**Exhibit 10.26**

**Summary of Family Dollar Stores, Inc. Executive LifePlan**

 

                TheCompany’s named executive officers receive increased coverage amounts under theCompany’s life and accidental death and dismemberment policy generallyavailable to all Company employees.   A copy of the policy is attached hereto.

 

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| [Jefferson Pilot Financial Logo] |   | Jefferson Pilot Financial Insurance Company   |
|----------------------------------|--------|-----------------------------------------------|
|                             |   | 8801 Indian Hills Drive, Omaha NE 68114- 4066 |
|                             |   | (402) 361-7300                                |   | A Stock Company |

 
| CERTIFIES THAT Group Policy No |   | GL 000010006033            |   | has been issued to |
|--------------------------------|--------|----------------------------|--------|--------------------|
|                           |   | Family Dollar Stores, Inc. |   |               |
|                           |   | (The Group Policyholder)   |   |               |

 

The Issue Date of thePolicy is January 1, 2003.  Thiscertificate supercedes and replaces any previously issued certificate with aneffective date of January 1, 2003.

 

The insurance is effective only if the Associate is eligible forinsurance and becomes and remains insured as provided in the Group Policy.

 
| Certificate of  Insurance   |
|-----------------------------|
|                        |   |   |   |   |
| {INSURED}                   |   |   |   |   |
| **{Schedule of Insurance}** |   |   |   |   |
| **{Coverage}**              | ** ** | ** ** | ** ** | **{Insurance  Amount}** |
| {BENEFIT_1}                 |   |   |   |   |
| {BENEFIT_2}                 |   |   |   |   |
| {BENEFIT_3}                 |   |   |   |   |
| {BENEFIT_4}                 |   |   |   |   |
| {BENEFIT_5}                 |   |   |   |   |
| {BENEFIT_6}                 |   |   |   |   |
| {BENEFIT_7}                 |   |   |   |   |
| {BENEFIT_8}                 |   |   |   |   |
| {BENEFIT_9}                 |   |   |   |   |
| {BENEFIT_10}                |   |   |   |   |
|                        |   |   |   |   |

 

 

 

You are entitled to the benefits described in this Certificate if you areeligible for insurance under the provisions of the Policy.  This Certificate replaces any othercertificates for the benefits described inside. As a Certificate of Insurance, it is not a contract of insurance; itonly summarizes the provisions of the Policy and is subject to the Policy’sterms.

** **

**ACCELERATED BENEFITS PAID UNDER THIS POLICY ORATTACHED RIDER MAY BE TAXABLE.  IF SO,THE INSURED PERSON OR INSURED PERSON’S BENEFICIARY MAY INCUR A TAXOBLIGATION.  AS WITH ALL TAX MATTERS, THEINSURED PERSON SHOULD CONSULT A PROFESSIONAL TAX ADVISOR TO ASSESS THE EFFECTOF THIS BENEFIT.  ACCELERATED BENEFITSPROVIDED BY A RIDER ARE NOT PAYABLE IF THE POLICY TO WHICH IT IS ATTACHED ISNOT IN EFFECT.**

** **

**IMPORTANT CANCELLATION INFORMATION - PLEASE READTHE PROVISION ENTITLED ‘TERMINATION OF COVERAGE’, FOUND ON FORM ‘2 93’.**

 
|   |   |                         |
|--------|--------|-------------------------|
|   |   | Chief Executive Officer |

 

----

 

Family Dollar Stores, Inc.

000010006033

 

**SCHEDULE OF INSURANCE**

 

Corporate Executive

Corporate Director

Chief Pilot

Assistant General Counsel

Corporate Exempt

Corporate Non-exempt

Distribution CenterExecutive (RVP Only)

Distribution CenterManager

Distribution CenterExempt (non-managerial, includes Supervisor and Area Managers)

Distribution CenterNon-Exempt

District Manager (Stores)

Store Manager

Store Manager — Trainee,Assistant Store Manager

Clerks, New-Remodel Staff

 

 

 
| **WAITING PERIOD:**                                                                           |   |       |
|-----------------------------------------------------------------------------------------------|--------|------------|
| Corporate Executive:                                                                          |   | None       |
| Corporate Director:                                                                           |   | None       |
| Chief Pilot:                                                                                  |   | None       |
| Assistant General Counsel:                                                                    |   | None       |
| Distribution Center Executive (RVP Only):                                                     |   | None       |
| District Manager (Stores):                                                                    |   | None       |
|                                                                                          |   |       |
| Corporate Exempt:                                                                             |   | One Month  |
| Corporate Non-exempt:                                                                         |   | One Month  |
| Distribution Center Manager:                                                                  |   | One Month  |
| Distribution Center Exempt (non-managerial, includes  Supervisor and Area Managers):          |   | One Month  |
| Distribution Center Non-Exempt:                                                               |   | One Month  |
|                                                                                          |   |       |
| Store Manager:                                                                                |   | Six Months |
| Store Manager — Trainee, Assistant Store Manager:                                        |   | Six Months |
| Clerks, New-Remodel Staff:                                                                    |   | Six Months |
|                                                                                          |   |       |
| MINIMUM HOURS:           30  hours per week |   |       |

 

----

 

LIFE AND AD&DINSURANCE

 

 
| ** **                                                                                                                               | ** ** | **Amount of Personal  Life Insurance**                                                                                                       | ** ** | **AD&D Insurance  Principal Sum**                                                                                                       |
|------------------------------------------------------------------------------------------------------------------------------------------|------------|----------------------------------------------------------------------------------------------------------------------------------------------|------------|---------------------------------------------------------------------------------------------------------------------------------------------|
|                                                                                                                                     |       |                                                                                                                                         |       |                                                                                                                                        |
| Executives                                                                                                                               |       | Two times Basic Annual Earnings, rounded to the next  higher $1,000; subject to a minimum of $50,000 and a maximum of $1,000,000             |       | Two times Basic Annual Earnings, rounded to the next  higher $1,000; subject to a minimum of $50,000 and a maximum of $75,000               |
|                                                                                                                                     |       |                                                                                                                                         |       |                                                                                                                                        |
| Distribution Center  Managers, Corporate Directors, Chief Pilot, Assistant General Counsel,  Corporate Exempt, District Manager (Stores) |       | One and one-half times Basic Annual Earnings,  rounded to the next higher $1,000; subject to a minimum of $20,000 and a  maximum of $300,000 |       | One and one-half times Basic Annual Earnings,  rounded to the next higher $1,000; subject to a minimum of $20,000 and a  maximum of $75,000 |
|                                                                                                                                     |       |                                                                                                                                         |       |                                                                                                                                        |
| Distribution Center  Exempt, Store Managers                                                                                              |       | One times Basic Annual Earnings, rounded to the next  higher $1,000; subject to a minimum of $10,000 and a maximum of $240,000               |       | One times Basic Annual Earnings, rounded to the next  higher $1,000; subject to a minimum of $10,000 and a maximum of $75,000               |
|                                                                                                                                     |       |                                                                                                                                         |       |                                                                                                                                        |
| Distribution Center and  Corporate Non-Exempt, Store Manager-Trainee, Assistant Store Manager                                            |       | $5,000                                                                                                                                       |       | $5,000                                                                                                                                      |
|                                                                                                                                     |       |                                                                                                                                         |       |                                                                                                                                        |
| Store Clerks,  New-Remodel Staff                                                                                                         |       | $4,000                                                                                                                                       |       | $4,000                                                                                                                                      |
|                                                                                                                                     |       |                                                                                                                                         |       |                                                                                                                                        |

 

Personal Life andAD&D Insurance will be reduced as follows:

-                    At age 65, benefits will reduce by 35% of the originalamount;

-                    At age 70, benefits will reduce an additional 15% ofthe original amount.

Benefits will terminate when your employment terminates.

 

 

If you first enroll for Personal Life and AD&D Insurance at age 65or older, the above age reductions will apply to:

-                    Any Guarantee Issue Amount available without evidenceof insurability; and

-                    The maximum amount of insurance for which you areeligible.

 

----

 

**Basic Annual Earnings** means your annual base salary orannualized hourly pay from the Employer before taxes on the determinationdate.  The determination date is the lastday worked just prior to the loss.

 

It also includes:

1.                           commissions averaged over the 12 monthsjust prior to the determination date or over the actual period of employmentwith the Employer just prior to that date, if shorter.  It does **not** includebonuses, overtime pay, or any other extra compensation.  It does **not** includeincome from a source other than the Employer. It will not exceed the amount shown in the Employer’s financial recordsor the amount for which premium has been paid, whichever is less.

 

Any reference to Employee or Full-Time Employee refers to an Associateof the Group Policyholder.

 

----

 

**TABLE OF CONTENTS**

 
| Amount of Insurance                                                        | 3      |
|----------------------------------------------------------------------------|--------|
|                                                                       |   |
| Definitions                                                                | 3      |
|                                                                       |   |
| Eligibility                                                                | 4      |
|                                                                       |   |
| Effective Dates of Coverages                                               | 4      |
|                                                                       |   |
| Termination of Coverage                                                    | 4      |
|                                                                       |   |
| Death  Benefit                                                             | 5      |
|                                                                       |   |
| Beneficiary                                                                | 5      |
|                                                                       |   |
| Extension of Death Benefit                                                 | 6      |
|                                                                       |   |
| Accelerated Death Benefit                                                  | 7      |
|                                                                       |   |
| Conversion Privilege                                                       | 9      |
|                                                                       |   |
| Accidental Death and  Dismemberment Insurance                              | 10     |
|                                                                       |   |
| Safe  Driver Benefit                                                       | 12     |
|                                                                       |   |
| Claims Procedures for Life  or Accidental Death and Dismemberment Benefits | 13     |
|                                                                       |   |
| Prior Insurance Credit Provision                                           | 16     |
|                                                                       |   |
| Notice                                                                     | 17     |

 

 

2

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**AMOUNT OFINSURANCE**

 

The amount of yourinsurance is determined by the Schedule of Insurance in the Policy.  The initial amount of coverage is the amountwhich applies to your class on the day your coverage takes effect.  You may become eligible for increases in theamount of insurance in accord with the Schedule of Insurance.  Any such increase will take effect on thelatest of:

(1)                      the date on which you become eligible forthe increase; provided you are Actively at Work on that day;

(2)                      the day you resume Active Work, if youare not Actively at Work on the day the increase would otherwise take effect;or

(3)                      the day any required evidence ofinsurability is approved by the Company.

 

Any decrease will takeeffect on the day of the change; whether or not you are Actively at Work.

 

**DEFINITIONS**

 

ACTIVE WORK or ACTIVELYAT WORK means an employee’s full-time performance of all customary duties ofhis or her occupation at:

(1)                      the EMPLOYER’S place of business; or

(2)                      any other business location where theemployee is required to travel.

 

Unless disabled on the prior workday or on the day of absence, anemployee will be considered Actively at Work on the following days:

(1)                      a Saturday, Sunday or holiday which isnot a scheduled workday;

(2)                      a paid vacation day, or other scheduledor unscheduled non-workday; or

(3)                      an excused or emergency leave of absence(except a medical leave).

 

COMPANY means Jefferson Pilot Financial Insurance Company, a Nebraskacorporation, whose Home Office address is 8801 Indian Hills Drive, Omaha,Nebraska 68114-4066.

 

DAY or DATE means at12:01 A.M., Standard Time, at the Group Policyholder’s place of business; whenused with regard to eligibility dates and effective dates.  It means 12:00 midnight, Standard Time, atthe same place; when used with regard to termination dates.

 

EMPLOYER means the GroupPolicyholder or the Participating Employer named on the Face Page.

 

FULL-TIME EMPLOYEE meansan Associate of the EMPLOYER:

(1)                      whose employment with the EMPLOYER is theemployee’s principal occupation;

(2)                      who is not a temporary or seasonalemployee; and

(3)                      who is regularly scheduled to work atsuch occupation at least the number of hours as shown in the Schedule ofInsurance.

 

INSURANCE MONTH means:

(1)                      that period of time beginning on theIssue Date of the Policy and extending for one month; and

(2)                      each subsequent month beginning on thesame day after that.

 

PERSONAL INSURANCE meansthe insurance provided by the Policy on Insured Persons.

 

PHYSICIAN means a licensed practitioner of the healing arts other thanthe Insured Person or a relative of the Insured Person.

 

POLICY means the GroupInsurance Policy issued by the Company to the Group Policyholder.  A copy of the Policy may be examined uponrequest at the Home Office of the Group Policyholder.

 

 

3

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**ELIGIBILITY**

 

If you are a Full-TimeEmployee and a member of an employee class shown in the Schedule of Insurance;then you will become eligible for the coverage provided by the Policy on thelater of:

(1)                      the Policy’s date of issue; or

(2)                      the day you complete the Waiting Period.

 

WAITING PERIOD.  (See Schedule of Insurance).

 

**EFFECTIVEDATES OF COVERAGES**

 

Your insurance iseffective on the latest of:

(1)                      the day you enroll after becomingeligible for the coverage;

(2)                      the day you resume Active Work, if youare not Actively at Work on the day you become eligible;

(3)                      the day you make written application forcoverage; and sign:

(a)                       a payroll deduction order, if you pay anypart of the premium; or

(b)                      an order to pay premiums from yourSection 125 Plan account, if Employer contributions are paid through a Section125 Plan; or

(4)                      the day the Company approves yourcoverage, if evidence of insurability is required.

 

Evidence of insurabilityis required if:

(1)                      you apply for coverage more than 31 daysafter you become eligible; or

(2)                      you make written application to re-enrollfor coverage after you have requested:

(a)                       to cancel your coverage;

(b)                      to stop payroll deductions for thecoverage.

 

EXCEPTION.  If your coverage terminates due to anapproved leave of absence or a military leave, any Waiting Period or evidenceof insurability requirement will be waived upon your return; provided:

(1)                      you return within six months after theleave begins;

(2)                      you apply or are enrolled within 31 daysafter resuming Active Work; and

(3)                      the reinstated amount of insurance doesnot exceed the amount which terminated.

 

**TERMINATIONOF COVERAGE**

 

Your coverage terminateson the earliest of:

(1)                      the day the Policy terminates;

(2)                      the first day of the pay period in whichyou request termination;

(3)                      the last day of the pay period for whichthe premium for your insurance has been paid;

(4)                      the day you cease to be a member of anemployee class shown in the Schedule of Insurance;

(5)                      with respect to any particular insurancebenefit, the day the part of the Policy providing that benefit terminates;

(6)                      the day your employment with the Employerterminates; or

(7)                      the day you enter the armed services ofany state or country on active duty; except for duty of 30 days or less fortraining in the Reserves or National Guard. (If you send proof of military service, the Company will refund anyunearned premium to the Group Policyholder.)

 

Ceasing Active Work terminates your eligibility.  However, it may be possible to continue allor part of your insurance during a temporary layoff, leave of absence ormilitary leave; or while you are unable to work due to sickness or injury.  The conditions concerning such a continuancemay be found in the Policy.  See yourEmployer for this information.

 

 

4

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**DEATHBENEFIT**

 

Upon receipt ofsatisfactory proof of your death, the Company will pay a death benefit equal tothe amount of Personal Life Insurance in effect on the date of your death.  The benefit will be paid in accord with theBeneficiary section.  Arrangements may bemade to have this death benefit paid in installments.

 

**BENEFICIARY**

 

Your Beneficiary is theperson or persons named on your enrollment card.  The Beneficiary may be changed in accord withthe terms of the Policy.  If you have notnamed a Beneficiary, or if no named Beneficiary is living when you die; thenthe death benefit will be paid to your:

(1)                      surviving spouse; or, if none

(2)                      surviving child or children in equalshares; or, if none

(3)                      surviving parent or parents in equalshares; or, if none

(4)                      surviving brothers and sisters in equalshares; or, if none

(5)                      estate, or in accord with the Facility ofPayment section of the Policy.

 

CHANGING THEBENEFICIARY.  Only you, or your assignee,may change the Beneficiary.  A newBeneficiary may be named by filing a written notice of the change with theGroup Policy Holder at its Home Office. The change will be effective as of the date it was signed; subject toany action the Company takes before receiving notice of the change.

 

When applying for aconversion policy under the Conversion Privilege Section, you must name aBeneficiary.  The Beneficiary named forthe conversion policy may be someone other than the person named under thePolicy.  In that event, the applicationfor the conversion policy will be treated as a written notice of change ofBeneficiary.

 

 

5

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**EXTENSION OF DEATH BENEFIT IF YOUBECOME TOTALLY DISABLED**

 

Your life insurance willbe continued, **without payment of premiums**, if:

(1)                      you become Totally Disabled while insuredand before reaching age 60;

(2)                      you remain Totally Disabled for at least6 months in a row; and

(3)                      you submit satisfactory proof within the7th through 12th months of disability; or:

(a)                      as soon as reasonably possible afterthat; but

(b)                     not later than the 24th month of disability, unlessyou were legally incapacitated.

 

PREMIUM PAYMENT.  Premium payments must continue until you areapproved for this benefit, or the Policy terminates, if earlier.  Upon receipt of satisfactory proof, theCompany will refund up to 12 months’ premium paid for your life insurance, fromyour 1st day of Total Disability.

 

DEFINITION.  For this benefit,Total Disability or Totally Disabled means you:

(1)                      are unable, due to sickness or injury, toengage in any employment or occupation for which you are or become qualified byreason of education, training, or experience; and

(2)                      are not engaging in any gainfulemployment or occupation.

 

AMOUNT CONTINUED.  The amount of Personal Life Insurance and anyDependent Life Insurance continued will be subject to the reductions andterminations in effect under the Policy on the day your Total Disability begins.  Any Accidental Death and DismembermentBenefit will not be continued.

 

ADDITIONAL PROOF.  From time to time, you must submit proof thatyour Total Disability is continuing. Proof will be at your expense; unless the Company requests to have youexamined by a Physician of its choice.  Ifyou die after submitting proof, further proof must be submitted to the Companyshowing that you remained continuously and Totally Disabled until death.  If you die within 12 months after TotalDisability begins, but before submitting proof; then your death benefit willstill be paid under the terms of the Policy. But the Company must first receive satisfactory proof of your continuousTotal Disability, from your last day of Active Work until your date of death.

 

TERMINATION.  Any life insurance continued under thissection will terminate automatically on:

(1)                      the day you cease to be Totally Disabled;

(2)                      the day you fail to take a requiredmedical examination;

(3)                      the 60th day after the Company mails arequest for additional proof, if it is not given;

(4)                      the effective date of your individualconversion policy, with respect to any amount of life insurance converted inaccord with the Conversion Privilege section;

(5)                      the day you reach age 70; or

(6)                      the day you have been Totally Disabledfor twelve months (whichever occurs first).

 

If your Total Disabilityends, and you **do not return** to a class eligiblefor Policy coverage; then you may exercise the Conversion Privilege.  If your Total Disability ends, and you **do return** to an eligible class; then your Policy coveragewill resume when premium payments are resumed, and any conversion policy issurrendered as provided in the Policy.

 

 

6

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**ACCELERATED DEATH BENEFIT**

 

BENEFIT.  The Accelerated Death Benefit is an advancepayment of part of your Personal Life Insurance.  It may be paid to you, in a lump sum, onceduring your lifetime.

 

To qualify, you must:

(1)                      have satisfied the Active Workrequirement under the Policy;

(2)                      have been insured under the Policy:

(a)                      on the date of an injury which results ina Terminal condition; or

(b)                     for 30 days before being diagnosed Terminal as aresult of sickness; and

(3)                      have at least $2,000 of Personal LifeInsurance under the Policy on the day before the Accelerated Death Benefit ispaid.

 

Receiving the AcceleratedDeath Benefit will reduce the Remaining Life Insurance and the Death Benefitpayable at death, as shown on the next page.

 

“Claimant,” as used inthis section, means the Terminal Insured Person for whom the Accelerated DeathBenefit is requested.

 

“Terminal” means you havea medical condition which is expected to result in death within 12 months,despite appropriate medical treatment.

 

APPLYING FOR THEBENEFIT.  To withdraw the AcceleratedDeath Benefit, you (or your legal representative) must send the Company:

(1)                      written election of the Accelerated DeathBenefit, on forms supplied by the Company; and

(2)                      satisfactory proof that the Claimant isTerminal, including a Physician’s written statement.

 

The Company reserves theright to decide whether such proof is satisfactory.

 

Before paying anAccelerated Death Benefit, the Company must also receive the written consent ofany irrevocable beneficiary, assignee or bankruptcy court with an interest inthe benefit.  (See Limitations 3, 4, and5.)

 

**NOTE:  THIS IS NOT A LONG-TERM CARE POLICY.  RECEIVING THIS ACCELERATED DEATH BENEFIT WILLREDUCE THE BENEFIT PAYABLE AT DEATH.  ANYAMOUNT WITHDRAWN MAY BE TAXABLE INCOME, SO YOU SHOULD CONSULT A TAX ADVISORBEFORE APPLYING FOR THIS BENEFIT.**

 

AMOUNT OF THEBENEFIT.  You may elect to withdraw anAccelerated Death Benefit in any $1,000 increment; subject to:

(1)                      a minimum of $1,000 or 10% of theClaimant’s amount of Life Insurance (whichever is greater); and

(2)                      a maximum of $250,000 or 75% of theClaimant’s amount of Life Insurance (whichever is less).

 

To determine theAccelerated Death Benefit, the Company will use the lesser of A or B below:

A.                       the Claimant’s amount of Life Insurancewhich is in force on the day before the Accelerated Death Benefit is paid; or

B.                         the Claimant’s amount of Life Insurancewhich would be in force 12 months after that date; if the coverage is scheduledto reduce, due to age, within 12 months after the Accelerated Death Benefit ispaid.

 

 

7

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ADMINISTRATIVE CHARGE: NONE

 

WITHDRAWAL FEE: NONE

 

EFFECT ON AMOUNT OF LIFEINSURANCE.  “Remaining Life Insurance”means the amount of Life Insurance which remains in force on the Claimant’slife after an Accelerated Death Benefit is paid.  The Remaining Life Insurance will equal:

(1)                      the Claimant’s amount of Life Insurancewhich was used to determine the Accelerated Death Benefit (A or B above); minus

(2)                      any percentage by which the Claimant’scoverage is scheduled to reduce, due to age; if the reduction occurs more than12 months after the Accelerated Death Benefit is paid, and while he or she isstill living; minus

(3)                      the amount of the Accelerated DeathBenefit withdrawn.

 

PREMIUM:  There is no additional charge for this benefit.  Continuation of the Remaining Life Insurancewill be subject to timely payment of the premium for the reduced amount; unlessyou qualify for waiver of premium under the Policy’s Extension of Death Benefitprovision, if included.

 

CONDITIONS.  If the Claimant exercises the ConversionPrivilege after an Accelerated Death Benefit is paid, the amount of theconversion policy will not exceed the amount of his or her Remaining LifeInsurance.  If the Claimant has AccidentalDeath and Dismemberment benefits under the Policy, the Principal Sum will notbe affected by the payment of an Accelerated Death Benefit.

 

EFFECT ON DEATHBENEFIT.  When the Claimant dies after anAccelerated Death Benefit is paid, the amount of Remaining Life Insurance inforce on the date of death will be paid as a Death Benefit.  Your Death Benefit will be paid in accordwith the Beneficiary section of the Policy. If the Claimant dies after application for an Accelerated Death Benefithas been made, but before the Company has made payment; then the request willbe void and no Accelerated Death Benefit will be paid.  The amount of Life Insurance in force on thedate of death will be paid in accord with Policy provisions.

 

EFFECT ON TAXES ANDGOVERNMENT BENEFITS.  Any AcceleratedDeath Benefit amount withdrawn may be taxable income to you.  Receipt of the Accelerated Death Benefit mayalso affect the Claimant’s eligibility for Medicaid, Supplemental SecurityIncome and other government benefits. The Claimant should consult his or her own tax and legal advisor beforeapplying for an Accelerated Death Benefit. The Company is not responsible for any tax owed or government benefitdenied, as a result of the Accelerated Death Benefit payment.

 

LIMITATIONS.  No Accelerated Death Benefit will be paid:

(1)                      if any required premium is due andunpaid;

(2)                      on any conversion policy purchased inaccord with the Conversion Privilege;

(3)                      without the written approval of thebankruptcy court, if you have filed for bankruptcy;

(4)                      without the written consent of thebeneficiary, if you have named an irrevocable beneficiary;

(5)                      without the written consent of theassignee, if you have assigned your rights under the Policy;

(6)                      if any part of the Life Insurance must bepaid to your child, spouse or former spouse; pursuant to a legal separationagreement, divorce decree, child support order or other court order;

(7)                      if the Claimant is Terminal due to asuicide attempt, while sane or insane; or due to an intentionallyself-inflicted injury;

(8)                      if a government agency requires you orthe Claimant to use the Accelerated Death Benefit to apply for, receive orcontinue a government benefit or entitlement; or

(9)                      if an Accelerated Death Benefit has beenpreviously paid for the Claimant under the Policy.

 

 

8

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**CONVERSION PRIVILEGE**

 

If your insurance or insurance on a Dependent terminates for any reasonexcept:

(1)                      termination or amendment of the Policy;or

(2)                      your request for:

(a)                      termination of insurance; or

(b)                     cancellation of your payroll deduction,

an individual life policy, known as a conversion policy, may bepurchased without evidence of insurability.

 

To purchase a conversion policy, application and payment of the firstpremium must be made within 31 days after the life insurance is terminated.

 

The conversion policy will:

(1)                      be in an amount not to exceed the amountof life insurance which was terminated;

(2)                      be on any form (except term) then issuedby the Company at the age and amount for which application is made;

(3)                      be issued at the person’s age at nearestbirthday;

(4)                      be issued without disability or othersupplemental benefits; and

(5)                      require premiums based on the class ofrisk to which the person then belongs.

 

A conversion policy also may be purchased if:

(1)                      all or part of your insurance orinsurance on a Dependent terminates due to amendment or termination of thePolicy; and

(2)                      the person applying for the conversionpolicy has been covered continuously under the Policy for at least 5 years.

 

The amount of the conversion policy may not exceed the lesser of:

(1)                      $10,000; or

(2)                      the amount of life insurance whichterminates, less the amount of any group life insurance for which the personbecomes eligible within 31 days after the termination.

 

The conversion policy will take effect on the later of:

(1)                      its date of issue; or

(2)                      31 days after the date the insuranceterminated.

 

If death occurs during the 31 day conversion period, the Company willpay the life insurance which could have been converted even if no one appliedfor the conversion policy.

 

When your insurance terminates, written notice of your right to convertwill be given to you.

 

No death benefit will be payable under the Policy after the 31 dayconversion period has expired even though the right to convert may be extended.

 

 

9

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**ACCIDENTAL DEATH ANDDISMEMBERMENT INSURANCE**

 

**DEATH OR DISMEMBERMENT BENEFITFOR AN INSURED PERSON**.  The Company will pay thebenefit listed below, if:

(1)                      you sustain an accidental bodily injurywhile insured under this provision; and

(2)                      that injury directly causes one of thefollowing losses within 365 days after the date of the accident.

The loss must resultdirectly from the injury and from no other causes.

 
| **LOSS**                               | ** ** | **BENEFIT  FOR****COMMON CARRIER****ACCIDENT** | ** ** | **BENEFIT  FOR****OTHER COVERED****ACCIDENT** |
|----------------------------------------|------------|------------------------------------------------|------------|-----------------------------------------------|
| Loss of Life                           |       | 2 Times Principal Sum                          |       | Principal Sum                                 |
| Loss of One Member (Hand, Foot or Eye) |       | Principal Sum                                  |       | 1/2 Principal Sum                             |
| Loss of Two or More Members            |       | 2 Times Principal Sum                          |       | Principal Sum                                 |

 

The Principal Sum foryour class is shown in the Schedule of Insurance.

 

**MAXIMUMPER PERSON**.  If you sustain more than one loss resultingfrom the same accident, the benefit:

(1)                      will be the one largest amount listed;

(2)                      will not exceed two times the PrincipalSum for all of your combined losses resulting from a Common Carrier Accident;and

(3)                      will not exceed the Principal Sum for allof your combined losses resulting from any other covered accident.

 

**TO WHOMPAYABLE**.  Benefits for your loss of life will be paidin accord with the Beneficiary section. All other benefits will be paid to you.

 

**LIMITATIONS**. Benefits are not payable for any loss to which a contributing cause is:

(1)                      intentional self-inflicted injury orself-destruction;

(2)                      disease, bodily or mental infirmity, ormedical or surgical treatment of these; except for:

(a)                      a bacterial infection resulting from anaccidental cut or wound;

(b)                     the accidental ingestion of a poisonous foodsubstance;

(3)                      participation in a riot;

(4)                      duty as a member of any military, navalor air force;

(5)                      war or any act of war, declared orundeclared;

(6)                      participation in the commission of afelony;

(7)                      voluntary use of drugs; except whenprescribed by a Physician;

(8)                      voluntary inhalation of gas, includingcarbon monoxide;

(9)                      travel or flight in any aircraft,including balloons and gliders; except as a fare paying passenger on aregularly scheduled flight; or

(10)                driving a vehicle while intoxicated.

 

 

10

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**DEFINITIONS**.

 

“Beneficiary” means the person(s) named on your enrollment form.  You may change the Beneficiary by filing awritten notice of the change with the Company at its Home Office.

 

“Common Carrier Accident” means a covered accidental bodily injury,which is sustained while riding as a fare paying passenger (not a pilot,operator or crew member) in or on, boarding or getting off from a CommonCarrier

 

“Common Carrier” means any land, air or water conveyance operated undera license to transport passengers for hire.

 

“Intoxicated” shall be defined by the jurisdiction where the accidentoccurs.  The exclusion will apply whetheror not the driver is convicted.

 

“Loss of a Member” includes the following:

(1)                      “Loss of Hand or Foot,” means completeseverance through or above the wrist or ankle joint.

(2)                      “Loss of an Eye,” means total andirrevocable loss of sight in that eye.

 

 

11

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**SAFE DRIVER BENEFIT**

 

BENEFIT.  If you die as a directresult of a covered auto accident, for which Accidental Death and DismembermentBenefits are payable; then:

(1)                      an additional Seat Belt Benefit will bepayable, if you were wearing a properly fastened seat belt at the time of theaccident; and

(2)                      an additional Air Bag Benefit will bepayable, if the auto was equipped with air bag(s).

 

The Seat Belt Benefit equals $10,000 or 10% of the Principal Sum,whichever is less; and the Air Bag Benefit equals $10,000 or 10% of thePrincipal Sum, whichever is less.  TheSeat Belt Benefit and the Air Bag Benefit will not be less than $1,000.  The Principal Sum is the amount payablebecause of the Insured Person’s accidental death.

 

A copy of the police report must be submitted with the claim.  The position of the seat belt or presence ofan air bag must be certified by:

(1)                      the official accident report; or

(2)                      the coroner, traffic officer or otherinvestigating officer.

Upon receipt of satisfactory written proof, the additional benefit willbe paid in accord with the Beneficiary section.

 

DEFINITIONS.  As used in thisprovision:

 

“Auto” means a 4-wheel passenger car, station wagon, jeep, pick-uptruck or van-type car.  It must belicensed for use on public highways.  Itincludes a car owned or leased by the Employer.

 

“Intoxicated,” “Impaired,” or “Under the Influence of Drugs” shall bedefined as by the jurisdiction where the accident occurs.

 

“Seat Belt” means a properly installed:

(1)                      seat belt or lap and shoulder restraint;or

(2)                      other restraint approved by the NationalHighway Traffic Safety Administration.

 

LIMITATIONS.  Safe DriverBenefits will not be paid if:

(1)                      the Accidental Death and DismembermentBenefit is not paid under the Policy for your death; or

(2)                      at the time of the accident, you or anyother person who was driving the auto in which you were traveling:

(a)                      was driving without a valid drivers’license;

(b)                     was driving in excess of the legal speed limit; or

(c)                      was driving while intoxicated, impaired,or under the influence of drugs (except for drugs taken as prescribed by aPhysician for the driver’s use).

The above limitations will apply, whether or not thedriver is convicted.

 

 

12

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**CLAIMSPROCEDURES**

**FOR LIFE OR ACCIDENTAL DEATH AND DISMEMBERMENTBENEFITS**

 

**NOTE:  ThePolicy may include an Extension of Death Benefit, an Accelerated Death Benefitor a Living Benefit.  If so, please referto that section for special claim procedures.**

 

**NOTICE AND PROOF OF CLAIM**

 

**Notice of Claim**.  Writtennotice of an accidental death or dismemberment claim must be given within 20days after the loss occurs;  or as soonas reasonably possible after that.*  Thenotice must be sent to the Company’s Home Office.  It should include:

(1)                      your name and address; and

(2)                      the number of the Policy.

 

**Claim Forms**.  When noticeof claim is received, the Company will send claim forms for filing the requiredproof.  If the Company does not send theforms within 15 days; then you or your Beneficiary (the claimant) may send theCompany written proof of claim in a letter. It should state the nature, date and cause of the loss.

 

**Proof of Claim**.  The Companymust be given written proof of claim within 180 days after the date of theloss; or as soon as reasonably possible after that.*  Proof of claim must be provided at theclaimant’s own expense.  It must show thenature, date and cause of the loss.  Inaddition to the information requested on the claim form, documentation mustinclude:

(1)                      A certified copy of the deathcertificate, for proof of death.

(2)                      A copy of any police report, for proof ofaccidental death or dismemberment.

(3)                      A signed authorization for the Company toobtain more information.

(4)                      Any other items the Company mayreasonably require in support of the claim.

 

*** Exception:**  Failure togive notice or furnish proof of claim within the required time period will notinvalidate or reduce the claim; if it is shown that it was done:

(1)                      as soon as reasonably possible; and

(2)                      in no event more than one year after itwas required.

These time limits will not apply while the claimantlacks legal capacity.

 

**EXAM OR AUTOPSY**.  At anytimewhile a claim is pending, the Company may have you examined:

(1)                      by a Physician of the Company’s choice;

(2)                      as often as reasonably required.

If you fail to cooperate with an examiner or fail to take an exam,without good cause; then the Company may deny benefits, until the exam iscompleted.  In case of death, the Companymay also have an autopsy done, where it is not forbidden by law.  Any such exam or autopsy will be at theCompany’s expense.

 

**TIME OF PAYMENT OF CLAIMS**. Any benefits payable under the Policy will be paid immediately after theCompany receives complete proof of claim and confirms liability.

 

**TO WHOM PAYABLE**

 

**Death**.  Any benefitspayable for your death will be paid in accord with the Beneficiary, Facility ofPayment and Settlement Options sections of the Policy.  If the Policy includes Dependent LifeInsurance; then any benefits payable for an insured Dependent’s death will bepaid to:

(1)                      you, if you survive that Dependent; or

(2)                      your Beneficiary, or in accord with theFacility of Payment section; if you do not survive that Dependent.

 

**Dismemberment. **If thePolicy includes Accidental Death and Dismemberment Benefits; then any benefit,other than your death benefit, will be paid to you.

 

 

13

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**NOTICE OF CLAIM DECISION.** The Company will send the claimant a written notice of its claimdecision.  If the Company denies any partof the claim; then the written notice will explain:

(1)                      the reason for the denial, under theterms of the Policy and any internal guidelines;

(2)                      how the claimant may request a review ofthe Company’s decision; and

(3)                      whether more information is needed tosupport the claim.

 

The Company will send this notice within 15 days after resolving theclaim.  If reasonably possible, theCompany will send it within:

(1)                      90 days after receiving the first proofof a death or dismemberment claim; or

(2)                      45 days after receiving the first proofof a claim for any Extension of Death Benefit, Living Benefit or AcceleratedDeath Benefit available under the Policy.

 

**Delay Notice. **If the Company needs more than 15 days to process aclaim, in a special case; then an extension will be permitted.  If needed, the Company will send the claimanta written delay notice:

(1)                      by the 15th day afterreceiving the first proof of claim; and

(2)                      every 30 days after that, until the claimis resolved.

 

The notice will explain the special circumstances which require thedelay, and when a decision can be expected. In any event, the Company must send written notice of its decisionwithin:

(1)                      180 days after receiving the first proofof a death or dismemberment claim; or

(2)                      105 days after receiving the first proofof a claim for any Extension of Death Benefit, Living Benefit or AcceleratedDeath Benefit available under the Policy.

If the Company fails to do so; then there is a right to an immediatereview, as if the claim was denied.

 

**Exception:**  If the Companyneeds more information from the claimant to process a claim; then it must besupplied within 45 days after the Company requests it.  The resulting delay will not count towardsthe above time limits for claim processing.

 

**REVIEW PROCEDURE.** The claimant may request a claim review, within:

(1)                      60 days after receiving a denial noticeof a death or dismemberment claim; or

(2)                      180 days after receiving a denial noticeof a claim for any Extension of Death Benefit, Living Benefit or AcceleratedDeath Benefit available under the Policy.

 

To request a review, the claimant must send the Company a writtenrequest, and any written comments or other items to support the claim.  The claimant may review certainnon-privileged information relating to the request for review.

 

**Notice of Decision. **The Company will review the claim and send theclaimant a written notice of its decision. The notice will explain the reasons for the Company’s decision, underthe terms of the Policy and any internal guidelines.  If the Company upholds the denial of all orpart of the claim; then the notice will also describe:

(1)                      any further appeal procedures availableunder the Policy;

(2)                      the right to access relevant claiminformation; and

(3)                      the right to request a state insurancedepartment review, or to bring legal action.

 

For a death or dismemberment claim, the notice will be sent within 60days after the Company receives the request for review; or within 120 days, ifa special case requires more time.  For aclaim for any Extension of Death Benefit, Living Benefit or Accelerated DeathBenefit available under the Policy, the notice will be sent within 45 daysafter the Company receives the request for review; or within 90 days, if aspecial case requires more time.

 

 

14

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**Delay Notice.**  If the Companyneeds more time to process an appeal, in a special case; then it will send theclaimant a written delay notice, by the 30th day after receiving therequest for review.  The notice willexplain:

(1)                      the special circumstances which requirethe delay;

(2)                      whether more information is needed toreview the claim; and

(3)                      when a decision can be expected.

 

**Exception:**  If the Companyneeds more information from the claimant to process an appeal; then it must besupplied within 45 days after the Company requests it.  The resulting delay will not count towardsthe above time limits for appeal processing.

 

**Claims Subject to ERISA** (Employee Retirement Income Security Actof 1974).  Before bringing a civil legalaction under the federal labor law known as ERISA, an employee benefit planparticipant or beneficiary must exhaust available administrative remedies.  Under the Policy, the claimant must firstseek two administrative reviews of the adverse claim decision, in accord withthis section.  If an ERISA claimant bringslegal action under Section 502(a) of ERISA after the required reviews; then theCompany will waive any right to assert that he or she failed to exhaustadministrative remedies.

 

**RIGHT OF RECOVERY**.  If benefitshave been overpaid on any claim; then full reimbursement to the Company isrequired within 60 days.  Ifreimbursement is not made; then the Company has the right to:

(1)                      reduce future benefits until fullreimbursement is made; and

(2)                      recover such overpayments from you, orfrom your Beneficiary or estate.

Such reimbursement is required whether the overpayment is due to fraud,the Company’s error in processing a claim, or any other reason.

 

**LEGAL ACTIONS**.  No legalaction to recover any benefits may be brought until 60 days after the requiredwritten proof of claim has been given. No such legal action may be brought more than three years after the datewritten proof of claim is required.

 

**COMPANY’S DISCRETIONARY AUTHORITY**. Except for the functions that the Policy clearly reserves to the GroupPolicyholder or Employer, the Company has the authority to:

(1)                      manage the Policy and administer claimsunder it; and

(2)                      interpret the provisions and resolvequestions arising under the Policy.

 

The Company’s authority includes (but is not limited to) the right to:

(1)                      establish and enforce procedures foradministering the Policy and claims under it;

(2)                      determine your eligibility for insuranceand entitlement to benefits;

(3)                      determine what information the Companyreasonably requires to make such decisions; and

(4)                      resolve all matters when a claim reviewis requested.

 

Any decision the Company makes, in the exercise of its authority, shallbe conclusive and binding; subject to your or your Beneficiary’s rights to:

(1)                      request a state insurance department review;or

(2)                      bring legal action.

 

 

15

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CERTIFICATE AMENDMENT

 

TO BE ATTACHED TO THE CERTIFICATE FOR GROUP POLICY NO.:  000010006033

 

ISSUED TO:  Family Dollar Stores,Inc.

 

 

Your Certificate is amended by the addition of the followingprovisions.

 

PRIOR INSURANCE CREDITUPON TRANSFER OF

LIFE INSURANCE CARRIERS

 

This provision prevents loss of life insurance coverage for you, whichcould otherwise occur solely because of a transfer of insurance carriers.  The Policy will provide the following PriorInsurance Credit, when it replaces a prior plan.

 

“Prior Plan” means a prior carrier’s group life insurance policy, whichthe Policy replaced within 1 day of the prior plan’s termination date.

 

FAILURE TO SATISFY ACTIVE WORK RULE. Subject to payment of premiums, the Policy will provide life coverage ifyou:

(1)                      were insured under the prior plan on itstermination date;

(2)                      were otherwise eligible under the Policy;but were not Actively-At-Work due to Injury or Sickness on its Effective Date;

(3)                      are not entitled to any extension of lifeinsurance under the prior plan; and

(4)                      are not Totally Disabled (as defined inthe Extension of Death Benefit section of the Policy) on the date the Policytakes effect.

 

AMOUNT OF LIFE INSURANCE.  Untilyou satisfy the Policy’s Active Work rule, the amount of your group lifeinsurance under the Policy will not exceed the amount for which you wereinsured under the prior plan on its termination date.

 

This Amendment takes effect on your effective date of coverage underthe Policy.  In all other respects, yourCertificate remains the same.

 
|   |   | **Jefferson  Pilot Financial Insurance Company** |
|--------|--------|--------------------------------------------------|
|   |   | ** **                                       |
|   |   |                                                  |
|   |   | Officer of the Company                           |

 

 

16

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**NOTICE CONCERNING COVERAGELIMITATIONS AND EXCLUSIONS**

**UNDER THE NORTH CAROLINA LIFE ANDHEALTH INSURANCE GUARANTY**

**ASSOCIATION ACT**

 

Residents of thisstate who purchase life insurance, annuities or health insurance should knowthat the insurance companies licensed in this state to write these types ofinsurance are members of the North Carolina Life and Health Insurance GuarantyAssociation.  The purpose of thisAssociation is to assure that policyholders will be protected, within limits,in the unlikely event that a member insurer becomes financially unable to meetits obligations.  If this should happen,the Guaranty Association will assess its other member insurance companies forthe money to pay the claims of insured persons who live in this state and, insome cases, to keep coverage in force. The valuable extra protection provided by these insurers through theGuaranty Association is not unlimited, however. And, as noted below, this protection is not a substitute for consumers’care in selecting companies that are well-managed and financially stable.

 

**The NorthCarolina Life and Health Insurance Guaranty Association may or may not providecoverage for this policy.  If coverage isprovided, it may be subject to substantial limitations or exclusions, andrequire continued residency in North Carolina. You should not rely on coverage by the North Carolina Life and HealthInsurance Guaranty Association in selecting an insurance company or inselecting an insurance policy.**

 

**Coverageis NOT provided for your policy or any portion of it that is not guaranteed bythe insurer or for which you have assumed the risk, such as a variable contractsold by prospectus.**

 

**Insurancecompanies or their agents are required by law to give or send you thisnotice.  However, insurance companies andtheir agents are prohibited by law from using the existence of the guarantyassociation to induce you to purchase any kind of insurance policy.**

 

**The NorthCarolina Life and Health Insurance Guaranty Association**

**PostOffice Box #10218**

**Raleigh,North Carolina  27605-0218**

 

**NorthCarolina Department of Insurance, Consumer Division**

**PostOffice Box #26387**

**Raleigh,North Carolina  27611**

 

 

The state law thatprovides for this safety-net is called the North Carolina Life and HealthInsurance Guaranty Association Act.  Thefollowing is a brief summary of this law’s coverages, exclusions andlimits.  This summary does not cover allprovisions of the law; nor does it in any way change anyone’s rights orobligations under the Act or the rights or obligations of the GuarantyAssociation.

 

 

**COVERAGE.** Generally, individuals will be protected by the life and healthinsurance guaranty association if they live in this state and hold a life orhealth insurance contract, or an annuity, or if they are insured under a groupinsurance contract, issued by a member insurer. The beneficiaries, payees or assignees of insured persons are protectedas well, even if they live in another state.

 

 

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** **

**EXCLUSIONS.** However, persons holding such policies are NOT protected by thisAssociation if:

•                     they are eligible for protection under the laws ofanother state (this may occur when the insolvent insurer was incorporated inanother state whose guaranty association protects insureds who live outsidethat state);

•                     the insurer was not authorized to dobusiness in this State;

•                     their policy was issued by an HMO, afraternal benefit society, a mandatory state pooling plan, a mutual assessmentcompany or similar plan in which the policyholder is subject to futureassessments, or by an insurance exchange.

 

The Associationalso does NOT provide coverage for:

•                     any policy or portion of a policy whichis not guaranteed by the insurer or for which the individual has assumed therisk, such as a variable contract sold by prospectus;

•                     any policy of reinsurance (unless anassumption certificate was issued);

•                     interest rate yields that exceed theaverage rate specified by law;

•                     dividends;

•                     experience or other credits given inconnection with the administration of a policy for a group contractholder;

•                     employers’ plans to the extent they areself-funded (that is, not insured by an insurance company, even if an insurancecompany administers them);

•                     unallocated annuity contracts (which giverights to group contractholders, not individuals), unless they fund agovernment lottery or a benefit plan of an employer, association or union,except that unallocated annuities issued to employee benefit plans protected bythe Federal Pension Benefit Guaranty Corporation are not covered.

 

**LIMITS ONAMOUNT OF COVERAGE.**  The Act also limits the amount theAssociation is obligated to pay out.  TheAssociation cannot pay more than what the insurance company would owe under apolicy or contract.  Also, for any oneindividual, the Association will pay a maximum of $300,000 - no matter how manypolicies and contracts there were with the same company, even if they provideddifferent types of coverages.  For anyone group holder of an unallocated annuity contract, the association will pay amaximum of $5,000,000.

** **

**NOTICE OF PROHIBITIONS**

 

UNDER NORTHCAROLINA GENERAL STATUTE SECTION 58-50-40, NO PERSON, EMPLOYER, PRINCIPAL,AGENT, TRUSTEE OR THIRD PARTY ADMINISTRATOR, WHO IS RESPONSIBLE FOR THE PAYMENTOF GROUP HEALTH OR LIFE INSURANCE OR HEALTH CARE PLAN PREMIUMS, SHALL:

 

(1)                CAUSE THE CANCELLATION OR NONRENEWAL OFGROUP HEALTH OR LIFE INSURANCE, HOSPITAL, MEDICAL OR DENTAL SERVICE CORPORATIONPLAN, MULTIPLE EMPLOYER WELFARE ARRANGEMENT, OR HEALTH PLAN COVERAGES (AND THECONSEQUENTIAL LOSS OF THE COVERAGES OF THE PERSONS INSURED) BY WILLFULLYFAILING TO PAY THOSE PREMIUMS IN ACCORDANCEWITH THE TERMS OF THE INSURANCE OR PLAN CONTRACT; AND

(2)                WILLFULLY FAIL TO DELIVER, AT LEAST 45DAYS BEFORE THE TERMINATION OF SUCH COVERAGES, TO ALL PERSONS COVERED BY THEGROUP POLICY A WRITTEN NOTICE OF THE PERSON’S INTENTION TO STOP PAYMENT OFPREMIUMS.  THIS WRITTEN NOTICE MUST ALSOCONTAIN A NOTICE TO ALL PERSONS COVERED BY THE GROUP POLICY OF THEIR RIGHTS TOHEALTH INSURANCE CONVERSION POLICIES UNDER ARTICLE 53 OF CHAPTER 58 OF THEGENERAL STATUTES AND THEIR RIGHTS TO PURCHASE INDIVIDUAL POLICIES UNDER THEFEDERAL HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT AND UNDER ARTICLE68 OF CHAPTER 58 OF THE GENERAL STATUES. VIOLATION OF THIS LAW IS A FELONY.  ANY PERSON VIOLATING THIS LAW IS ALSO SUBJECTTO A COURT ORDER REQUIRING THE PERSON TO COMPENSATE PERSONS INSURED FOREXPENSES OR LOSSES INCURRED AS A RESULT OF THE TERMINATION OF THE INSURANCE.

 

 

18

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**SUMMARYPLAN DESCRIPTION**

 

The following information together with your groupinsurance certificate issued to you by Jefferson Pilot Financial InsuranceCompany of Omaha, Nebraska, is the Summary Plan Description required by theEmployee Retirement Income Security Act of 1974 to be distributed toparticipants in the Plan.  This SummaryPlan Description is only intended to provide an outline of the Plan’sbenefits.  The Plan Document will governif there is any discrepancy between the information contained in thisDescription and the Plan.

 

The name of the Plan is:  Group Life and Accidental Death andDismemberment Insurance for Employees of Family Dollar Stores, Inc..

 

The name, address and ZIP code of the Sponsor of thePlan is:  Family Dollar Stores, Inc.,10301 Monroe Road, Matthews, NC, 28206.

 
| Employer Identification Number (EIN): 56-0942963 |   | IRS Plan Number: 501 |
|--------------------------------------------------|--------|----------------------|

 

The name, business address, ZIP code and businesstelephone number of the Plan Administrator is: Family Dollar Stores, Inc., 10301 Monroe Road, Matthews, NC, 28206,(800) 547-0359.

 

The Plan Administrator is responsible for theadministration of the Plan and is the designated agent for the service of legalprocess for the Plan.  Functionsperformed by the Plan Administrator include: the receipt and deposit of contributions, maintenance of records of Planparticipants, authorization and payment of Plan administrative expenses,selection of the insurance consultant, selection of the insurance carrier andassisting Jefferson Pilot Financial Insurance Company. Jefferson PilotFinancial Insurance Company has the sole discretionary authority to determineeligibility and to administer claims in accord with its interpretation ofpolicy provisions, on the Plan Administrator’s behalf.

 

Type of Administration.  The Plan is administered directly by the PlanAdministrator with benefits provided in accordance with provisions of the groupinsurance policy issued by Jefferson Pilot Financial Insurance Company whoseHome Office address is 8801 Indian Hills Drive, Omaha, Nebraska.

 

Type of Plan.  The benefits provided under the Planare:  Group Life and Accidental Death andDismemberment Insurance benefits.

 

Type of FundingArrangement:  Jefferson Pilot FinancialInsurance Company.

 

All employees are given aCertificate of Group Insurance which contains a detailed description of theBenefits.  The Certificate also containsthe Schedule of Insurance which includes the amount of Personal Life insurance,AD&D Principal Sum, Dependent Life amounts (if any), Waiting Period and agereduction information.  If your Booklet,Certificate or Schedule of Insurance has been misplaced, you may obtain a copyfrom the Plan Administrator at no charge.

 

Eligibility.  Full-time employees working at least 30 hoursper week.

 

Employees become eligibleon the day they complete their waiting period.

 

Contributions.  You are not required to make contributionsfor Personal Life Insurance and AD&D Insurance.

 

The Plan’s year endson:  December 31st of each year.

 

The name and section ofrelevant Collective Bargaining Agreements: None

 

The name, title andaddress of each Plan Trustee:  None

 

 

----

** **

**Loss ofBenefits**.  The Plan Administrator may terminate thepolicy, or subject to Jefferson Pilot Financial Insurance Company’s approval,may modify, amend or change the provisions, terms and conditions of thepolicy.  Coverage will also terminate ifthe premiums are not paid when due.  Noconsent of any Insured Person or any other person referred to in the policywill be required to terminate, modify, amend or change the policy.  See your Plan Administrator to determinewhat, if any, arrangements may be made to continue your coverage beyond thedate you cease active work.

 

**Claims Procedures**.  You mayobtain claim forms and instructions for filing claims from the PlanAdministrator or from the Home Office of Jefferson Pilot Financial InsuranceCompany.  To expedite the processing ofyour claim, instructions on the claim form should be followed carefully; besure all questions are answered fully. In accordance with ERISA, Jefferson Pilot Financial Insurance Companywill send you or your beneficiary a written notice of its claim decisionwithin:

•                                    90 days after receiving the first proof of a death ordismemberment claim (180 days under special circumstances);

•                                    45 days after receiving the first proof of a claim forany Extension of Death Benefit or Accelerated Death Benefit, if available underthe Policy (105 days under special circumstances).

If a claim is partially or wholly denied, this writtennotice will explain the reason(s) for denial, how a review of the decision maybe requested, and whether more information is needed to support the claim.  You, or another person on your behalf, mayrequest a review of the claim by making a written request to Jefferson PilotFinancial Insurance Company within:

•                                    60 days after receiving a denial notice of a death ordismemberment claim;

•                                    180 days after receiving a denial notice of a claimfor any Extension of Death Benefit or Accelerated Death Benefit, if available underthe Policy.

This written request for review should state thereasons why you feel the claim should not have been denied and should includeany additional documentation to support your claim.  You may also submit for considerationadditional questions or comments you feel are appropriate, and you may reviewcertain non-privileged information relating to the request for review.  Jefferson Pilot Financial Insurance Companywill make a full and fair review of the claim and provide a final writtendecision to you or your beneficiary within:

•                                    60 days after receiving the request for a review of adeath or dismemberment claim (120 days under special circumstances);

•                                    45 days after receiving the request for review of aclaim for any Extension of Death Benefit or Accelerated Death Benefit, ifavailable under the Policy (90 days under special circumstances).

If more information is needed to resolve a claim, theinformation must be supplied within 45 days after requested.  Any resulting delay will not count toward theabove time limits for claims or appeals processing.  Please refer to your certificate of insurancefor more information about how to file a claim, how to appeal a denied claim,and for details regarding the claims procedures.

 

**Statementof ERISA Rights**

The following statement of ERISA rights is required byfederal law and regulation.  As aparticipant in this plan, you are entitled to certain rights and protectionsunder the Employee Retirement Income Security Act of 1974 (ERISA).  ERISA provides that all Plan participantsshall be entitled to:

 

**Receive Information About Your Plan and Benefits.** Examine, without charge, at the Plan Administrator’s office and at otherspecified locations, such as work sites and union halls, all documentsgoverning the plan, including insurance contracts and collective bargainingagreements, and a copy of the latest annual report (Form 5500 Series), if any,filed by the plan with the U.S. Department of Labor and available at the PublicDisclosure Room of the Pension and Welfare Benefit Administration.

 

Obtain, upon written request to the PlanAdministrator, copies of documents governing the operation of the plan,including insurance contracts and collective bargaining agreements, and copiesof the latest annual report (Form 5500 Series), if any, and updated summaryplan description. The administrator may make a reasonable charge for copies.

 

Receive a summary of the plan’s annual financialreport if the plan covers 100 or more participants.  The Plan Administrator is required by law tofurnish each participant with a copy of this summary annual report.

 

**Prudent Actions by Plan Fiduciaries.** In addition to creating rights for plan participants, ERISA imposesduties upon the people who are responsible for the operation of the employeebenefit plan.  The people who operateyour plan, called “fiduciaries” of the plan, have a duty to do so prudently andin the interest of you and other plan participants and beneficiaries.  No one, including your employer, your union,or any other person, may fire you or otherwise discriminate against you in anyway to prevent you from obtaining a welfare benefit or exercising your rightsunder ERISA.

 

**Enforce Your Rights.** If your claim for a welfare benefit is denied or ignored, in whole or inpart, you have a right to know why this was done, to obtain copies of documentsrelating to the decision without charge, and to appeal any denial, all withincertain time schedules.

 

Under ERISA, there are steps you can take to enforcethe above rights.  For instance, if yourequest a copy of plan documents or the latest annual report from the plan anddo not receive them within 30 days, you may file suit in a Federal court.  In such a case, the court may require thePlan Administrator to provide the materials and pay you up to $110 a day untilyou receive the materials, unless the materials were not sent because ofreasons beyond the control of the Administrator.  If you have a claim for benefits which isdenied or ignored, in whole or in part, you may file suit in a state or Federalcourt.  If it should happen that planfiduciaries misuse the plan’s money, or if you are discriminated against forasserting your rights, you may seek assistance from the U.S. Department ofLabor, 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 theperson you have sued to pay these costs and fees.  If you lose, the court may order you to paythese costs and fees, for example, if it finds your claim is frivolous.

 

**Assistance with Your Questions.** If you have any questions about your plan, you should contact the PlanAdministrator.  If you have any questionsabout this statement or about your rights under ERISA, or if you needassistance in obtaining documents from the plan administrator, you shouldcontact the nearest office of the Pension and Welfare Benefits Administration,U.S. Department of Labor, listed in your telephone directory or the Division ofTechnical Assistance and Inquiries, Pension and Welfare BenefitsAdministration, U.S. Department of Labor, 200 Constitution Avenue, N.W.,Washington, D.C. 20210.  You may alsoobtain certain publications about your rights and responsibilities under ERISAby calling the publications hotline of the Pension and Welfare BenefitsAdministration.

 

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**PRIVACY PRACTICES NOTICE**

 

The JeffersonPilot Financial companies* are concerned about your privacy.  In order to issue and service high qualityfinancial products and services, we collect personal information aboutyou.  **We do notsell your information to third parties**, and we disclose yourpersonal information only as necessary to provide the products and services youexpect from a financial services leader. **This summary of our practices is provided for yourinformation.  You do not need to take anyaction as a result of this notice, but you do have certain rights as describebelow.**

 

**Collecting Information.** To conduct our business, we may collect nonpublic personal informationabout you from:

•                  applications or other forms, such as name, address, Social Securitynumber, assets and income, employment status and dependent information;

•                  your transactions with us, our affiliates, or with others, such asaccount activity, payment history, and products and services purchased;

•                  consumer reporting agencies, such as credit relationships and credithistory.  These agencies may retain theirreports and share them with others who use their services;

•                  other individuals, businesses and agencies, such as motor vehiclereports, and medical and demographic information; and

•                  visitors to our websites, such as information from on-line forms, sitevisitorship data and on-line information collecting devices commonly called “cookies.”

 

*We do not collect medical or health information,nor do we request financial information from consumer reporting agencies, onour mutual fund and brokerage consumers.*

 

**How We Treat the Information.** Within Jefferson Pilot Financial we restrict access to nonpublicpersonal information about you to those employees who need to know thatinformation to provide our products or services or to otherwise conduct ourbusiness, including actuarial or research studies.  We maintain physical, electronic, and proceduralsafeguards that comply with federal and state regulations to safeguard all yournonpublic personal information.  We mayalso disclose all of the information described above to third parties withwhich we contract for services.  Wecontractually require these third parties to protect your information.  Examples of these third parties are:

•                  financial service providers, such as third party administrators,broker-dealers, insurance agents and brokers, investment companies, registeredrepresentatives, investment advisors, companies that perform marketing serviceson our behalf or on behalf of Jefferson Pilot Financial and another financialinstitution, or to other financial institutions with whom we have jointmarketing agreements; and

•                  non-financial companies and individuals, such as our consultants andvendors and the Medical Information Bureau.

 

In addition, we may disclose your nonpublic personal information tomedical care institutions or medical professionals, insurance regulatoryauthorities, law enforcement or other government authorities, or to affiliatedor nonaffiliated third parties as reasonably necessary to conduct our businessor as otherwise permitted by law.

 

Our privacy procedures apply even after you stop having any customerrelationship with Jefferson Pilot Financial.

 

We retain the right to use ideas, concepts, know-how, or techniquescontained in any nonpublic personal information you provide to us for our ownpurposes, including developing and marketing products and services.

 

**We do not disclose to our affiliates any informationwe receive about you from a consumer reporting agency.**

 

**We do not disclose your nonpublic personalinformation to third parties except as necessary to provide you our productsand services.**  You do have the right to review the personalinformation about you relating to any insurance or annuity product issued by usthat we can reasonably locate and retrieve. You also can request that we correct, amend or delete any inaccurateinformation.  If you wish to do this,please write Attn: Privacy Inquiry, to the address you normally use for yourcorrespondence with us.  If you don’thave that address, write to:  JeffersonPilot Financial, Attn: Client Services Department-Privacy, P.O. Box 21008,Greensboro, NC 27420, describe the information you wish to see and enclosepayment for our $25.00 handling fee.

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*This Notice applies for the following Jefferson Pilot Financialcompanies:

 
| Allied Professional Advisors, Inc.      |   | Jefferson Pilot  LifeAmerica Insurance Company |   | Jefferson Pilot  Variable Corporation |
|-----------------------------------------|--------|------------------------------------------------|--------|---------------------------------------|
| Hampshire Funding, Inc.                 |   | Jefferson-Pilot Life  Insurance Company        |   | Polaris Advisory  Services, Inc.      |
| Jefferson Pilot  Securities Corporation |   | Jefferson Pilot  Financial Insurance Company   |   | Westfield Assigned  Benefits Company  |

 

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