day after the 31 day
conversion period.

What happens if I die during the 31 day conversion period?

If Sun Life receives Notice and Proof of Claim, a death benefit is payable to
your Beneficiary, whether or not you had applied for an individual policy or had
paid the first premium.

The death benefit is the amount of Life Insurance you would have been eligible
to convert.

 

93C-LH-LIFE.2    Page No. 23   

Employee Life Insurance

June 1, 2012

--------------------------------------------------------------------------------

BENEFIT PROVISIONS

EMPLOYEE LIFE INSURANCE

What happens when my Employer transfers Insurance Carriers to Sun Life?

In order to prevent losing your insurance, Sun Life will provide the following
coverage.

If you are not Actively at Work on April 1, 2001, you will be insured if:

 

1. you were insured under the prior insurer’s group Life policy at the time of
the transfer; and

 

2. you are a member of an Eligible Class; and

 

3. premiums for you are paid up to date; and

 

4. you are not receiving or eligible to receive benefits under the prior
insurer’s group Life policy.

Any Life benefit payable will be the lesser of:

 

  •  

the Life benefit payable under the Group Policy; or

 

  •  

the Life benefit payable under the prior insurer’s group Life policy had it
remained in force. All other provisions of Sun Life’s Group Policy will apply.

 

93C-LH-LIFE.2    Page No. 24   

Employee Life Insurance

June 1, 2012

--------------------------------------------------------------------------------

BENEFIT PROVISIONS

DEPENDENT OPTIONAL LIFE INSURANCE

What is my Dependent Optional Life Insurance Benefit?

If your Dependent dies while insured, you will receive the amount of your
Dependent Optional Life Insurance in force when Sun Life receives written Notice
and Proof of Claim.

What is the amount of my Dependent Optional Life Insurance?

The amount of your Dependent Optional Life Insurance is the lesser of:

 

1. the amount of Optional Life Insurance you elected for your Dependent as
determined in the Benefit Highlights; or

 

2. the Guaranteed Issue Amount shown in the Benefit Highlights, plus any amount
of insurance over your Dependent’s Guaranteed Issue Amount for which Sun Life
has approved your Dependent’s Evidence of Insurability.

The amount of your Dependent’s Optional Life Insurance is subject to the
Exclusions shown below and any Evidence of Insurability requirements shown in
the Benefit Highlights.

What are the Exclusions?

If your Dependent Spouse’s cause of death is suicide:

 

  •  

No amount of Dependent Spouse Optional Life Insurance is payable if your
Dependent Spouse’s suicide occurs within 24 months after your Dependent Spouse’s
Optional Life Insurance first starts.

 

  •  

No increased or additional amount of Dependent Spouse Optional Life Insurance is
payable if your Dependent Spouse’s suicide occurs within 24 months after your
Dependent Spouse’s increased or additional amount of Optional Life Insurance
starts.

 

  •  

No amount of Dependent Spouse Optional Life Insurance over your Dependent
Spouse’s Guaranteed Issue Amount is payable if your Dependent Spouse’s suicide
occurs within 24 months after the amount over your Dependent Spouse’s Guaranteed
Issue Amount starts.

What is the Conversion Privilege?

If your Dependent’s Optional Life Insurance ceases, your Dependent may be able
to convert the Optional Life Insurance to an individual policy.

 

93C-LH-DLIFE.2    Page No. 25   

Dependent Optional

Life Insurance

June 1, 2012

--------------------------------------------------------------------------------

BENEFIT PROVISIONS

DEPENDENT OPTIONAL LIFE INSURANCE

When can my Dependent convert?

 

1. Your Dependent can convert if all or part of your Dependent’s Optional Life
Insurance ceases or reduces due to:

 

  •  

termination of your employment;

 

  •  

termination of your membership in an Eligible Class;

 

  •  

your retirement;

 

  •  

your reaching a specified age;

 

  •  

your death; or

 

  •  

your changing to a different Eligible Class; or

 

  •  

your Dependent no longer qualifying as a Dependent.

 

2. Your Dependent can convert if your Dependent has been continuously insured
for 5 or more years under Sun Life’s Group Life Policy and all or part of your
Dependent’s Optional Life Insurance ceases due to:

 

  •  

termination of the Dependent Optional Life Insurance Benefit Provision;

 

  •  

termination of the Group Policy;

 

  •  

an amendment to the Group Policy to terminate your Eligible Class.

What amount of Optional Life Insurance can my Dependent convert?

The amount of Optional Life Insurance your Dependent can convert depends on the
reason your Dependent’s Optional Life Insurance ceased.

If your Dependent’s amount of Optional Life Insurance ceased or reduced for the
reasons stated in #1 “When can my Dependent convert?”, your Dependent can
convert up to the amount that ceased or reduced. If your Dependent’s amount of
Optional Life Insurance that ceased is $10,000 or more, the minimum amount of
your Dependent’s individual policy must be $10,000.

If your Dependent’s amount of Optional Life Insurance ceased for the reasons
stated in #2 “When can my Dependent convert?”, your Dependent can convert up to
the lesser of:

 

  •  

$2,000; or

 

  •  

the amount that ceased, less any amount of group life insurance your Dependent
may become eligible for within 31 days after your Dependent’s Optional Life
Insurance ceased.

How can my Dependent convert?

You or your Dependent need to apply to Sun Life for an individual policy along
with sending payment of the first premium within 31 days after any part of your
Dependent’s Optional Life Insurance ceases or reduces. This is your Dependent’s
31 day conversion period. However, if your Dependent is not notified by your
Employer of this conversion privilege, your Dependent will have an additional 15
days to exercise this conversion privilege. In no event will this conversion
privilege be extended beyond 30 days following your Dependent’s 31 day
conversion period.

What type of individual policy is available?

Your Dependent can convert to any plan of permanent life insurance available by
Sun Life for conversion. The individual policy will not include any additional
benefits such as disability benefits or accidental death and dismemberment
benefits.

Your Dependent does not have to submit Evidence of Insurability to convert to an
individual policy.

 

93C-LH-DLIFE.2    Page No. 26   

Dependent Optional

Life Insurance

June 1, 2012

--------------------------------------------------------------------------------

BENEFIT PROVISIONS

DEPENDENT OPTIONAL LIFE INSURANCE

When does my Dependent’s individual policy start?

If your Dependent’s application for the individual policy is received and the
first premium paid when due, your Dependent’s individual policy starts on the
day after your Dependent’s 31 day conversion period.

What happens if my Dependent dies during the 31 day conversion period?

If Sun Life receives Notice and Proof of Claim, a death benefit is payable to
you, whether or not your Dependent had applied for an individual policy or had
paid the first premium.

The death benefit is the amount of Optional Life Insurance your Dependent would
have been eligible to convert.

 

93C-LH-DLIFE.2    Page No. 27   

Dependent Optional

Life Insurance

June 1, 2012

--------------------------------------------------------------------------------

BENEFIT PROVISIONS

EMPLOYEE ACCIDENTAL DEATH

AND DISMEMBERMENT INSURANCE

What is the Accidental Death and Dismemberment Benefit?

If Sun Life receives written Notice and Proof of Claim that you:

 

  •  

died from an accidental drowning while insured; or

 

  •  

sustained an Accidental Bodily Injury while insured, which results in your loss
of life, sight or limb within 365 days of the date of that Accidental Bodily
Injury; or

 

  •  

sustained a loss of life, sight or limb within 365 days due to an accidental
exposure to the elements while insured; an Accidental Death and Dismemberment
benefit may be payable to you or to your Beneficiary.

The benefit is a percentage of the amount of Accidental Death and Dismemberment
Insurance in force for your class shown in the Benefit Highlights on the date of
the Accidental Bodily Injury. The following is a list of percentages payable for
the applicable loss.

 

Life

     100 % 

Sight of one eye

     50 % 

One limb

     50 % 

Speech and hearing

     100 % 

Speech or hearing

     50 % 

Thumb and index finger of the same hand

     25 % 

Quadriplegia

     100 % 

Paraplegia

     75 % 

Hemiplegia

     50 % 

The maximum amount of Accidental Death and Dismemberment Benefit payable for
losses resulting from any one accident is 100%.

Loss of limb means severance of the hand or foot at or above the wrist or ankle
joint. Loss of sight, speech or hearing must be total and irrecoverable. Loss of
thumb and index finger means severance through or above the metacarpophalangeal
joints.

Quadriplegia means the total and permanent paralysis of both upper and lower
limbs. Paraplegia means the total and permanent paralysis of both lower limbs.
Hemiplegia means the total and permanent paralysis of the upper and lower limbs
on one side of the body.

 

93C-LH-AD&D.2    Page No. 28   

Accidental Death and

Dismemberment Insurance

June 1, 2012

--------------------------------------------------------------------------------

BENEFIT PROVISIONS

EMPLOYEE ACCIDENTAL DEATH

AND DISMEMBERMENT INSURANCE

What happens if I Disappear?

Sun Life will presume, subject to no objective evidence to the contrary, that
you are dead and your death is a result of an Accidental Bodily Injury if:

 

  •  

you disappear as a result of an accidental wrecking, sinking or disappearance of
a conveyance in which you were known to be a passenger; and

 

  •  

your body is not found within 365 days after the date of the conveyance’s
disappearance.

What are the Exclusions?

No AD&D benefit will be payable for your loss that is due to or results from:

 

  •  

suicide while sane or insane.

 

  •  

intentionally self-inflicted injuries.

 

  •  

bodily or mental infirmity or disease of any kind, or an infection unless due to
an Accidental cut or wound.

 

  •  

your committing or attempting to commit an assault, felony or other criminal
act.

 

  •  

active participation in a war (declared or undeclared) or active duty in any
armed service during a time of war.

 

  •  

your active participation in a riot, rebellion, or insurrection.

 

  •  

injury sustained while operating, riding in, descending or falling from or with
any kind of aircraft, other than riding as a fare-paying passenger without any
duties on-board the aircraft or other than a loss connected with a civilian
aircraft operated by a licensed pilot.

 

  •  

your voluntary use of any controlled substance as defined in Title II of the
Comprehensive Drug Abuse Prevention and Control Act of 1970, as now or hereafter
amended, unless administered on the advice of a Physician.

 

93C-LH-AD&D.2    Page No. 29   

Accidental Death and

Dismemberment Insurance

June 1, 2012

--------------------------------------------------------------------------------

BENEFIT PROVISIONS

EMPLOYEE ACCIDENTAL DEATH

AND DISMEMBERMENT INSURANCE

What happens when my Employer transfers Insurance Carriers to Sun Life?

In order to prevent losing your insurance, Sun Life will provide the following
coverage. If you are not Actively at Work on April 1, 2001 you will be insured
if:

 

  •  

you were insured under the prior insurer’s group AD&D policy at the time of
transfer; and

 

  •  

you are a member of an Eligible Class; and

 

  •  

premiums for you are paid up to date; and

 

  •  

you are not receiving or eligible to receive benefits under the prior insurer’s
group AD&D policy.

Any AD&D benefit payable will be the lesser of:

 

  •  

the AD&D benefit payable under the Group Policy; or

 

  •  

the AD&D benefit payable under the prior insurer’s group AD&D policy had it
remained in force.

All other provisions of Sun Life’s Group Policy will apply.

 

93C-LH-AD&D.2    Page No. 30   

Accidental Death and

Dismemberment Insurance

June 1, 2012

--------------------------------------------------------------------------------

CLAIM PROVISIONS

How is a claim submitted?

To submit a claim, you or someone on your behalf must send Sun Life written
Notice and Proof of Claim within the time limits specified. Your Employer has
the Sun Life Notice and Proof of Claim forms.

When does written Notice of Claim have to be submitted?

for a Death Claim - written notice of claim must be given to Sun Life no later
than 30 days after the date of death.

for Life Waiver of Premium - written notice of claim must be given to Sun Life
no later than 12 months after you cease to be Actively at Work.

for Accidental Dismemberment - written notice of claim must be given to Sun Life
no later than 12 months after the date of your loss.

If notice cannot be given within the applicable time period, Sun Life must be
notified as soon as it is reasonably possible.

When Sun Life has received written notice of claim, Sun Life will send the forms
for proof of claim. If the forms are not

received within 15 days after written notice of claim is sent, proof of claim
may be sent to Sun Life without waiting to receive the proof of claim forms.

When does written Proof of Claim have to be submitted?

for a Death Claim - proof of claim must be given to Sun Life no later than 90
days after date of death.

for Life Waiver of Premium - proof of claim must be given to Sun Life no later
than 15 months after you cease to be Actively at Work.

for Accidental Dismemberment - proof of claim must be given to Sun Life no later
than 15 months after the date of your loss.

If proof cannot be given within these time limits, proof must be given as soon
as reasonably possible. Proof of claim may not be given later than one year
after the time proof is otherwise required unless the individual is legally
incompetent.

What is considered Proof of Claim?

Proof of Claim must consist of at least the following information:

 

  •  

a description of the loss or disability;

 

  •  

the date the loss or disability occurred; and

 

  •  

the cause of the loss or disability.

(For example: a Death Claim would include at least the Death Certificate for
Proof of Claim)

Proof of Claim may include, but is not limited to, police accident reports,
autopsy reports, laboratory results, toxicology results, hospital records,
x-rays, narrative reports, or other diagnostic testing materials as required.

Proof of Claim for disability must include evidence demonstrating the disability
including, but not limited to, hospital records, Physician records, Psychiatric
records, x-rays, narrative reports, or other diagnostic testing materials as
appropriate for the disabling condition.

Sun Life may require as part of the Proof, authorizations to obtain medical and
non-medical information.

 

93C-LH-CLAIM.3    Page No. 31   

Claim Provisions

June 1, 2012

--------------------------------------------------------------------------------

CLAIM PROVISIONS

Proof of your continued disability and regular and continuous care by a
Physician must be given to Sun Life within 30 days of the request for proof.

Proof must be satisfactory to Sun Life.

When are benefits payable?

Benefits are payable when Sun Life receives satisfactory Proof of Claim. Payment
will be made not later than 60 days after receipt of Proof of Claim.

What if my claim is denied?

If Sun Life denies any part of a claim, you will receive a written notice of
denial containing:

the reason for the denial;

 

  •  

a reference to the parts of the Group Policy on which the decision is based;

 

  •  

a description of any additional information needed to support the claim; and

 

  •  

information concerning your right to a review of the denial.

If all or part of your claim is denied, you may request a review in writing
within 60 days after receiving notice of denial.

You may submit written comments or other items to support the claim, and may
review any non-privileged information that relates to the request for review.

Sun Life will review the claim promptly on receipt of the written request, and
will notify you of Sun Life’s decision within 60 days after the request has been
received. If an extension of time is required in order to obtain or review
relevant information, Sun Life will notify you in writing of the required
extension, not to exceed 120 days from the date of the request.

Who are benefits payable to?

Benefits payable upon your death are payable to your Beneficiary living at the
time (other than your Employer). You must name your Beneficiary on a form
acceptable to Sun Life. Unless you otherwise specify, if more than one
Beneficiary survives you, all surviving Beneficiaries will share equally. If no
Beneficiary is alive on the date of your death or you do not elect a
Beneficiary, payment will be made as follows:

 

  •  

your surviving spouse; or if none,

 

  •  

your surviving children, in equal shares; or if none,

 

  •  

your surviving parents, in equal shares; or if none,

 

  •  

your surviving sisters and brothers, in equal shares; or if none,

 

  •  

your estate.

If you named Beneficiaries under your Employer’s Plan prior to the effective
date of the Group Policy, that beneficiary designation will remain in effect
unless you elect to change Beneficiaries.

All other benefits payable during your lifetime are payable to you.

If a benefit is payable to your estate, if you are a minor, or you are not
competent, Sun Life has the right to pay an amount of the benefit up to $5,000
to any of your relatives that Sun Life considers entitled. If Sun Life pays
benefits in good faith to a relative, Sun Life will not have to pay those
benefits again.

 

93C-LH-CLAIM.3    Page No. 32   

Claim Provisions

June 1, 2012

--------------------------------------------------------------------------------

CLAIM PROVISIONS

If your Beneficiary is a minor or is not competent, Sun Life has the right to
pay up to $1,000 to the person or institution that appears to have assumed
custody and main support for the minor, until the appointed legal representative
makes a formal claim. If Sun Life pays benefits in good faith to a person or
institution, Sun Life will not have to pay those benefits again.

Can I change my Beneficiary?

You can change your Beneficiary at any time, unless you have stated your choice
of Beneficiary is irrevocable or you have assigned your interest in your Life
Insurance to another person. Any request for change of Beneficiary must be in a
written form and will take effect on the date you sign and file the change with
your Employer. If Sun Life has taken any action or made payment before receiving
notice of that change, your change of Beneficiary will not affect any action or
payment made by Sun Life. The consent of your Beneficiary is not required to
change any Beneficiary unless the Beneficiary designation was irrevocable.

Can I assign my Life Insurance?

You can transfer ownership of your Life Insurance under the Group Policy by
means of an absolute assignment. You cannot make an absolute assignment to your
Employer. All your rights and duties as owner are transferred to the new owner.
The new owner can make any change the Group Policy allows, such as a change of
Beneficiary.

If you made an assignment under your Employer’s plan prior to the effective date
of the Group Policy, that assignment remains in force with respect to the Group
Policy.

Any assignment must be in a written form and will take effect on the date you
sign and file the assignment with your Employer. If Sun Life has taken any
action or made payment before receiving notice of that change, the assignment
will not affect any action or payment made by Sun Life. Sun Life will not be
responsible for the legal, tax or other effects of any assignment.

 

93C-LH-CLAIM.3    Page No. 33   

Claim Provisions

June 1, 2012

--------------------------------------------------------------------------------

GENERAL PROVISIONS

How can statements made in any application for insurance be used?

All statements made in any application are considered representations and not
warranties. No representation by you in applying for insurance under the Group
Policy will be used to reduce or deny a claim unless a copy of your written
application for insurance is or has been given to you or to your Beneficiary, if
any.

No statement made by you or any of your Dependents, relating to Evidence of
Insurability for an initial, increased or additional amount of insurance, will
be used in contesting the validity of that insurance, after such initial,
increased or additional amount of insurance has been in force for a period of
two years during that individual’s lifetime. This statement must be contained in
a form signed by that individual.

What happens if facts are misstated?

If relevant facts about you or any one of your Dependents are not accurate:

 

  •  

an equitable adjustment of premium will be made; and

 

  •  

the true facts will be used to determine if and in what amount insurance is
valid under the Group Policy.

If the amount of benefit depends on your age, the benefit will be the amount you
would have been entitled to if your correct age were known.

What are Sun Life’s examination and autopsy rights?

Sun Life, at its own expense, has the right to have any person, whose Injury or
Sickness is the basis of a claim:

 

  •  

examined by a Physician, other health professional or vocational expert of its
choice; and/or

 

  •  

interviewed by an authorized Sun Life representative. This right may be used as
often as reasonably required.

Sun Life has the right, in the case of death, to request an autopsy.

What are the time limits for legal proceedings?

No legal action may start:

 

  •  

until 60 days after Proof of Claim has been given; nor

 

  •  

more than 3 years after the time Proof of Claim is required.

Do these group benefits affect Workers’ Compensation?

The Group Policy is not in lieu of, and does not affect, any requirement for
coverage by Workers’ Compensation Insurance.

Can the Policyholder act as a Sun Life agent?

For all purposes of the Group Policy, the Policyholder acts on its own behalf or
as your agent. Under no circumstances will the Policyholder be deemed a Sun Life
agent.

 

93C-LH-GENP    Page No. 34   

General Provisions

June 1, 2012

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DEFINITIONS

These are some of the general terms you need to know.

Actively at Work means that you perform all the regular duties of your job for a
full work day scheduled by your Employer at your Employer’s normal place of
business or a site where your Employer’s business requires you to travel.

You are considered Actively at Work on any day that is not your regular
scheduled work day (e.g., you are on vacation or holiday) as long as you were
Actively at Work on your immediately preceding scheduled work day, and you:

 

  •  

are not hospital confined; or

 

  •  

are not disabled due to an injury or sickness.

You are considered Actively at Work if you usually perform the regular duties of
your job at your home as long as you can perform all the regular duties of your
job for a full work day and could do so at your Employer’s normal place of
business, if required, and you:

 

  •  

are not hospital confined; or

  •  

are not disabled due to an injury or sickness.

Eligibility Date means the date or dates you become eligible for insurance under
the Group Policy. Classes eligible for insurance are shown in the Benefit
Highlights.

Employee (You) means a person who is employed by the Employer, scheduled to work
at least the number of hours shown in the Benefit Highlights, and paid regular
earnings.

Employer means Pier 1 Imports, Inc. and includes any Subsidiary or Affiliated
company insured under the Group Policy.

Evidence of Insurability means a statement or records of your or your
Dependent’s medical history upon which acceptance for insurance will be
determined by Sun Life. In some cases, Sun Life may require that you or your
Dependent submit to a paramedical examination, at Sun Life’s expense, as part of
the Evidence of Insurability.

Guaranteed Issue Amount means the maximum amount of insurance available to you
or your Dependent without Evidence of Insurability.

Injury means bodily impairment resulting directly from an accident and
independently of all other causes. Any Injury must occur and Disability must
begin while you are insured under the Group Policy.

Physician means an individual who is operating within the scope of his license
and is either:

 

  •  

licensed to practice medicine and prescribe and administer drugs or to perform
surgery; or

 

  •  

legally qualified as a medical practitioner and required to be recognized, under
the Group Policy for insurance purposes, according to the insurance regulations
of the governing jurisdiction.

The Physician cannot be you, your spouse or the parents, brothers, sisters or
children of you or your spouse.

Pregnancy means childbirth, miscarriage, abortion or any disease resulting from
or aggravated by the pregnancy.

Retirement Plan means a program which provides retirement benefits to you and is
not funded entirely by your contributions. The term does not include a 401(k)
plan, a profit sharing plan, a thrift plan, an individual retirement account
(IRA), a tax sheltered annuity (TSA), a stock ownership plan, or a nonqualified
plan of deferred compensation.

Your Employer’s Retirement Plan will include any Retirement Plan:

 

  •  

which is part of any federal, state, county, municipal or association retirement
system; and

 

  •  

you are eligible for as a result of your employment with your Employer.

 

93C-LH-DEF.6    Page No. 35   

Life Definitions

June 1, 2012

--------------------------------------------------------------------------------

DEFINITIONS

Sickness means illness, disease or pregnancy. A Disability, because of Sickness,
must begin while you are insured under the Group Policy.

Waiting Period means the continuous length of time immediately before your
Eligibility Date during which you must be employed in an Eligible Class. Any
period of time before the Group Policy Effective Date that you were Actively at
Work for your Employer as a full-time Employee or part-time Employee will count
towards completion of your Waiting Period. The Waiting Period is shown in the
Benefit Highlights.

 

93C-LH-DEF.6    Page No. 36   

Life Definitions

June 1, 2012

--------------------------------------------------------------------------------

DEFINITIONS

These are Life Insurance terms you need to know.

Basic Maximum Benefit means the amount of Basic Life Insurance available to you.
The Basic Maximum Benefit is shown in the Benefit Highlights.

Beneficiary means the person (it cannot be your Employer) who is entitled to
receive death benefit proceeds as they become due under the Group Policy. A
Beneficiary must be named by you on a form acceptable to Sun Life and executed
by you.

Retirement for the purposes of your being considered retired means the first of
the following dates to occur:

 

1. the effective date of your retirement benefits under:

 

  a. any plan of a federal, state, county, municipal or an association
retirement system for which you are eligible as a result of your employment with
your Employer;

 

  b. any Retirement Plan your Employer sponsors; or

 

  c. any Retirement Plan your Employer makes or has made contributions to.

 

2. the effective date of your retirement benefits under the Social Security Act
or any similar plan or act. However, if you meet the definition of an Employee
Actively at Work and you are receiving retirement benefits under the Social
Security Act or similar plan or act, you will not be considered retired.

Terminally Ill or Terminal Illness means your Sickness or physical condition
that is certified by a Physician to reasonably be expected to result in your
death within twelve months or less.

Total Disability or Totally Disabled for purposes of determining eligibility for
Waiver of Premium, means because of your Injury or Sickness, you are unable to
perform the material and substantial duties of any occupation for which you are
or become reasonably qualified for by education, training or experience.

 

93C-LH-DEF.6    Page No. 37   

Life Definitions

June 1, 2012

--------------------------------------------------------------------------------

DEFINITIONS

These are Dependent Optional Life Insurance terms you need to know.

Dependent means your:

 

  •  

spouse;

 

  •  

unmarried child from live birth to age 25.

Your unmarried step-child, foster child, adopted child or child under legal
guardianship is included as a Dependent if he/she depends on you for 50% or more
of his/her support and is living with you in a regular parent-child
relationship. A child is considered adopted if in your legal custody under an
interim court order of adoption, whether or not a final adoption order is ever
issued.

Dependent does not include:

 

  •  

any person who is insured as an Employee; or

 

  •  

any person residing outside the United States, Canada or Mexico.

If an unmarried child is:

 

  •  

incapable of self-sustaining employment because of mental retardation,
developmental disability or physical handicap; and

 

  •  

depends on you for 50% or more of his/her support; that child will continue to
be a Dependent for as long as these two conditions exist.

No person may be considered to be a Dependent of more than one Employee.

 

93C-LH-DEF.6    Page No. 38   

Dependent Life Definitions

June 1, 2012

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DEFINITIONS

This is an Accidental Death and Dismemberment Insurance term you need to know.

Accidental Bodily Injury means bodily harm caused solely by external, violent
and accidental means which is sustained directly and independently of all other
causes.

 

93C-LH-DEF.5    Page No. 39   

AD&D Definitions

June 1, 2012

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Pier 1 Imports, Inc. Employee Benefit Plan (The Plan) has been established to
provide welfare benefits for its employees.

The Employee Retirement Income Security Act of 1974 (ERISA) requires that the
Plan Administrator provide you with a Summary Plan Description which discloses
required information about the employee benefit plan. The following section
entitled “Summary Plan Description” is not part of the Group Insurance Policy.
The information in the Summary Plan Description is provided by the Policyholder
and is included in this Booklet/Certificate for your convenience. Sun Life
Assurance Company of Canada assumes no responsibility for the accuracy or
sufficiency of the information in the Summary Plan Description.

SUMMARY PLAN DESCRIPTION

 

Plan Sponsor:    Pier 1 Imports, Inc.    100 Pier 1 Place    Fort Worth, TX
76102 Plan Administrator:    Pier 1 Imports, Inc.    100 Pier 1 Place    Fort
Worth, TX 76102

The Plan Administrator has authority to control and manage the operation and
administration of the Plan.

 

Subsidiaries/Affiliates:    Pier 1 Imports (U.S.), Inc; Pier 1 Services Company;
Pier 1 National Bank; Cargo Furniture

Agent for Service of Legal Process:

Pier 1 Imports, Inc.

100 Pier 1 Place

Fort Worth, TX 76102

Employer Identification Number (EIN):                 75-1729843

Plan Number: 501

End of Plan Year:             December 31st

Type of Administration: The Plan is administered by the Plan Administrator. The
benefits provided by the Group Insurance Policy issued by Sun Life Assurance
Company of Canada are included in the Plan.

Participants: The insured employees described in the Sun Life Assurance Company
of Canada Booklet/Certificate.

Plan Changes and Termination: The Plan Administrator may amend, modify or
terminate the Plan.

Contributions: The cost of your benefits under the Plan is paid for by your
employer and (if applicable) include the cost of any insurance premiums
contributed by you.

Funding: Sun Life provides the Plan Administrator with certain insurance
benefits in connection with the Plan. Those insurance benefits are described in
your Booklet/Certificate.

Claims Procedure: When you or your beneficiary wish to file a claim under the
Plan, you should contact your benefits department for claim forms and
instructions for filing. Your Booklet/Certificate explains the procedure for
filing a claim under the Group Insurance Policy.

--------------------------------------------------------------------------------

If your claim for benefits is denied in whole or in part, you will receive a
written notice within 45 days from the date you filed your claim, stating the
reasons why your claim was denied. You will then have the right, upon written
notice from you or your authorized representative, to review that claim denial.
The claim denial notice will include the name and address of the person you may
ask for such a review. Additional information about claims submitted and review
procedures may be obtained by contacting your Plan Administrator.

ERISA Rights: As a participant in the Plan, you are entitled to certain rights
and protections under the Employee Retirement Income Security Act of 1974
(ERISA). ERISA provides that all plan participants shall be entitled to:

Examine, without charge, at the Plan Administrator’s office, all Plan documents
filed by the Plan with the U.S. Department of Labor, such as detailed annual
reports and plan descriptions.

Obtain copies of all Plan documents and other plan information upon written
request to the Plan Administrator. The Administrator is required under ERISA to
furnish each participant with a copy of this summary annual report.

In addition to creating rights for Plan participants, ERISA imposes duties upon
the people who are responsible for the operation of the Plan. The people who
operate your plan, called “fiduciaries” of the Plan, have a duty to act
prudently, in your interest and that of the other Plan participants and
beneficiaries.

No one, including your employer, may terminate you or otherwise discriminate
against you in any way to prevent you from obtaining a benefit or exercising
your rights under ERISA. If your claim for a benefit is denied in whole or in
part, you must receive a written explanation of the reason for the denial. You
have the right to have the Plan Administrator review and reconsider your claim.

Under ERISA, there are steps you can take to enforce the above rights. For
instance, if you request materials from the Plan and do not receive them within
30 days, you may file suit in a federal court. In such a case, the court may
require the Plan Administrator to provide the materials and pay you up to $110 a
day until you receive the materials, unless the materials were not sent because
of reasons beyond the control of the Plan Administrator.

If you have a claim for benefits which is denied or ignored, in whole or in
part, you may file suit in a state or federal court. If it should happen that
Plan fiduciaries misuse the Plan’s money, or if you are discriminated against
for asserting your rights, you may seek assistance of the U.S. Department of
Labor, or you may file suit in a federal court. The court will decide who should
pay court costs and legal fees. If you are successful the court may order the
person you have sued to pay these costs and fees. If you lose, the court may
order you to pay these costs and fees, for example, if it finds your claim is
frivolous.

If you have questions about your Plan, you should contact the Plan
Administrator. If you have any questions about your rights under ERISA, you
should contact the nearest office of the Pension and Welfare Benefits
Administration, U.S. Department of Labor, listed in your telephone directory or
the Division of Technical Assistance and Inquiries, Pension and Welfare Benefits
Administration, U.S. Department of Labor, 200 Constitution Avenue, N.W.,
Washington, DC 20210.

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