Document:

Exhibit 10.25

 

Summary of Family Dollar Stores, Inc. Executive Supplemental
Disability Income Plan

 

  The
Company has established a supplemental disability program for certain of the Company’s
officers, including each of the Company’s named executive officers.  The following Plan summary, which has been
provided to each of the Company’s named executive officers, sets forth the
terms of the Plan:

 

 

	
  [FDO Inc. logo]

  	
   

  	
  Executive Supplemental Disability Plan

  

 

 

	
   

  	
   

  	
  Coordinating
  with the group LTD plan, the supplemental policy increases your disability
  income insurance to a maximum of 75% of base salary. It includes the
  following features:

  
	
   

  	
   

  	
   

  
	
   

  	
  •

  	
  Up to
  $10,000 guaranteed standard issue benefit –

  
	
   

  	
   

  	
  (subject
  to MetLife’s risk management criteria)

  
	
   

  	
   

  	
  To
  be eligible for guaranteed issue coverage, you must be actively employed for
  a minimum of 90 days prior to the application date. You do not have to prove
  you are insurable to qualify for monthly supplemental disability benefits up
  to $10,000.

  
	
   

  	
   

  	
   

  
	
   

  	
  •

  	
  Own
  Occupation protection to age 65 – Your Regular Occupation Period continues until you
  reach age 65.  If, during the Regular
  Occupation Period, you become unable to perform the material and substantial
  duties of your regular occupation, you are
  considered disabled and are entitled to benefits.  To be considered disabled, you must not be
  gainfully employed and must be under the care of a physician.  After the Regular Occupation Period
  expires, if you become unable to perform the material and substantial duties
  of any occupation for which you are
  or have become reasonably qualified by your education, training or
  experience, you are considered disabled and are entitled to benefits.

  
	
   

  	
   

  	
   

  
	
   

  	
  •

  	
  Non-cancelable/guaranteed
  renewable to age 65, or 5 policy years if later – As long as your premiums are paid on time, MetLife
  cannot change your coverage or your premium rates until the first premium due
  date on or after your 65th birthday, or on the fifth policy
  anniversary if later.

  
	
   

  	
   

  	
   

  
	
   

  	
  •

  	
  Conditionally
  Renewable after age 65 – Your policy, without riders, is renewable after age 65 or after the
  5th policy anniversary if later, so long as you are employed at
  least 30 hours per week and are not disabled. If Total Disability starts
  before your 75th birthday, the maximum benefit will be 2 years. If
  Total Disability starts after your 75th birthday, the maximum
  benefit period will be 12 months. Premiums will be based on your attained age
  on each policy anniversary. Premium rates are subject to change.

  
	
   

  	
   

  	
   

  
	
   

  	
  •

  	
  Residual
  Disability Rider – If you lose
  20% or more of your income due to a disability and you are under the care of
  a licensed physician, this rider pays you a percentage of your monthly benefit
  proportional to your loss of income.

  
	
   

  	
   

  	
   

  
	
   

  	
  •

  	
  Presumptive
  Total Disability Rider – With this rider, if an injury or
  sickness causes you complete and irreparable loss of your sight, speech,
  hearing, or the use of 2 limbs, you will be considered totally and
  permanently disabled even if you are able to work.

  
	
   

  	
   

  	
   

  
	
   

  	
  •

  	
  Catastrophic
  Disability Benefit – This rider
  provides an additional monthly benefit if the insured’s condition meets the
  criteria for a catastrophic disability as defined in the rider. The
  catastrophic disability benefit amount applied for can be up to 100% of the
  insured’s monthly income minus any other DI coverage inforce or applied for.
  In no event can the monthly benefit, under this rider, exceed $8,000. For the
  first 12 months that a catastrophic disability benefit is paid, the
  catastrophic benefit will be paid at 120%.

  
	
   

  	
   

  	
   

  
	
   

  	
  •

  	
  Cost
  of Living Adjustment (COLA Rider) – This rider increases your monthly benefit annually
  (while you remain disabled), after you have been disabled for 12 months, by a
  compound rate of 1% to 7%, based on the Consumer Price Index (CPI).

  
	
   

  	
   

  	
   

  
	
   

  	
  •

  	
  Mental
  Disorder and/or Substance Use Disorder Benefits (MNAD) payable to Age 65
  Rider – This MNAD
  Rider extends the benefit period for disabilities caused by Mental Disorder
  and/or Substance Use Disorder to Age 65 (or the longest period available by
  age).

  
	
   

  	
   

  	
   

  
	
   

  	
  •

  	
  90 Day
  Elimination Period – Disability
  benefits will be payable after 90 days of disability.

  
	
   

  	
   

  	
   

  
	
   

  	
  •

  	
  Portable
  – You can take your policy with you if you leave Family Dollar.

  

 

 

2Exhibit 10.26

Summary of Family Dollar Stores, Inc. Executive Life
Plan

 

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

 

 

	
  [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 the
Policy is January 1, 2003.  This
certificate supercedes and replaces any previously issued certificate with an
effective date of January 1, 2003.

 

The insurance is effective only if the Associate is eligible for
insurance 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 are
eligible for insurance under the provisions of the Policy.  This Certificate replaces any other
certificates for the benefits described inside. 
As a Certificate of Insurance, it is not a contract of insurance; it
only summarizes the provisions of the Policy and is subject to the Policy’s
terms.

 

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

 

IMPORTANT CANCELLATION INFORMATION - PLEASE READ
THE 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 Center
Executive (RVP Only)

Distribution Center
Manager

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

Distribution Center
Non-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&D
INSURANCE

 

 

	
   

  	
   

  	
  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 and
AD&D Insurance will be reduced as follows:

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

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

Benefits will terminate when your employment terminates.

 

 

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

-                    Any Guarantee Issue Amount available without evidence
of insurability; and

-                    The maximum amount of insurance for which you are
eligible.

 

 

Basic Annual Earnings means your annual base salary or
annualized hourly pay from the Employer before taxes on the determination
date.  The determination date is the last
day worked just prior to the loss.

 

It also includes:

1.                           commissions averaged over the 12 months
just prior to the determination date or over the actual period of employment
with the Employer just prior to that date, if shorter.  It does not include
bonuses, overtime pay, or any other extra compensation.  It does not include
income from a source other than the Employer. 
It will not exceed the amount shown in the Employer’s financial records
or the amount for which premium has been paid, whichever is less.

 

Any reference to Employee or Full-Time Employee refers to an Associate
of 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

 

AMOUNT OF
INSURANCE

 

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

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

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

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

 

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

 

DEFINITIONS

 

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

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

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

 

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

(1)                      a Saturday, Sunday or holiday which is
not a scheduled workday;

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

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

 

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

 

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

 

EMPLOYER means the Group
Policyholder or the Participating Employer named on the Face Page.

 

FULL-TIME EMPLOYEE means
an Associate of the EMPLOYER:

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

(2)                      who is not a temporary or seasonal
employee; and

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

 

INSURANCE MONTH means:

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

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

 

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

 

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

 

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

 

 

3

 

ELIGIBILITY

 

If you are a Full-Time
Employee 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 the
later of:

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

(2)                      the day you complete the Waiting Period.

 

WAITING PERIOD.  (See Schedule of Insurance).

 

EFFECTIVE
DATES OF COVERAGES

 

Your insurance is
effective on the latest of:

(1)                      the day you enroll after becoming
eligible for the coverage;

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

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

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

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

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

 

Evidence of insurability
is required if:

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

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

(a)                       to cancel your coverage;

(b)                      to stop payroll deductions for the
coverage.

 

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

(1)                      you return within six months after the
leave begins;

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

(3)                      the reinstated amount of insurance does
not exceed the amount which terminated.

 

TERMINATION
OF COVERAGE

 

Your coverage terminates
on the earliest of:

(1)                      the day the Policy terminates;

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

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

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

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

(6)                      the day your employment with the Employer
terminates; or

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

 

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

 

 

4

 

DEATH
BENEFIT

 

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

 

BENEFICIARY

 

Your Beneficiary is the
person or persons named on your enrollment card.  The Beneficiary may be changed in accord with
the terms of the Policy.  If you have not
named a Beneficiary, or if no named Beneficiary is living when you die; then
the death benefit will be paid to your:

(1)                      surviving spouse; or, if none

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

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

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

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

 

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

 

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

 

 

5

 

EXTENSION OF DEATH BENEFIT IF YOU
BECOME TOTALLY DISABLED

 

Your life insurance will
be continued, without payment of premiums, if:

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

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

(3)                      you submit satisfactory proof within the
7th through 12th months of disability; or:

(a)                      as soon as reasonably possible after
that; but

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

 

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

 

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

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

(2)                      are not engaging in any gainful
employment or occupation.

 

AMOUNT CONTINUED.  The amount of Personal Life Insurance and any
Dependent Life Insurance continued will be subject to the reductions and
terminations in effect under the Policy on the day your Total Disability begins.  Any Accidental Death and Dismemberment
Benefit will not be continued.

 

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

 

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

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

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

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

(4)                      the effective date of your individual
conversion policy, with respect to any amount of life insurance converted in
accord with the Conversion Privilege section;

(5)                      the day you reach age 70; or

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

 

If your Total Disability
ends, and you do not return to a class eligible
for 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 coverage
will resume when premium payments are resumed, and any conversion policy is
surrendered as provided in the Policy.

 

 

6

 

ACCELERATED DEATH BENEFIT

 

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

 

To qualify, you must:

(1)                      have satisfied the Active Work
requirement under the Policy;

(2)                      have been insured under the Policy:

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

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

(3)                      have at least $2,000 of Personal Life
Insurance under the Policy on the day before the Accelerated Death Benefit is
paid.

 

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

 

“Claimant,” as used in
this section, means the Terminal Insured Person for whom the Accelerated Death
Benefit is requested.

 

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

 

APPLYING FOR THE
BENEFIT.  To withdraw the Accelerated
Death Benefit, you (or your legal representative) must send the Company:

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

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

 

The Company reserves the
right to decide whether such proof is satisfactory.

 

Before paying an
Accelerated Death Benefit, the Company must also receive the written consent of
any irrevocable beneficiary, assignee or bankruptcy court with an interest in
the benefit.  (See Limitations 3, 4, and
5.)

 

NOTE:  THIS IS NOT A LONG-TERM CARE POLICY.  RECEIVING THIS ACCELERATED DEATH BENEFIT WILL
REDUCE THE BENEFIT PAYABLE AT DEATH.  ANY
AMOUNT WITHDRAWN MAY BE TAXABLE INCOME, SO YOU SHOULD CONSULT A TAX ADVISOR
BEFORE APPLYING FOR THIS BENEFIT.

 

AMOUNT OF THE
BENEFIT.  You may elect to withdraw an
Accelerated Death Benefit in any $1,000 increment; subject to:

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

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

 

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

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

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

 

 

7

 

ADMINISTRATIVE CHARGE: 
NONE

 

WITHDRAWAL FEE: 
NONE

 

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

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

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

(3)                      the amount of the Accelerated Death
Benefit withdrawn.

 

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

 

CONDITIONS.  If the Claimant exercises the Conversion
Privilege after an Accelerated Death Benefit is paid, the amount of the
conversion policy will not exceed the amount of his or her Remaining Life
Insurance.  If the Claimant has Accidental
Death and Dismemberment benefits under the Policy, the Principal Sum will not
be affected by the payment of an Accelerated Death Benefit.

 

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

 

EFFECT ON TAXES AND
GOVERNMENT BENEFITS.  Any Accelerated
Death Benefit amount withdrawn may be taxable income to you.  Receipt of the Accelerated Death Benefit may
also affect the Claimant’s eligibility for Medicaid, Supplemental Security
Income and other government benefits. 
The Claimant should consult his or her own tax and legal advisor before
applying for an Accelerated Death Benefit. 
The Company is not responsible for any tax owed or government benefit
denied, as a result of the Accelerated Death Benefit payment.

 

LIMITATIONS.  No Accelerated Death Benefit will be paid:

(1)                      if any required premium is due and
unpaid;

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

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

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

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

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

(7)                      if the Claimant is Terminal due to a
suicide attempt, while sane or insane; or due to an intentionally
self-inflicted injury;

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

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

 

 

8

 

CONVERSION PRIVILEGE

 

If your insurance or insurance on a Dependent terminates for any reason
except:

(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 be
purchased without evidence of insurability.

 

To purchase a conversion policy, application and payment of the first
premium 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 amount
of life insurance which was terminated;

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

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

(4)                      be issued without disability or other
supplemental benefits; and

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

 

A conversion policy also may be purchased if:

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

(2)                      the person applying for the conversion
policy 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 which
terminates, less the amount of any group life insurance for which the person
becomes 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 insurance
terminated.

 

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

 

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

 

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

 

 

9

 

ACCIDENTAL DEATH AND
DISMEMBERMENT INSURANCE

 

DEATH OR DISMEMBERMENT BENEFIT
FOR AN INSURED PERSON.  The Company will pay the
benefit listed below, if:

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

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

The loss must result
directly 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 for
your class is shown in the Schedule of Insurance.

 

MAXIMUM
PER PERSON.  If you sustain more than one loss resulting
from the same accident, the benefit:

(1)                      will be the one largest amount listed;

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

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

 

TO WHOM
PAYABLE.  Benefits for your loss of life will be paid
in 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 or
self-destruction;

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

(a)                      a bacterial infection resulting from an
accidental cut or wound;

(b)                     the accidental ingestion of a poisonous food
substance;

(3)                      participation in a riot;

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

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

(6)                      participation in the commission of a
felony;

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

(8)                      voluntary inhalation of gas, including
carbon monoxide;

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

(10)                driving a vehicle while intoxicated.

 

 

10

 

DEFINITIONS.

 

“Beneficiary” means the person(s) named on your enrollment form.  You may change the Beneficiary by filing a
written 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 Common
Carrier

 

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

 

“Intoxicated” shall be defined by the jurisdiction where the accident
occurs.  The exclusion will apply whether
or not the driver is convicted.

 

“Loss of a Member” includes the following:

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

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

 

 

11

 

SAFE DRIVER BENEFIT

 

BENEFIT.  If you die as a direct
result of a covered auto accident, for which Accidental Death and Dismemberment
Benefits are payable; then:

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

(2)                      an additional Air Bag Benefit will be
payable, 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 the
Principal Sum, whichever is less.  The
Seat Belt Benefit and the Air Bag Benefit will not be less than $1,000.  The Principal Sum is the amount payable
because 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 of
an air bag must be certified by:

(1)                      the official accident report; or

(2)                      the coroner, traffic officer or other
investigating officer.

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

 

DEFINITIONS.  As used in this
provision:

 

“Auto” means a 4-wheel passenger car, station wagon, jeep, pick-up
truck or van-type car.  It must be
licensed for use on public highways.  It
includes a car owned or leased by the Employer.

 

“Intoxicated,” “Impaired,” or “Under the Influence of Drugs” shall be
defined 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 National
Highway Traffic Safety Administration.

 

LIMITATIONS.  Safe Driver
Benefits will not be paid if:

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

(2)                      at the time of the accident, you or any
other 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 a
Physician for the driver’s use).

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

 

 

12

 

CLAIMS
PROCEDURES

FOR LIFE OR ACCIDENTAL DEATH AND DISMEMBERMENT
BENEFITS

 

NOTE:  The
Policy may include an Extension of Death Benefit, an Accelerated Death Benefit
or a Living Benefit.  If so, please refer
to that section for special claim procedures.

 

NOTICE AND PROOF OF CLAIM

 

Notice of Claim.  Written
notice of an accidental death or dismemberment claim must be given within 20
days after the loss occurs;  or as soon
as reasonably possible after that.*  The
notice 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 notice
of claim is received, the Company will send claim forms for filing the required
proof.  If the Company does not send the
forms within 15 days; then you or your Beneficiary (the claimant) may send the
Company written proof of claim in a letter. 
It should state the nature, date and cause of the loss.

 

Proof of Claim.  The Company
must be given written proof of claim within 180 days after the date of the
loss; or as soon as reasonably possible after that.*  Proof of claim must be provided at the
claimant’s own expense.  It must show the
nature, date and cause of the loss.  In
addition to the information requested on the claim form, documentation must
include:

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

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

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

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

 

* Exception:  Failure to
give notice or furnish proof of claim within the required time period will not
invalidate 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 it
was required.

These time limits will not apply while the claimant
lacks legal capacity.

 

EXAM OR AUTOPSY.  At anytime
while 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 is
completed.  In case of death, the Company
may also have an autopsy done, where it is not forbidden by law.  Any such exam or autopsy will be at the
Company’s expense.

 

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

 

TO WHOM PAYABLE

 

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

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

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

 

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

 

 

13

 

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

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

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

(3)                      whether more information is needed to
support the claim.

 

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

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

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

 

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

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

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

 

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

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

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

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

 

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

 

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

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

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

 

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

 

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

(1)                      any further appeal procedures available
under the Policy;

(2)                      the right to access relevant claim
information; and

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

 

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

 

 

14

 

Delay Notice.  If the Company
needs more time to process an appeal, in a special case; then it will send the
claimant a written delay notice, by the 30th day after receiving the
request for review.  The notice will
explain:

(1)                      the special circumstances which require
the delay;

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

(3)                      when a decision can be expected.

 

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

 

Claims Subject to ERISA (Employee Retirement Income Security Act
of 1974).  Before bringing a civil legal
action under the federal labor law known as ERISA, an employee benefit plan
participant or beneficiary must exhaust available administrative remedies.  Under the Policy, the claimant must first
seek two administrative reviews of the adverse claim decision, in accord with
this section.  If an ERISA claimant brings
legal action under Section 502(a) of ERISA after the required reviews; then the
Company will waive any right to assert that he or she failed to exhaust
administrative remedies.

 

RIGHT OF RECOVERY.  If benefits
have been overpaid on any claim; then full reimbursement to the Company is
required within 60 days.  If
reimbursement is not made; then the Company has the right to:

(1)                      reduce future benefits until full
reimbursement is made; and

(2)                      recover such overpayments from you, or
from 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 legal
action to recover any benefits may be brought until 60 days after the required
written proof of claim has been given. 
No such legal action may be brought more than three years after the date
written proof of claim is required.

 

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

(1)                      manage the Policy and administer claims
under it; and

(2)                      interpret the provisions and resolve
questions arising under the Policy.

 

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

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

(2)                      determine your eligibility for insurance
and entitlement to benefits;

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

(4)                      resolve all matters when a claim review
is requested.

 

Any decision the Company makes, in the exercise of its authority, shall
be 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

 

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 following
provisions.

 

PRIOR INSURANCE CREDIT
UPON TRANSFER OF

LIFE INSURANCE CARRIERS

 

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

 

“Prior Plan” means a prior carrier’s group life insurance policy, which
the 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 if
you:

(1)                      were insured under the prior plan on its
termination 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 life
insurance under the prior plan; and

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

 

AMOUNT OF LIFE INSURANCE.  Until
you satisfy the Policy’s Active Work rule, the amount of your group life
insurance under the Policy will not exceed the amount for which you were
insured under the prior plan on its termination date.

 

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

 

	
   

  	
   

  	
  Jefferson
  Pilot Financial Insurance Company

  
	
   

  	
   

  	
   

  
	
   

  	
   

  	
  

  
	
   

  	
   

  	
  Officer of the Company

  

 

 

16

 

NOTICE CONCERNING COVERAGE
LIMITATIONS AND EXCLUSIONS

UNDER THE NORTH CAROLINA LIFE AND
HEALTH INSURANCE GUARANTY

ASSOCIATION ACT

 

Residents of this
state who purchase life insurance, annuities or health insurance should know
that the insurance companies licensed in this state to write these types of
insurance are members of the North Carolina Life and Health Insurance Guaranty
Association.  The purpose of this
Association is to assure that policyholders will be protected, within limits,
in the unlikely event that a member insurer becomes financially unable to meet
its obligations.  If this should happen,
the Guaranty Association will assess its other member insurance companies for
the money to pay the claims of insured persons who live in this state and, in
some cases, to keep coverage in force. 
The valuable extra protection provided by these insurers through the
Guaranty 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 North
Carolina Life and Health Insurance Guaranty Association may or may not provide
coverage for this policy.  If coverage is
provided, it may be subject to substantial limitations or exclusions, and
require continued residency in North Carolina. 
You should not rely on coverage by the North Carolina Life and Health
Insurance Guaranty Association in selecting an insurance company or in
selecting an insurance policy.

 

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

 

Insurance
companies or their agents are required by law to give or send you this
notice.  However, insurance companies and
their agents are prohibited by law from using the existence of the guaranty
association to induce you to purchase any kind of insurance policy.

 

The North
Carolina Life and Health Insurance Guaranty Association

Post
Office Box #10218

Raleigh,
North Carolina  27605-0218

 

North
Carolina Department of Insurance, Consumer Division

Post
Office Box #26387

Raleigh,
North Carolina  27611

 

 

The state law that
provides for this safety-net is called the North Carolina Life and Health
Insurance Guaranty Association Act.  The
following is a brief summary of this law’s coverages, exclusions and
limits.  This summary does not cover all
provisions of the law; nor does it in any way change anyone’s rights or
obligations under the Act or the rights or obligations of the Guaranty
Association.

 

 

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

 

 

17

 

EXCLUSIONS. 
However, persons holding such policies are NOT protected by this
Association if:

•                     they are eligible for protection under the laws of
another state (this may occur when the insolvent insurer was incorporated in
another state whose guaranty association protects insureds who live outside
that state);

•                     the insurer was not authorized to do
business in this State;

•                     their policy was issued by an HMO, a
fraternal benefit society, a mandatory state pooling plan, a mutual assessment
company or similar plan in which the policyholder is subject to future
assessments, or by an insurance exchange.

 

The Association
also does NOT provide coverage for:

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

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

•                     interest rate yields that exceed the
average rate specified by law;

•                     dividends;

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

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

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

 

LIMITS ON
AMOUNT OF COVERAGE.  The Act also limits the amount the
Association is obligated to pay out.  The
Association cannot pay more than what the insurance company would owe under a
policy or contract.  Also, for any one
individual, the Association will pay a maximum of $300,000 - no matter how many
policies and contracts there were with the same company, even if they provided
different types of coverages.  For any
one group holder of an unallocated annuity contract, the association will pay a
maximum of $5,000,000.

 

NOTICE OF PROHIBITIONS

 

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

 

(1)                CAUSE THE CANCELLATION OR NONRENEWAL OF
GROUP HEALTH OR LIFE INSURANCE, HOSPITAL, MEDICAL OR DENTAL SERVICE CORPORATION
PLAN, MULTIPLE EMPLOYER WELFARE ARRANGEMENT, OR HEALTH PLAN COVERAGES (AND THE
CONSEQUENTIAL LOSS OF THE COVERAGES OF THE PERSONS INSURED) BY WILLFULLY
FAILING TO PAY THOSE PREMIUMS IN ACCORDANCE
WITH THE TERMS OF THE INSURANCE OR PLAN CONTRACT; AND

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

 

 

18

 

SUMMARY
PLAN DESCRIPTION

 

The following information together with your group
insurance certificate issued to you by Jefferson Pilot Financial Insurance
Company of Omaha, Nebraska, is the Summary Plan Description required by the
Employee Retirement Income Security Act of 1974 to be distributed to
participants in the Plan.  This Summary
Plan Description is only intended to provide an outline of the Plan’s
benefits.  The Plan Document will govern
if there is any discrepancy between the information contained in this
Description and the Plan.

 

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

 

The name, address and ZIP code of the Sponsor of the
Plan 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 business
telephone 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 the
administration of the Plan and is the designated agent for the service of legal
process for the Plan.  Functions
performed by the Plan Administrator include: 
the receipt and deposit of contributions, maintenance of records of Plan
participants, authorization and payment of Plan administrative expenses,
selection of the insurance consultant, selection of the insurance carrier and
assisting Jefferson Pilot Financial Insurance Company. Jefferson Pilot
Financial Insurance Company has the sole discretionary authority to determine
eligibility and to administer claims in accord with its interpretation of
policy provisions, on the Plan Administrator’s behalf.

 

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

 

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

 

Type of Funding
Arrangement:  Jefferson Pilot Financial
Insurance Company.

 

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

 

Eligibility.  Full-time employees working at least 30 hours
per week.

 

Employees become eligible
on the day they complete their waiting period.

 

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

 

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

 

The name and section of
relevant Collective Bargaining Agreements: 
None

 

The name, title and
address of each Plan Trustee:  None

 

 

 

Loss of
Benefits.  The Plan Administrator may terminate the
policy, or subject to Jefferson Pilot Financial Insurance Company’s approval,
may modify, amend or change the provisions, terms and conditions of the
policy.  Coverage will also terminate if
the premiums are not paid when due.  No
consent of any Insured Person or any other person referred to in the policy
will be required to terminate, modify, amend or change the policy.  See your Plan Administrator to determine
what, if any, arrangements may be made to continue your coverage beyond the
date you cease active work.

 

Claims Procedures.  You may
obtain claim forms and instructions for filing claims from the Plan
Administrator or from the Home Office of Jefferson Pilot Financial Insurance
Company.  To expedite the processing of
your claim, instructions on the claim form should be followed carefully; be
sure all questions are answered fully. 
In accordance with ERISA, Jefferson Pilot Financial Insurance Company
will send you or your beneficiary a written notice of its claim decision
within:

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

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

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

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

•                                    180 days after receiving a denial notice of a claim
for any Extension of Death Benefit or Accelerated Death Benefit, if available under
the Policy.

This written request for review should state the
reasons why you feel the claim should not have been denied and should include
any additional documentation to support your claim.  You may also submit for consideration
additional questions or comments you feel are appropriate, and you may review
certain non-privileged information relating to the request for review.  Jefferson Pilot Financial Insurance Company
will make a full and fair review of the claim and provide a final written
decision to you or your beneficiary within:

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

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

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

 

Statement
of ERISA Rights

The following statement of ERISA rights is required by
federal law and regulation.  As a
participant in this 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:

 

Receive Information About Your Plan and Benefits. 
Examine, without charge, at the Plan Administrator’s office and at other
specified locations, such as work sites and union halls, all documents
governing the plan, including insurance contracts and collective bargaining
agreements, 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 Public
Disclosure Room of the Pension and Welfare Benefit Administration.

 

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

 

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

 

Prudent Actions by Plan Fiduciaries. 
In addition to creating rights for plan participants, ERISA imposes
duties upon the people who are responsible for the operation of the employee
benefit plan.  The people who operate
your plan, called “fiduciaries” of the plan, have a duty to do so prudently and
in 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 any
way to prevent you from obtaining a welfare benefit or exercising your rights
under ERISA.

 

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

 

Under ERISA, there are steps you can take to enforce
the above rights.  For instance, if you
request a copy of plan documents or the latest annual report 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 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 from 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.

 

Assistance with Your Questions. 
If you have any questions about your plan, you should contact the Plan
Administrator.  If you have any questions
about this statement or about your rights under ERISA, or if you need
assistance in obtaining documents from the plan administrator, 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, D.C. 20210.  You may also
obtain certain publications about your rights and responsibilities under ERISA
by calling the publications hotline of the Pension and Welfare Benefits
Administration.

 

 

PRIVACY PRACTICES NOTICE

 

The Jefferson
Pilot Financial companies* are concerned about your privacy.  In order to issue and service high quality
financial products and services, we collect personal information about
you.  We do not
sell your information to third parties, and we disclose your
personal information only as necessary to provide the products and services you
expect from a financial services leader. 
This summary of our practices is provided for your
information.  You do not need to take any
action as a result of this notice, but you do have certain rights as describe
below.

 

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

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

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

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

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

•                  visitors to our websites, such as information from on-line forms, site
visitorship 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, on
our mutual fund and brokerage consumers.

 

How We Treat the Information. 
Within Jefferson Pilot Financial we restrict access to nonpublic
personal information about you to those employees who need to know that
information to provide our products or services or to otherwise conduct our
business, including actuarial or research studies.  We maintain physical, electronic, and procedural
safeguards that comply with federal and state regulations to safeguard all your
nonpublic personal information.  We may
also disclose all of the information described above to third parties with
which we contract for services.  We
contractually 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, registered
representatives, investment advisors, companies that perform marketing services
on our behalf or on behalf of Jefferson Pilot Financial and another financial
institution, or to other financial institutions with whom we have joint
marketing agreements; and

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

 

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

 

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

 

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

 

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

 

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

*This Notice applies for the following Jefferson Pilot Financial
companies:

 

	
  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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