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MassMutual Disability Option-Agents September 2015 of 33

MassMutual Disability Option Summary Plan Description

for Career Contract Agents and for General Agents and General Managers

Effective January 1, 2015

This Summary Plan Description (SPD), published in September 2015, takes the place of any SPDs and Summaries of Material Modifications (SMMs) previously issued to you describing your benefits.


Table of Contents

Disclaimer ........................................................................................................................................................... 3

Introduction ......................................................................................................................................................... 4

Contact Information ............................................................................................................................................. 5

Short Term Disability (STD) Program – For Career Contract Agents ................................................................... 6

Short Term Disability (STD) Program – For General Agents and General Managers .......................................... 11

Long Term Disability (LTD) Coverage – For Career Contract Agents ................................................................ 14

Long Term Disability (LTD) Coverage – For General Agents and General Managers......................................... 17

Claiming Benefits .............................................................................................................................................. 20

Appeals Procedures ........................................................................................................................................... 23

About Your Coverage ........................................................................................................................................ 25

Plan Information ................................................................................................................................................ 28

ERISA Rights .................................................................................................................................................... 30

Dictionary Terms ............................................................................................................................................... 32

Appendix A: Liberty Life Assurance Company of Boston Certificate ................................................................. 33


Disclaimer

This Summary Plan Description (SPD) provides details of the disability options available to you through the MassMutual Agents’ Welfare Benefits Plan. This SPD contains detailed and important information about the Plan; every attempt has been made to communicate this information clearly and in easily understandable terms. This SPD replaces and supersedes all previous SPD versions and Summaries of Material Modifications (SMMs).

Benefits are determined under the terms of the Plan in effect at the time you become eligible for the specific benefits. Benefits are based on current laws and regulations, which are subject to change. Massachusetts Mutual Life Insurance Company (“the Company” or “MassMutual”) reserves the right to modify, revoke, change, suspend or terminate any one or all plans, programs, policies, benefits or services described in this SPD or the underlying Plan documents at any time and from time to time, with or without notice. This SPD does not guarantee any particular benefit. Receipt of this SPD describing the Plan or option for which you are not eligible does not imply that you are eligible. To be eligible to receive benefits from the Plan, you must meet all eligibility requirements of the Plan.

In the event of a discrepancy between descriptions in this SPD and information in relevant Plan documents, the Plan documents will govern.

Career contract and general agents are independent contractors; provision of benefits does not change that relationship.


Introduction

MassMutual provides a disability program to give you continued income if you become sick or Disabled and cannot be in Active Service. Short-Term Disability (STD) benefits precede any Long-Term Disability (LTD) benefits. Both programs are described in this document to illustrate how the programs work together.

Career Contract Agents: STD coverage, which is provided at no cost to you if you meet minimum production requirements, replaces 50% of your Basic Weekly Earnings, up to $2,308 per week, before LTD coverage begins. For LTD coverage, the Plan provides you flexibility to choose the coverage that is right for you. You have two LTD options to choose from: • Base LTD (also known as LTD 50): Replaces up to 50% of your Basic Monthly Earnings at no cost to you

if you meet minimum production requirements (refer to the Production Requirements section and the definition of “Basic Monthly Earnings” in the Appendix for more information).

• Buy Up LTD (also known as LTD 70): Replaces up to 70% of your Basic Monthly Earnings; you pay for the cost of this coverage (refer to the Cost of Coverage section for more information).

General Agents and General Managers: STD coverages, which are provided at no cost to you, provide a Weekly Benefit (up to $2,308 per week maximum) before LTD benefits begin. For LTD coverage, the Plan provides you flexibility to choose the coverage that is right for you. You have two LTD options to choose from: • Base LTD: Provides a flat Monthly Benefit of $10,000, at no cost to you. • Buy Up LTD: Provides an additional flat Monthly Benefit ranging from $2,000 to $10,000. Eligibility is

based on your agency production (refer to the Eligibility section for more information). You pay for the cost of this additional coverage.

The coverage options described here are effective as of January 1, 2015. If your disabling condition occurred before January 1, 2015, your coverage is determined under the provisions in effect when the Disability occurred and you should refer to the SPD that was in place at that time.

Liberty Life Assurance Company of Boston (Liberty Mutual), a member of the Liberty Mutual Group, currently administers and issues the policy for, and fully insures, the STD and LTD benefits. A copy of Liberty Mutual’s Certificate of Coverage is included with this document. Refer to Appendix A: Liberty Life Assurance Company of Boston Certificate for details of the LTD option.

You must satisfy the requirements described in this SPD and the Plan to receive STD and LTD coverage.


Contact Information

Resource Website Telephone Liberty Mutual Disability Claims P.O. Box 7211 London, KY 40742-7211

www.MyLibertyConnection.com Company ID: Agents

800-713-7384 (claim submission) 888-440-6118 (claim service)

MassMutual Benefits Human Resources Leave Services Unit

Website: https://mmfgonline.massmutual.com Email: [email protected]

866-662-6448, select prompt for Leave Services

Producer Services & Operations Performance Excellence-Disability Unit

Website: https://benedirect.massmutual.com/irj/portal Email: [email protected]

800-767-1000, Ext. 48850 on business days, 8 a.m. to 6 p.m., ET., select prompt for Group Disability Unit

http://www.mylibertyconnection.com/

https://mmfgonline.massmutual.com/

mailto:[email protected]

https://benedirect.massmutual.com/irj/portal



Short Term Disability (STD) Program – For Career Contract Agents

Eligibility

You are eligible for STD coverage if you are a career contract agent: • With a valid career agent contract; and • Acting in the capacity of sales manager with a career contract and valid sales manager contract.

Note: The disability coverage option for general agents and general managers is described in a separate section of this SPD.

Ineligible Participants

You are not eligible for this coverage if you are: • A broker; • A retired agent; • An agency staff member; • An employee of MassMutual or one of its subsidiaries; • An eligible agent who did not elect disability coverage; or • Otherwise excluded by Plan terms.

Production Requirements

As a career contract agent, to be eligible for subsidized benefits, each year you must satisfy certain requirements: Agent Type Production Requirements Non-financed career contract agent Annual contract minimum requirements Financed career contract agent Cumulative financing plan validation requirements Sales manager/unit sales manager Annual sales manager compensation plan requirements

Production requirements, and information specific to agents receiving disability payments under the STD or LTD options, are updated from time to time and are published in Company memoranda, which can be found on FieldNet.

Disability Earnings

Your weekly STD benefit is based on your disability earnings, up to the applicable STD maximum. Disability earnings are updated annually, no later than April 1. Prior disability earnings will continue to apply until this annual update.


Disability earnings are defined as follows: • If you have at least one full calendar year under a career contract or sales manager agreement with

MassMutual: o If you are a non-financed career contract agent, your disability earnings are equal to your prior full

calendar year’s Aggregated Agent Allowance Weighted Commission Credits (AAA WCCs, as described in Company Memo 2015-006, or its successor) paid by MassMutual.

o If you are a sales manager, your disability earnings are equal to your prior full calendar year’s AAA WCCs, sales manager production compensation and deferred production compensation paid by MassMutual.

o If you are a financed career contract agent, your disability earnings are equal to your prior full calendar year’s AAA WCCs paid by MassMutual.

• If you have less than one full calendar year under a career contract or sales manager agreement with MassMutual: o If you are a non-financed career contract agent or a sales manager, refer to the following table. o If you are a financed career contract agent, your disability earnings through December 31 of your first

year under contract are equal to your current year career contract commission requirement. For the first full calendar year under a career contract, your disability earnings remain equal to your current year career contract commission requirement if greater than your actual AAA WCCs.

If you do not have prior career agent/sales manager experience

If you do have prior career agent/sales manager experience

Disability earnings through December 31 of first year under a career contract

Equal to current year career contract commission requirement

Equal to the greater of: • Your prior non-MassMutual calendar

year’s first year and renewal commissions for life, annuity and disability sales or financial services management income, as determined by MassMutual*; or • The current year career contract

commission requirement. * You must submit documentation, acceptable to MassMutual, from the prior year reflecting your non-MassMutual career agent or financial services management experience.

Disability earnings first full calendar year under a career contract

Equal to the current career contract commission requirement, if greater than your actual AAA WCCs as of the previous December 31

Equal to the greater of: • Your prior year’s non-MassMutual first

year and renewal commissions for life, annuity and disability sales or financial services management income as defined by MassMutual, if greater than your actual AAA WCCs as of the previous December 31; or • The current year career contract

commission requirement, if greater than your actual AAA WCCs as of the previous December 31.


Enrollment

If you are a subsidized agent, you are automatically eligible for this coverage subject to Plan terms; no enrollment is necessary. Your coverage is effective as of your career contract endorsement date and there is no cost to you for this coverage.

If you are an unsubsidized agent, you pay the full cost of coverage on an After-Tax basis.

If you are a corporate agent, you pay the full cost of coverage on an After-Tax basis.

The cost of coverage is reviewed annually and is subject to change. If you are responsible for paying the full cost of coverage, the full cost of coverage amount is deducted from your commission voucher. The value of the Company subsidy, if any, is paid through the same voucher and appears as an adjustment.

Summary of Benefits

The STD Program continues a portion of your income when you cannot work because of Disability. You are considered Disabled if you are unable to perform all of the material and substantial duties of your occupation on an Active Service basis due to Injury or Sickness.

Note: Loss of a license for any reason is not considered a total or Partial Disability whatsoever.

STD benefits provide 50% of your basic weekly earnings (not to exceed a maximum of $2,308) for up to 26 weeks. You can apply for short-term disability coverage after your 30th consecutive day of disability (fully disabled and not working in any capacity) or 8th day in the case of childbirth.

Note: You may participate in Annual Benefits Enrollment while out on STD. However, any increase to your Life Insurance or LTD election will not become effective until you return to active status. As long as you remain disabled, benefits you receive while out on disability are based on the elections you had in place on your last day immediately prior to your disability date.

See Appendix A: Liberty Life Assurance Company of Boston Certificate for specific information about this benefit.


Applying for STD Benefits

You must apply for STD by contacting Liberty Mutual. The following table summarizes the action steps required for STD to begin and to continue. How to Apply for STD* Who Action When You Keep your general agent informed. At the beginning of your STD and

periodically, if a continued absence You See your Physician or medical-care

provider. Provide your Physician’s office with a copy of the Liberty Mutual authorization form.

At the beginning of your STD

You Contact Liberty Mutual at 800-713-7384 or online at www.MyLibertyConnection.com (Claimant ID: Agents). Be prepared to provide the following information and to respond to any additional questions: • Social Security number, address and

phone number; • Physician’s name, phone number and fax

number; • Last day worked/first day absence due to

your Injury/Sickness; • Plan Sponsor’s name (MassMutual); and • General agent’s name and phone number.


Liberty Mutual Gives you the claim number and the telephone number of your Liberty Claim Case Manager.

At the time of your initial phone call

You Inform your general agent that your claim has been filed.


Liberty Mutual Contacts you (and may contact your Physician) periodically for an update on your condition and the possibility of your return to service.

Throughout your STD period

You Notify your general agent and Liberty Mutual of return-to-service date.

As soon as your return-to-service date is known

* Failure to follow these steps could delay STD payments.

It is your obligation to submit information needed about your disabling condition—including information required to be provided by your Physician—as a requirement for benefits and to provide all necessary information requested to Liberty Mutual in support of your claim. STD may be denied if you fail to support your claim.



Applying for STD Benefits due to Maternity How to Apply for Short-Term Disability Maternity* What to do When Contact your general agent and inform him/her of your upcoming absence.

As soon as you feel comfortable sharing the information but allowing your general agent time to plan for your absence

Provide your Physician’s office with a copy of the Liberty Mutual authorization form.

As soon as possible after pregnancy has been confirmed

Inform Liberty Mutual of the expected due date by using the toll-free number shown on the authorization form (800-713-7384).

Two weeks before expected due date

Contact your Liberty Mutual case manager at 888-440-6118 if your Physician determines you are Disabled or orders a reduced work schedule before your delivery date.

As soon as you are Disabled or put on reduced work schedule, as ordered by your Physician

Notify Liberty Mutual of delivery. Within three days after delivery

*Failure to follow these steps could delay STD payments.


Short Term Disability (STD) Program – For General Agents and General Managers

Eligibility

You are eligible for STD coverage if you are a: • General agent with a valid general agent contract (including a formula general agent); or • General manager with a valid employment agreement.

Note: The disability coverage options for career contract agents are described in a separate section of this SPD.


You are not eligible for this coverage if you are: • A career contract agent; • A broker; • A retired agent; • An agency staff member; • An employee of MassMutual or one of its subsidiaries; or • Otherwise excluded by Plan terms.

Enrollment

You are automatically eligible for this coverage subject to Plan terms; no enrollment is necessary. Your coverage is effective as of your general agent or general manager contract endorsement date and there is no cost to you for this coverage.

Summary of Benefits

The STD Program continues a portion of your income when you cannot work because of Disability. You are considered Disabled if you are unable to perform all of the material and substantial duties of your occupation on an Active Service basis due to Injury or Sickness.

Note: Loss of a license for any reason is not considered a total or Partial Disability, whatsoever.



Applying for STD Benefits

You must apply for STD by contacting Liberty Mutual. The following table summarizes the action steps required for STD to begin and to continue. How to Apply for STD* Who Action When You Keep your agency vice president informed. At the beginning of your STD and

periodically, if a continued absence You See your Physician or medical-care

provider. Provide your Physician’s office with a copy of the Liberty Mutual authorization form.


You Contact Liberty Mutual at 800-713-7384 or online at www.MyLibertyConnection.com (Claimant ID: Agents). Be prepared to provide the following information and to respond to any additional questions: • Social Security number, address and

phone number; • Physician’s name, phone number and fax

number; • Last day worked/first day absence due to

your Injury/Sickness; • Plan Sponsor’s name (MassMutual); and • Agency vice president’s name and phone

number.


Liberty Mutual Gives you the claim number and the telephone number of your Liberty Claim Case Manager.

At the time of your initial phone call

You Inform your agency vice president that your claim has been filed.


Liberty Mutual Contacts you (and may contact your Physician) periodically for an update on your condition and the possibility of your return to service.

Throughout your STD period

You Notify your agency vice president and Liberty Mutual of return-to-service date.

As soon as your return-to-service date is known

* Failure to follow these steps could delay STD payments.

It is your obligation to submit information needed about your disabling condition—including information required to be provided by your Physician —as a requirement for benefits and to provide all necessary information requested to Liberty Mutual in support of your claim. STD may be denied if you fail to support your claim.



Applying for STD Benefits due to Maternity How to Apply for Short-Term Disability Maternity* What to do When Contact your agency vice president and inform him/her of your upcoming absence.

As soon as you feel comfortable sharing the information but allowing your agency vice president time to plan for your absence

Provide your Physician’s office with a copy of the Liberty Mutual authorization form.

As soon as possible after pregnancy has been confirmed

Inform Liberty Mutual of the expected due date by using the toll-free number shown on the authorization form (800-713-7384).

Two weeks before expected due date

Contact your Liberty Mutual case manager at 888-408-7300 if your Physician determines you are Disabled or orders a reduced work schedule before delivery date.

As soon as you are Disabled or put on reduced work schedule, as ordered by your Physician

Notify Liberty Mutual of delivery. Within three days after delivery

*Failure to follow these steps could delay STD payments.


Long Term Disability (LTD) Coverage – For Career Contract Agents

Eligibility

You are eligible for LTD coverage options if you are a: • Career contract agent with a valid career agent contract; or • Sales manager with a career contract and valid sales manager agreement.

Note: The disability coverage option for general agents and general managers is described in a separate section of this SPD.


You are not eligible for these coverage options if you are: • A broker; • A retired agent; • An agency staff member; • An employee of MassMutual or one of its subsidiaries; • An eligible agent who did not elect disability coverage; or • Otherwise excluded by Plan terms.

Production Requirements

As a career contract agent, to be eligible for subsidized benefits, each year you must satisfy certain requirements: Agent Type Production Requirements Non-financed career contract agent Annual contract minimum requirements Financed career contract agent Cumulative financing plan validation requirements Sales manager/unit sales manager Annual sales manager compensation plan requirements

Production requirements, and information specific to agents receiving disability payments under the LTD options, are updated from time to time and are published in Company memoranda, which can be found on FieldNet.

Summary of Benefits

Liberty Mutual manages LTD coverage on an insured basis. If approved, benefit payments will be issued monthly by Liberty Mutual. LTD works in conjunction with the STD Program to provide you with the flexibility to choose a level of income if you become Disabled.

The Plan provides you flexibility in choosing the amount of LTD coverage you need at the time of enrollment; you may choose the Base LTD or Buy Up LTD option. For career agents and sales managers, LTD 50 is referenced as Class 1 or Core Plan and LTD 70 is referenced as Class 2 or Buy-up Plan in Appendix A: Liberty Life Assurance Company of Boston Certificate.



Mid-Year Qualifying Event

Any change to your LTD option due to a Mid-Year Qualifying Event must be consistent with and due to the Mid-Year Qualifying Event. If you have a Mid-Year Qualifying Event, you can change your existing level of LTD coverage – for instance, you may be able to enroll in Buy Up LTD coverage for the first time. You must make any changes and provide documentation within 30 days of your Mid-Year Qualifying Event (90 days in the case of birth, adoption or placement for adoption; 60 days if you work or reside in Puerto Rico). If Liberty Mutual does not permit a 90-day period (or 60-day period, as applicable), then documentation must be submitted within 30 days.

Changes you make due to a Mid-Year Qualifying Event become effective as of the date you make the change. Before July 1, 2015, changes due to a Mid-Year Qualifying Event became effective as of the date of your Mid-Year Qualifying Event.

To make changes to your coverage, you must notify Producer Services & Operations and provide documentation within 30 days of the event (90 days in the case of birth, adoption or placement for adoption; 60 days if you work or reside in Puerto Rico). If Liberty Mutual does not permit a 90-day period (or 60-day period, as applicable), then documentation must be submitted within 30 days.

See the Family Status Change section in Appendix A: Liberty Life Assurance Company of Boston Certificate for more information.

Cost of Coverage

In general, Base LTD option coverage is Company paid and you are automatically eligible for this coverage, subject to Plan terms and LTD coverage approval by Liberty Mutual.

If you elect Buy Up LTD option coverage, you and the Company pay premiums for coverage.

Unsubsidized agents pay the full cost of coverage on an After-Tax basis, for Base and Buy-Up coverage.

Your contributions, which are withheld from your commission vouchers, are based on the level of coverage you choose, your agent status (subsidized or unsubsidized) and your Basic Monthly Earnings (see the definition of “Basic Monthly Earnings” in the Appendix). Additionally, rates for Buy Up LTD coverage may also vary based on your age. Coverage Level Subsidized Agent Unsubsidized Agent LTD 50/Base LTD No cost to you (Company-paid) You pay full cost of coverage on an After-Tax basis LTD 70/Buy Up LTD You contribute toward the cost of coverage on a

Before-Tax or After-Tax basis. Before-Tax is the default election if you do not choose to have your contributions deducted on an After-Tax basis.

You pay full cost of coverage on an After-Tax basis

The cost of LTD coverage is subject to change annually.

Corporate Agents

Corporate agents’ contributions for LTD coverage are made on an After-Tax basis. The full coverage amount is deducted from your corporate commission voucher. The value of the Company subsidy, if any, is paid through the same voucher and appears as an adjustment.


Before-Tax Versus After-Tax Contributions

Since the Plan is administered at a group level for subsidized and unsubsidized agents, Before-Tax as well as After-Tax contributions are made to the Plan. Therefore, if you become Disabled and receive a benefit from the Plan, all or a portion of this benefit is subject to taxation.

If you elect the Buy Up LTD option and are a subsidized agent, you can choose whether your contributions for coverage are deducted from your commission voucher on a Before-Tax or After-Tax basis. When Buy Up LTD benefits are received, the 20% buy-up amount (difference between Base LTD and Buy Up LTD) may be tax-free to you if your contributions were paid on an After-Tax basis. If premiums were paid on a Before-Tax basis, your benefits will be taxable (Note: New Jersey and Puerto Rico do not allow After-Tax contributions, so contributions must be made on a Before-Tax basis).

Note: If, during Annual Benefits Enrollment, you switch between Before-Tax and After-Tax for your premiums, the portion of your benefit that is taxable will be based on the percent of premiums paid on a Before-Tax basis over the three years before your Disability.


Long Term Disability (LTD) Coverage – For General Agents and General Managers

Eligibility

You are eligible for LTD coverage options if you are a: • General agent with a valid general agent contract (including a formula general agent); or • General manager with a valid employment agreement.

Note: The disability coverage options for career contract agents are described in a separate section of this SPD.


You are not eligible for these coverage options if you are: • A career contract agent; • A broker; • A retired agent; • An agency staff member; • All other employees (non-general managers) of MassMutual or one of its subsidiaries; or • Otherwise excluded by Plan terms.

Summary of Benefits

Liberty Mutual manages LTD coverage on an insured basis. If approved, benefit payments will be issued monthly by Liberty Mutual. LTD works in conjunction with the STD Program to provide you with the flexibility to choose a level of income if you become Disabled.

The Plan provides you flexibility in choosing the amount of LTD coverage you need at the time of enrollment; you may choose the Base LTD or Buy Up LTD option. For general agents and general managers, Base LTD is referenced as Class 1 or Core Plan in Appendix A: Liberty Life Assurance Company of Boston Certificate; Buy Up LTD is referenced as Class 2 or Buy-up Plan.

Note: You may participate in Annual Benefits Enrollment while out on STD. However, any increase to your Life Insurance or LTD election will not become effective until you return to active status. As long as you remain disabled, benefits you receive while out on disability are based on the elections you had in place on your last day immediately prior to your disability date.



Benefits Pay/Agency Production Requirements

Your benefits pay determines the amount of Buy Up LTD coverage for which you are eligible (refer to the following table).

Benefits pay is defined as the rolling three-year average of your agency’s First Year Commissions (FYC) for certain Life, Annuity and Disability (LAD) production. This figure is determined annually and is updated no later than April 1. Producer Services & Operations will notify you when your benefits pay is updated. Benefits Pay Monthly Base LTD

(Company-paid) Monthly Buy Up LTD (You contribute towards the cost of this coverage)

Total Monthly LTD Coverage* (Base LTD + Buy Up LTD)

Under $1,000,000 $10,000 $2,000 $12,000 $1,000,000 - $1,999,999 $10,000 $4,000 $14,000 $2,000,000 - $2,999,999 $10,000 $6,000 $16,000 $3,000,000 - $3,999,999 $10,000 $8,000 $18,000 $4,000,000 and over $10,000 $10,000 $20,000

*Less other income offset

No matter what your agency’s production is, you are eligible for Company-paid Base LTD coverage of $10,000 monthly and Company-paid STD coverage for $2,308 weekly, less benefits from other income.

Mid-Year Qualifying Event

Any change to your LTD option due to a Mid-Year Qualifying Event must be consistent with and due to the Mid-Year Qualifying Event. If you have a Mid-Year Qualifying Event, you can change your existing level of LTD coverage – for instance, you may be able to enroll in Buy-Up LTD coverage for the first time. You must make any changes and provide documentation within 30 days of your Mid-Year Qualifying Event (90 days in the case of birth, adoption or placement for adoption; 60 days if you work or reside in Puerto Rico). If Liberty Mutual does not permit a 90-day period (or 60-day period, as applicable), then documentation must be submitted within 30 days.

Changes you make due to a Mid-Year Qualifying Event become effective as of the date you make the change. Before July 1, 2015, changes due to a Mid-Year Qualifying Event became effective as of the date of your Mid-Year Qualifying Event.

To make changes to your coverage, you must notify Producer Services & Operations and provide documentation within 30 days of the event (90 days in the case of birth, adoption or placement for adoption; 60 days if you work or reside in Puerto Rico). If Liberty Mutual does not permit a 90-day period (or 60-day period, as applicable), then documentation must be submitted within 30 days.

See the Family Status Change section in Appendix A: Liberty Life Assurance Company of Boston Certificate for more information.


Cost of Coverage

Base LTD option coverage is Company paid and you are automatically eligible for this coverage subject to Plan terms and LTD coverage approval by Liberty Mutual.

If you elect Buy-Up LTD option coverage, you and the Company pay premiums for coverage. You pay for coverage on an After-Tax basis.

Your contributions, which are withheld from your general agent voucher or general manager voucher/payroll, are based on the level of coverage you choose and your benefits pay (see the Benefits Pay/Agency Production Requirements section). Additionally, rates for Buy-Up LTD coverage may also vary based on your age.

The cost of LTD coverage is subject to change annually.

After-Tax Contributions

The full value of MassMutual subsidy for STD and Base LTD coverage is included in your taxable income. Since the full value of this subsidy coverage is included in your taxable income and you pay for Buy Up LTD coverage on an After-Tax basis, if you become Disabled and receive a benefit from the Plan, the Buy-Up portion of your benefit is not subject to taxation.


Claiming Benefits

Applying for LTD Benefits

The following table summarizes the action steps in the LTD process: Who Action When Liberty Mutual Starts the LTD process Approximately midway through the STD

period You Provide any information Liberty Mutual may

need to determine LTD status As requested by Liberty Mutual and before the end of your STD payment period

Liberty Mutual Will inform you and MassMutual of the claim determination

Before the end of your STD payment period (if medical documentation is not received, a decision could be delayed until on or after STD transitions to LTD)

You may also file your LTD claim directly with Liberty Mutual. Contact Liberty Mutual to report the claim by calling 800-713-7384. Be prepared to provide the following information and to respond to any additional questions: • Social Security number, address and phone number; • Physician’s name and phone number; • Last day worked/first day absent due to your Injury/Sickness; • Plan Sponsor’s name (MassMutual); and • General agent’s or manager’s name and phone number.

It is your obligation to submit to periodic review of your disabling condition—including examination by a Liberty Mutual consulting Physician—as a requirement for benefits and to provide all necessary information requested to Liberty Mutual in support of your claim. LTD benefits may be denied if you fail to support your claim.

If your LTD claim is denied, you may file for a review. See the ERISA Rights section in this book for information on reviewing and appealing denied claims.

Your Disability Authorization Form

A Liberty Mutual disability authorization form is available on the Benefit Forms page of myBenefits. Sign and date a copy of this form and leave it with your Physician or healthcare provider. This allows your healthcare provider to submit documentation to Liberty Mutual regarding your STD and/or LTD claim. Failure to do so may result in your claim being delayed or denied.

Filing a Claim

You must contact Liberty Mutual to report a claim within 30 calendar days of the date your Injury/Sickness occurred or as soon as reasonably possible. As the Plan’s claims fiduciary for LTD Benefits, Liberty Mutual has the right to review and adjudicate LTD and STD claims.


You will be asked to provide your: • Name, Social Security number, address and phone number; • Physician or healthcare provider’s name and phone number; • Last day of Active Service/first day absent due to your Injury/Sickness; and • Plan Sponsor’s name (MassMutual).

You will be asked additional questions about yourself, your Physician or healthcare provider and your medical condition. Liberty Mutual will provide you with your claim number and the telephone number for your Liberty Mutual Claim Team.

Additionally, at the mid-point of the STD Elimination Period, Liberty Mutual will initiate the LTD process, when applicable. Supply proof of your claim, as requested, to Liberty Mutual. LTD benefits may be denied if you fail to support your claim. Liberty Mutual will inform you of the claim determination.

Proof of Your Claim

Proof of your claim is medical documentation typically provided by your Physician or healthcare provider stating the: • Date the Disability or Partial Disability started; • Cause of Disability or Partial Disability; and • Degree of Disability or Partial Disability.

The proof must be given upon Liberty Mutual’s request, on behalf of the Plan Sponsor and at your expense. In determining if you are disabled, Liberty Mutual, on behalf of the Plan Sponsor, will not consider employment factors, including, but not limited to, interpersonal conflict in the workplace, recession, job obsolescence, pay cuts, job sharing and loss of a professional or occupational license or certification.

Proof must be provided to Liberty Mutual within 30 calendar days after the end of the Elimination Period.

Periodically throughout your STD and/or LTD period, Liberty Mutual may call you and your Physician for an update on your condition and the possibility of your return to service. When proof of regular care of a Physician and continued Disability or Partial Disability is requested, provide this information to Liberty Mutual within 30 days of their request.

Notify Liberty Mutual once your return to service date is known.

Failure to follow these steps could delay STD/LTD payments.

Submitting a Disability Claim: Liberty Mutual’s Right of Examination

Liberty Mutual, at its own expense, has the right to have you examined as often as reasonably required by a Physician or vocational expert of its choice.


Claim Decision Timeframes

If your claim is denied, Liberty Mutual will notify you of the adverse decision within a reasonable period, but not later than 45 days after receiving the claim. This 45-day period may be extended for up to 30 days, if Liberty Mutual: • Determines the extension is necessary because of matters beyond the Plan’s control; and • Notifies you, before the end of the 45-day period, why the extension is needed and the expected decision date.

If, before the end of the first 30-day extension, Liberty Mutual determines, due to matters beyond the Plan’s control, that a decision cannot be rendered within that extension period, the determination period may be extended for up to an additional 30 days, provided Liberty Mutual notifies you, before the end of the first 30-day extension period, why the extension is needed and of the expected decision date.

The notice of extension will explain the: • Standards on which benefit entitlement is based; • Unresolved issues that prevent a claim decision; and • Additional information needed.

You have 45 days to provide the information.

The claim determination period begins when a claim is filed, without regard to whether all the information necessary to make a claim determination accompanies the filing.

If an extension is necessary because you failed to submit necessary information, the days from the date Liberty sends you the extension notice until you respond to the request for additional information are not counted as part of the claim determination period.

If Your Claim Is Denied or Reduced

If your claim for benefits is denied or reduced, you will be notified in writing of the reason for the denial. The notice will include: • The specific reason or reasons for denial with reference to those specific Plan provisions on which the denial

is based; • A description of any additional material or information necessary to perfect the claim and an explanation of

why that material or information is necessary; • A description of the Plan’s appeals procedures and time frames, including a statement of the claimant’s right

to bring a civil action under ERISA following an adverse decision on appeal; • If applicable, any internal rule, guideline, protocol or other similar criterion relied upon in making the adverse

decision, or a statement that such a rule, guideline, protocol or other similar criterion was relied upon and a copy thereof, will be provided free of charge upon request; and

• If applicable, an explanation of any medically related exclusion or limitation involved in the decision.


Appeals Procedures

Appealing a Denied Claim

If the decision to deny or reduce the amount of the claim is not explained to your satisfaction or you have additional information that you believe may change the decision, you should follow these steps to try to bring the claim denial to resolution: • Contact your Liberty Mutual case manager at 888-440-6118 and request a review of the claim. • File a claim appeal by sending a written request to:

The Liberty Life Assurance Company of Boston Disability Claims P.O. Box 7211 London, KY 40742-7211

You also have the right to request, free of charge, access to copies of all documents, records and other information relevant to your claim for benefits.

The request for the appeal should include: • A copy of the denial; • Any additional documentation that supports the approval of the claim; and • The specific reasons why you think the claim should be reconsidered and approved.

The written request for review must be sent within 180 days of receipt of the denial and state the reasons why you feel your claim should not have been denied. Appeals must be in writing and signed and dated.

The review will give no deference to the original claim decision, and will not be made by the person(s) who made the initial claim decision. Any medical or vocational experts consulted by the Plan will be identified.

Liberty Mutual has 45 days to provide a decision to uphold or overturn the denial. Liberty Mutual may extend this by an additional 45 days (total 90 days) if there are extenuating circumstances.

Exception: Send appeals related to Plan eligibility matters (including loss or denial of coverage) within 180 days of loss or denial of coverage to the Claims Review Committee. You will receive written notification from the Claims Review Committee regarding the outcome of your appeal within 30 days from the date your appeal was received. If your appeal to the Claims Review Committee is denied, you may initiate a second-level appeal with the Plan Administrative Committee. Decisions made by the Plan Administrative Committee are final. The Claims Review and Plan Administrative Committees may be contacted at:

MassMutual Benefits 1295 State Street, F105 Springfield, MA 01111-0001

Appeal requests may also be submitted to [email protected] or via Fax to 413-226-4382.



Legal Action

This Plan is governed by ERISA. For ERISA programs, you have the right to bring a civil action under ERISA Section 502(a) if you are not satisfied with the outcome of the appeals procedure. In most instances, you may not initiate a legal action against the Plan until you have completed the appeal processes. No legal action may begin more than one year after the date you have exhausted the Plan’s claim and appeal process.

You have 180 days from the date the claim was denied to file an appeal. No action may be commenced more than one year after the time requirement has expired.

Right of Recovery

If for some reason a benefit is paid that is larger than the amount allowed by the Plan, the Plan has a right to recover the excess amount from the person or entity that received it. Liberty Mutual, as this Plan’s representative, must produce any instruments or papers necessary to ensure the right of recovery, unless prohibited by law, and present them to the person receiving benefits.

Subrogation

The Plan reserves the right of subrogation due to a loss. The Plan also reserves all rights to relief under ERISA, including those based in equity. If you incur health care expenses that a third party may be responsible for or contributed to, the Plan will automatically have a lien upon any amount recovered by you from any party. Some examples of situations when this might occur include, but are not limited to, a settlement from an automobile policy related to an automobile accident or a judgment in a lawsuit related to any loss.

If your Injury appears to be someone else’s fault, benefits otherwise payable under this Plan due to that Injury will not be paid unless you or your representative agrees to: • Repay the Company and/or Liberty Mutual for those benefits to the extent that they are for losses for which

compensation is paid to you or on behalf of the person at fault; • Allow the Company and/or Liberty Mutual a lien on the compensation and to hold the compensation in trust

for the Company and/or Liberty Mutual; and • Execute and give to the Company and Liberty Mutual any instruments needed to secure the rights under the

above items.

You or your representative must execute any documents that may be required to allow the Plan to secure its rights (i.e., to recover any amounts to reimburse the Plan for benefits paid). When the third party’s liability is determined, the Plan will be reimbursed either the amount actually paid by the Plan or an amount received from the third party, whichever is less. The amount of payments made includes the reasonable cash value of any benefits provided in the form of service.

Even if the monetary award you receive is less than the benefit paid by the Plan, the Plan maintains its right to be reimbursed for all medical expenses and attorney’s fees incurred by the Plan in pursuit of reimbursement. The Plan’s right of recovery extends to any amount paid with respect to, associated with or stemming from the Injury or Illness incurred whether paid directly to you or whether held in trust or constructive trust for the benefit of you. Amounts are recoverable regardless of whether they have been commingled with other assets and may be recovered by the Plan without the need to trace the source of the funds. If you or another third party distributes the funds without regard to the Plan’s rights of subrogation or reimbursement, such individual or individuals will be personally liable to the Plan for the amounts distributed.


About Your Coverage

If You Do Not Meet Production Requirements – For Career Contract Agents

If you are an eligible, non-financed career contract agent and do not meet the annual contract minimum requirements, your participation in the Plan can continue until March 31 of the following year, provided your career contract remains active.

If you continue to hold a career agent contract, you will be eligible to purchase benefits at unsubsidized rates with After-Tax contributions. Unsubsidized agents can drop or decrease their coverage at any time between April 1 and the end of the year by notifying Producer Services & Operations in writing. These requested changes will be effective the first of the month after Producer Services & Operations receives the written request.

An agent may re-qualify for subsidized benefits on a Before-Tax basis if they meet certain production requirements during this calendar year. Once the requirement is met, subsidized benefits will begin the first of the month following qualification.

If You Leave the Company

Your STD and LTD coverage ends the day your career contract, general agent contract or general manager agreement terminates.

If You Retire

If you retire from the Company, your STD and LTD coverage ends the day your career contract, general agent contract or general manager agreement terminates.

If You Die

If you die while covered under STD and LTD, your disability coverage ends the date of your death. Your surviving dependents may be eligible for continuation of coverage for options under the MassMutual Agents’ Welfare Benefits Plan (for example, medical, dental, vision). Refer to other SPDs (such as medical, dental, vision) for more information.

Additionally, if you die while receiving LTD benefits, your Eligible Survivors may receive a lump sum amount equal to three times your last monthly benefit. An eligible survivor is your spouse, if living, otherwise your children under age 25. Payment will be made in equal shares if survivors are your children. Eligible survivors must contact Liberty Mutual at 888-440-6118 and submit a copy of your death certificate to be paid the lump sum amount.

If the Company Ends Coverage

Although MassMutual does not now intend to terminate the benefits described in this booklet, nevertheless, it reserves the right to modify, revoke, change, suspend or terminate this Plan, policy or benefits described here or in the underlying Plan document at any time or from time to time, with or without notice. This may result in modification or termination of benefits.


When STD Coverage Ends

Your STD payments will end on the earliest of the: • Date you are no longer Disabled; • End of the maximum STD period; • Date your career contract, general agent contract or general manager agreement terminates; • Date the STD program is terminated or amended to limit eligibility, causing you to become ineligible; • Date you are no longer eligible to participate in the Plan; • Date your payment for coverage is not made when due (applicable to unsubsidized agents only); or • Date you die.

The maximum STD period is the period for which STD is payable, if approved, for any Disability. The end of the maximum STD period is the earliest of the: • End of the Disability; or • Last day of the 22nd consecutive week of Disability (25th consecutive week of Disability for maternity).

When the end date of your STD benefit is determined, the final week of your benefit is prorated if your STD benefit does not extend through a full week. The rate is one seventh of your Basic Weekly Earnings per day (Basic Weekly Earnings divided by 7).

When LTD Coverage Ends

Your LTD coverage ends on the earliest of the: • Date your career contract, general agent contract or general manager agreement terminates; • Date the LTD plan is terminated or amended to limit eligibility, causing you to become ineligible; • End of the maximum benefit period; • Date you are no longer eligible to participate in the Plan; • Date your payment for coverage is not made when due; • Date you are no longer Disabled; or • Date you die.

How LTD Affects Other MassMutual Benefits Upon Contract Termination

Your other benefits may be impacted by LTD and the end of your career contract, general agent contract or general manager agreement: • Medical Coverage: You may be eligible to continue medical through the retiree medical plan. See your LTD

approval letter, which you will receive when you begin LTD benefits. • Life Insurance: You may apply to UniCare for waiver of premium or apply to convert your policy. Refer to

the life insurance SPD on FieldNet for more information. • Thrift Plan: For career contract agents, contributions stop when your career contract terminates. You may

not initiate a Thrift loan. If you have an outstanding Thrift plan loan when you begin LTD, you must repay it within 90 days or it will default, resulting in a taxable distribution.

• Cash Balance Pension Plan: If you become Disabled and begin receiving LTD benefits, you will receive information about your benefit.

You may not change your benefit options during the Annual Benefits Enrollment period while on LTD.


You are not eligible for any other benefits, including, but not limited to: • Any additional benefit plans that become available while you are Disabled; • Dependent life insurance—you may request a right of conversion for group life coverage form to convert your

coverage to an individual policy if you want; • The dental option; • The vision care option; • Health Savings Accounts; and • Flexible Spending Accounts (FSAs).

Social Security Benefits

How Social Security Affects Your LTD Benefits

If you are eligible to receive Social Security benefits while you are on LTD, generally, you will receive the difference between the scheduled LTD amount payable and the amount you receive from Social Security. In some cases, Social Security awards are made retroactively. When this happens, you must repay the plan the amount it overpaid you.

MassMutual LTD benefits are reduced by Social Security benefits received by your spouse or children because of your Disability. If you receive Social Security cost-of-living increases, your disability benefits from MassMutual will not be further reduced to compensate for the increases.

Filing for Social Security Disability Benefits

The LTD plan requires you to apply for Social Security disability benefits, and you must apply through Liberty Mutual. These benefits are not paid automatically. You may be eligible for these benefits, if approved, when you have been Disabled for five months.

Often, LTD recipients are not immediately approved when applying for Social Security disability benefits. Third-party representation throughout the application process greatly increases the chances of a Social Security disability award being made. Liberty Mutual provides third-party representation at no cost to you.


Plan Information

The information presented in this SPD is intended to comply with the disclosure requirements of the regulations issued by the U.S. Department of Labor under the Employee Retirement Income Security Act (ERISA) of 1974.

Plan Name and Number

MassMutual Agents’ Welfare Benefits Plan, 506

Plan Administrator

The Plan Administrator is the Plan Administrative Committee, which is appointed by MassMutual’s Chief Executive Officer. The Plan Administrative Committee has the authority to control and manage the operations and administration of the Plan. You can reach the Plan Administrative Committee at:

Massachusetts Mutual Life Insurance Company MassMutual Benefits 1295 State Street, F105 Springfield, MA 01111-0001 866-662-6448

Plan Sponsor

Massachusetts Mutual Life Insurance Company 1295 State Street, F105 Springfield, MA 01111-0001 866-662-6448

Employer Identification Number (EIN)

The EIN of Massachusetts Mutual Life Insurance Company is 04-1590850.

Plan Year

The Plan Year is January 1 through December 31.

Agent for Service of Legal Process

General Counsel of Massachusetts Mutual Life Insurance Company 1295 State Street Springfield, MA 01111-0001

If legal action is necessary to settle a claim, any action may also be served upon the Plan Administrator.

Plan Type and Funding

This Plan is a welfare plan providing disability income benefits on an insured basis. Premiums are paid from the general assets of the Company and participant contributions, where applicable.


Claims Administrator

The claims administrator is Liberty Mutual, Disability Claims, P.O. Box 7211, London, KY 47402-7211. The claims administrator has full discretion and fiduciary authority to determine claims and appeals arising under this Plan.

Type of Administration

This Plan is administered by Liberty Life Assurance Company of Boston.

Continuation of the Plan

Although MassMutual does not now intend to terminate the benefits described in this SPD, nevertheless it reserves the right to modify, revoke, change, suspend or terminate the Plan, policies, benefits or services described here or in the underlying Plan document at any time or from time to time, with or without notice.


ERISA Rights

As an LTD Plan participant, you are entitled to certain rights and protections under the Employee Retirement Income Security Act (ERISA) of 1974, as amended. ERISA provides that you are entitled to the rights described in this section.

Receive Information about Plan and Benefits

You have the right to: • Examine, without charge, at the Plan Administrator’s office or other specified locations, such as worksites, all

documents governing the Plan. These include any insurance contracts and copies of the latest annual report (Form 5500 series) filed by the Plan with the U.S. Department of Labor and available at the Public Disclosure Room of the Employee Benefits Security Administration (EBSA).

• Obtain, upon written request, copies of documents governing the operation of the Plan. These include any insurance contracts and copies of the latest annual report (Form 5500 series) and current Summary Plan Description. A reasonable charge may be required for the copies.

• Receive a summary of the Plan’s annual financial report (summary annual report), which is required by law to be provided to each member.

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 Plan. The people who operate the Plan, called Plan fiduciaries, have a duty to do so prudently and in the interest of you and other Plan participants and beneficiaries. No one, including the Company or any other person, may 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 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. However, you may not begin any legal action, including proceedings before administrative agencies, until you have followed and exhausted the Plan’s claim and appeal procedures. Note: Any legal action must begin within one year from the time proof of claim is required.

Under ERISA, there are steps you can take to enforce the above rights. For instance, if you request a copy of a Plan document or the latest annual report and do not receive it 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 Plan Administrator’s control.

If you have a claim that is denied or ignored, in whole or in part, you may file suit in a state or federal court. In addition, if you disagree with the Plan’s decision or lack thereof, you may file suit in federal court. If you believe that Plan fiduciaries have misused the Plan’s money or if you believe that you have been 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 if, for example, it finds your claim is frivolous.


Assistance with Questions

If you have any questions about the Plan, you should contact the Plan Administrator. If you have any questions about your rights under ERISA or if you need assistance in getting documents from the Plan Administrator, you should contact the nearest EBSA office or the national office at:

Division of Technical Assistance and Inquiries Employee Benefits Security Administration U.S. Department of Labor 200 Constitution Avenue NW Washington, DC 20210 866-444-3272

For more information about your rights and responsibilities under ERISA or for a list of EBSA offices, contact EBSA by visiting their website at www.dol.gov/ebsa.

http://www.dol.gov/ebsa


Dictionary Terms

See definitions included in Appendix A: Liberty Life Assurance Company of Boston Certificate.

Note: Throughout the Liberty Life Assurance Company of Boston Certificate, the term “spouse” also refers to an eligible domestic partner.

Annual Benefits Enrollment, Benefits Enrollment or Open Enrollment

The period each year designated by the Company when you may make changes to your benefit elections. Changes are effective the following January 1.

Before-Tax or Pre-Tax

Contributions taken before applicable federal, state and/or local taxes are withheld.

Effective Date

The date coverage begins.

Member or Participant

A person enrolled in and covered by this Plan.

Plan Year

The Plan Year is the 12-month period from January 1 to December 31.


Appendix A: Liberty Life Assurance Company of Boston Certificate

Note: Appendix numbering restarts with page 1 for Certificate.

DISCLAIMER Sponsor: Massachusetts Mutual Life Insurance Company Policy Number(s): GD3-810-253705-01/GF3-810-253705-01 Date Provided: August 19, 2013 The following certificate(s) are a true copy of the certificate(s) issued under the policy(ies).

LIBERTY LIFE ASSURANCE COMPANY OF BOSTON

Appendix A: Certificate September 2015 Page 1 of 58

-2-

NOTICE OF CHANGE

In The Certificate Booklet Issued to Employees of:

Massachusetts Mutual Life Insurance Company

This Notice is a summary of changes that have been made to

your Booklet. These changes are effective on July 25, 2013. Keep this Notice with your Booklet.

LIBERTY LIFE ASSURANCE COMPANY OF BOSTON


-3-

AMENDMENT

to be attached to and made a part of the Certificate for Group Plan No. GF3-810-253241-01

issued by LIBERTY LIFE ASSURANCE COMPANY OF BOSTON

(Liberty)

to

Massachusetts Mutual Life Insurance Company

(Sponsor) Effective date of this Amendment: July 25, 2013 The attached pages reflect a clarification note regarding agents and Employees.


-4-

CERTIFICATE OF COVERAGE

Liberty Life Assurance Company of Boston (hereinafter referred to as "we", "our" and "us") welcomes your employer as a client. Sponsor: Massachusetts Mutual Life Insurance Company Plan Number: GD3-810-253705-01/GF3-810-253705-01 Effective Date: January 1, 2005 When this plan refers to "you" or "your" it means the Covered Person insured under this plan. This is your Disability Income certificate of coverage as long as you are eligible for insurance and remain insured. A few words about this certificate of coverage... It is written in plain English. A few terms and provisions are written as required by insurance law. PLEASE READ IT CAREFULLY. If you have any questions about any terms and provisions, please contact the Insurance Administrator at your work location or write to us. We will assist you in any way we can to help you understand your benefits. Also, if the terms of your certificate of coverage and the policy differ, the policy will govern. Your coverage may be terminated or modified in whole or in part under the terms and provisions of the policy.

Executive Vice President DOC3.08


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TABLE OF CONTENTS SECTION 1. . . . . . . . . . SCHEDULE OF BENEFITS SECTION 2. . . . . . . . . . TERMS YOU SHOULD KNOW SECTION 3. . . . . . . . . . ELIGIBILITY AND EFFECTIVE DATES SECTION 4. . . . . . . . . . DISABILITY INCOME BENEFITS SECTION 5. . . . . . . . . . EXCLUSIONS SECTION 6. . . . . . . . . . TERMINATION PROVISIONS SECTION 7. . . . . . . . . . GENERAL PROVISIONS DOC3-TOC-0001


-6-

SECTION 1 - SCHEDULE OF BENEFITS ELIGIBLE CLASSES FOR INSURANCE BENEFITS: (Agents, General Agents, Sales Managers, and General Managers who have a valid General Agent, General Manager, Career Agent or Sales Manager contract) Short Term Disability Benefits: Class 1: All Agents who have a valid career agent contract and All

Sales Managers who have a valid sales manager agreement Class 2: All General Agents who have a valid general agent

contract and all General Managers who have a valid employment agreement

Long Term Disability Benefits: Class 1: All Agents who have a valid career agent contract and All

Sales Managers who have a valid sales manager agreement participating in the Base Plan

Class 2: All Agents who have a valid career agent contract and All

Sales Managers who have a valid sales manager agreement electing the Buy-Up Plan

Class 3: All General Agents who have a valid general agent

contract and all General Managers who have a valid employment agreement participating in the Base Plan

Class 4: All General Agents who have a valid general agent

contract and all General Managers who have a valid employment agreement electing the Buy-Up Plan

Note: Any reference to the defined term Employee refers to Career

Agents, General Agents, General Managers and Sales Managers.

DOC3-SCH-0001


-7-

SECTION 1 - SCHEDULE OF BENEFITS ELIGIBILITY WAITING PERIOD: 1. Present Agents, General Agents, Sales Mangers and General Managers: None

2. New Agents, General Agents, Sales Managers and General Managers: None COVERED PERSON CONTRIBUTIONS REQUIRED: Short Term Disability Benefits:

Subsidized Agents

Unsubsidized Agents

No Yes Long Term Disability Benefits:

Subsidized Agents Unsubsidized Agents

Classes 1 and 3- Base Plan:

No Yes

Classes 2 and 4-Buy-Up Plan:

Yes Yes

DOC3-SCH-0002


-8-

SECTION 1 - SCHEDULE OF BENEFITS (Continued)

SHORT TERM DISABILITY COVERAGE Elimination Period: Applicable to Maternity Claims only: The period for which a benefit is payable will commence as follows: a. on the 8th day of continuous Disability resulting from

Injury; or

b. on the 8th day of continuous Disability resulting from Sickness.

Note: A Covered Person must be Totally Disabled during the Short

Term Disability Elimination Period. Applicable to all Other Claims: The period for which a benefit is payable will commence as follows: a. on the 30th day of continuous Disability resulting from

Injury; or

b. on the 30th day of continuous Disability resulting from Sickness.

Note: A Covered Person must be Totally Disabled during the Short

Term Disability Elimination Period. Amount of Insurance Benefits: Class 1: 50% (Benefit Percentage) of Basic Weekly Earnings not to

exceed a Maximum Weekly Benefit of $2,308 less Benefits from Other Income stated in this coverage

Class 2: Flat Weekly Benefit of $2,308 less Benefits from Other

Income stated in this coverage DOC3-SCH-0003



SHORT TERM DISABILITY COVERAGE (Continued) Maximum Benefit Period: Applicable to Maternity Claims: The period for which a benefit is payable for any one Disability will end on the earliest of: a. the end of the Disability; or

b. the end of the 25th week of Disability for which a benefit is payable.

Applicable to All Other Claims: The period for which a benefit is payable for any one Disability will end on the earliest of: a. the end of the Disability; or

c. the end of the 22nd week of Disability for which a benefit is payable.

DOC3-SCH-0004


-10-


LONG TERM DISABILITY COVERAGE Your Elimination Period: The Greater of :

a. the end of your Short Term Disability Benefits ; or b. 180 days.

Note: You must satisfy the Long Term Disability Elimination Period if you are Totally Disabled, or Partially Disabled, or a combination of Totally Disabled or Partially Disabled, during such time. Your Amount Of Insurance Benefits: Class 1 - Base Plan: 50% (Benefit Percentage) of Basic Monthly

Earnings not to exceed a Maximum Monthly Benefit of $10,000 less Benefits from Other Income as outlined in Section 4

Class 2 - Buy-Up Plan: 70% (Benefit Percentage) of Basic Monthly

Earnings not to exceed a Maximum Monthly Benefit of $20,000 less Benefits from Other Income as outlined in Section 4

Class 3 - Base Plan: Flat Monthly Benefit of $10,000 less

Benefits from Other Income as outlined in Section 4

DOC3-SCH-0005


-11-


LONG TERM DISABILITY COVERAGE (Continued) Your Amount Of Insurance Benefits: (Continued) Class 4 - Buy-Up Plan: The following Flat Benefit amounts are

based on Agency Production:

Agency Production Buy-Up Base + Buy-Up Benefit amount (total benefit

Less Benefits From Other Income as Outlined in Section 4)

Under $1,000,000 Production $ 2,000 $12,000 $1,000,000 - $1,999,999 $ 4,000 $14,000 $2,000,000 - $2,999,999 $ 6,000 $16,000 $3,000,000 - $3,999,999 $ 8,000 $18,000 $4,000,000 and over $10,000 $20,000 “Agency Production” will be based on a rolling 3 year average of the General Agent’s or General Manager’s agency’s production as determined by the Sponsor. Agency production is measured by first year commissions on sales generated by the agency for Mass Mutual products in life, annuity and disability lines of business. Minimum Monthly Benefit The Minimum Monthly Benefit is $100 or 10% of your gross Monthly Benefit, whichever is greater. DOC3-SCH-0006


-12-


LONG TERM DISABILITY COVERAGE (Continued) Your Maximum Benefit Period: Age at Disability Maximum Benefit Period Less than age 60 ......... To age 65 (but not less than 5 years) 60 ..................................... 60 Months 61 ..................................... 48 Months 62 ..................................... 42 Months 63 ..................................... 36 Months 64 ..................................... 30 Months 65 ..................................... 24 Months 66 ..................................... 21 Months 67 ..................................... 18 Months 68 ..................................... 15 Months 69 and over.....................……… 12 Months Return to Work Benefit (Applies to both Short Term Disability and long Term Disability) Period of Disability Benefit Additional

Benefit At least 4 months but less than 5 months. Amount equal to 4x

the last weekly STD benefit

At least 5 months but less than 6 months. Amount equal to 8x

the last weekly STD benefit

6 months or more Amount equal to 3x

the last monthly LTD benefit

DOC3-SCH-0007


-13-

SECTION 2 - TERMS YOU SHOULD KNOW

In this section we define some basic terms needed to understand this plan. "Active Service" means you must be actively at work for the Sponsor: 1. paid compensation; and 2. maintain a valid contract endorsed by the Sponsor; and

either perform such work: a. at the Sponsor's usual place of business, including

agencies; or b. at a location to which the Sponsor's business requires

you to travel; or c. at the principal place of service for you, as determined by

the Sponsor. You will be considered actively at work if you held a valid contract on the day immediately preceding: 1. a weekend (except where one or both of these days are

scheduled days of work); 2. holidays (except when such holiday is a scheduled work

day); 3. any non-scheduled work day; 4. an excused leave of absence (except medical leave for your

own disabling condition and lay-off); and 5. an emergency leave of absence (except emergency medical

leave for your own disabling condition). "Administrative Office" means Liberty Life Assurance Company of Boston, 9 Riverside Road, Weston, MA 02493. "Annual Enrollment Period" or "Enrollment Period" means the period before each policy anniversary so designated by the Sponsor during which you may enroll for coverage under this plan. DOC3-DEF-0001.21


-14-


(Continued) "Application" is the document completed by you when applying for coverage, it is attached to and is made a part of the policy. Applicable to Non-Financed Agents with at least one full calendar year of service with the Sponsor: “Basic Weekly Earnings” (Applicable to Short Term Disability) means your prior full calendar year’s AAA Weighted Commission Credits, as determined by the Sponsor; divided by 52 Note: Earnings are updated once per year no later than April

1st. Prior Basic Weekly Earnings continue to apply until the earnings update.

“Basic Monthly Earnings” (Applicable to Long Term Disability) means your prior full calendar year’s AAA Weighted Commission Credits, as determined by the Sponsor; divided by 12. Note: Earnings are updated once per year no later than April

1st. Prior Basic Monthly Earnings continue to apply until the earnings update.

Applicable to Newer Non-Financed Agents (with less than one full calendar year of service with the Sponsor); without prior career experience: “Basic Weekly Earnings” (Applicable to Short Term Disability) means the current year career contract commission requirement for your prior year of contract ( and for the first calendar year if greater than actual AAA Weighted Commission Credits, as determined by the Sponsor) divided by 52; thereafter, your prior full calendar year’s AAA Weighted Commission Credits, as determined by the Sponsor; divided by 52. Note: Earnings are updated once per year no later than April


DOC3-DEF-0001.22


-15-


(Continued) “Basic Monthly Earnings” (Applicable to Long Term Disability) means the current year career contract commission requirement for your year of contract (and for the first full calendar year if greater that actual AAA Weighted Commission Credits, as determined by the Sponsor); divided by 12; thereafter, your prior full calendar year’s AAA Weighted Commission Credits, as determined by the Sponsor divided by 12. Note: Earnings are updated once per year no later than April


Applicable to Newer Non-Financed Agents (with less than one full calendar year of service with the Sponsor) with prior career experience: “Basic Weekly Earnings” (Applicable to Short Term Disability) means the prior first year and renewal commissions for the last non-Sponsor calendar year as determined by the Sponsor or the current year career contract commission requirement for your year of contract (and for the first full calendar year if greater than actual AAA Weighted Commissions Credits, as determined by the Sponsor); divided by 52; thereafter, your prior full calendar years AAA Weighted Commission Credits, as determined by the Sponsor; divided by 52. Note: Earnings are updated once per year no later than April


“Basic Monthly Earnings” (Applicable to Long Term Disability) means the prior first year and renewal commissions for the last non-Sponsor calendar year as determined by the Sponsor or the current year career contract commission requirement for your year of contract (and for the first full calendar year if greater than actual AAA Weighted Commissions Credits, as determined by the sponsor); divided by 12; thereafter, your prior full calendar year’s AAA Weighted Commission Credits, as determined by the Sponsor; divided by 12. Note: Earnings are updated once per year no later than April


DOC3-DEF-0001.23


-16-


(Continued) Applicable to Financed Agents: “Basic Weekly Earnings” (Applicable to Short Term Disability) means the current year career contract commission requirement for your year of contract (and for the first full calendar year if greater than actual AAA Weighted Commission Credits, as determined by the Sponsor); divided by 52; thereafter, your prior full calendar year’s AAA Weighted Commission Credits, as determined by the Sponsor; divided by 52. Note: Earnings are updated once per year no later than April


“Basic Monthly Earnings” (Applicable to Long Term Disability) means the current year career contract commission requirement for your year of contract( and for the first full calendar year if greater than actual AAA Weighted Commission Credits, as determined by the Sponsor); divided by 12; thereafter your prior full calendar year’s AAA Weighted Commission Credits, as determined by the Sponsor; divided by 12. Note: Earnings are updated once per year no later than April


Applicable to Sales Managers with at least one full calendar year of service with the Sponsor: “Basic Weekly Earnings” (applicable to Short Term Disability) Means:

(a) Your prior full calendar year’s AAA Weighted Commission Credits, as determined by the Sponsor; plus

(b) Sales Manager Production Compensation paid by the Sponsor; plus

(c) Sales Manager deferred Production Compensation paid by the Sponsor; divided by 52

Note: Earnings are updated once per year no later than April 1st. Prior Basic Weekly Earnings continue to apply until the earnings update.

DOC3-DEF-0001.24


-17-


(Continued) “Basic Monthly Earnings” (applicable to Long Term Disability) Means:

(a) Your prior full calendar year’s AAA Weighted Commission Credits, as determined by the Sponsor; plus (b) Sales Manager Production Compensation paid by the

Sponsor; plus (c) Sales Manager deferred Production Compensation paid by

the Sponsor; divided by 12 Note: Earnings are updated once per year no later than April


Applicable to Sales Managers without prior experience in Life Insurance Sales or Financial Services Management with less than one full calendar year of service with the Sponsor: “Basic Weekly Earnings” (Applicable to Short Term Disability) means for the first year, earnings equal the current year Career Contract commission requirement (and for the first full calendar year if greater than actual AAA Weighted Commission Credits, as determined by the Sponsor; divided by 52; thereafter,

(a) Your prior full calendar year’s AAA Weighted Commission Credits, as determined by the sponsor; plus


(c) Sales Manager Deferred Production Compensation paid by the Sponsor; divided by 52.


DOC3-DEF-0001.25


-18-

SECTION 2 - TERMS YOU SHOULD KNOW (Continued)

Applicable to Sales Managers without prior experience in Life Insurance Sales or Financial Services Management with less than one full calendar year of service with the Sponsor):

“Basic Monthly Earnings” (Applicable to Long Term Disability) means for the first year, earnings equal the current year Career Contract commission requirement (and for the first full calendar year if greater than actual AAA Weighted Commission Credits, as determined by the Sponsor); divided by 12; thereafter,

(a) Your prior full calendar year’s AAA WeightedCommission Credits, as determined by the sponsor; plus

(b) Sales Manager Production Compensation paid by theSponsor; plus

(c) Sales Manager Deferred Production Compensation paidby the Sponsor; divided by 12.

Note: Earnings are updated once per year no later than April 1st. Prior Basic Monthly Earnings continue to apply until the earnings update.

“Basic Weekly Earnings” (Applicable to Short Term Disability) means for the first year, and renewal commissions (for Life, Annuity and Disability Sales) or Management Income as determined by the sponsor for the last non-Sponsor calendar year or current year career contract commission requirement (and for the first full calendar year if greater than actual AAA Weighted Commissioned Credits, as determined by the Sponsor); divided by 52; thereafter,

(a) Your prior full calendar year’s AAA WeightedCommission Credits, as determined by the Sponsor; plus

(b) Sales Manager Production Compensation paid by theSponsor; plus

(c) Sales Manager deferred Production Compensation paidby the sponsor; divided by 52.


DOC3-DEF-0001.25 (Cont.)


-19-


(Continued) Applicable to Sales Managers with prior experience in Life Insurance Sales or Financial Services Management with less than one full year of service with the Sponsor (Continued): Basic Monthly Earnings” (Applicable to Long Term Disability) means the prior first year, and renewal commissions (for Life, Annuity and Disability Sales) or Management Income as determined by the sponsor for the last non-Sponsor calendar year or current year career contract commission requirement (and for the first full calendar year if greater than actual AAA Weighted Commissioned Credits, as determined by the Sponsor); divided by 12; thereafter, (a) your prior full calendar year’s AAA Weighted Commission

Credits, as determined by the Sponsor; plus (b) Sales Manager Production Compensation paid by the

Sponsor; plus (c) Sales Manager deferred Production Compensation paid by

the sponsor; divided by 12. Note: Earnings are updated once per year no later than April 1st. Prior Basic Monthly Earnings continue to apply until the earnings update. “Basic Weekly Earnings” (Applicable to Short Term Disability) means the prior first year, and renewal commissions (for Life, Annuity and Disability Sales) or Management Income as determined by the Sponsor for the last non-Sponsor calendar year or the current year career contract commission requirement (and for the first full calendar year if greater than actual AAA Weighted Commissioned Credits, as determined by the Sponsor); divided by 52; thereafter,

(a) Your prior full calendar year’s AAA Weighted Commission Credits, as determined by the Sponsor; plus


(c) Sales Manager deferred Production Compensation paid by the sponsor; divided by 52.

"Covered Person" means a career contract agent of the sponsor as defined by the IRS Code Section 7701(a)(20) who maintains a valid career contract or a general agent or a general manager or a sales manager insured under this policy. DOC3-DEF-0001.26


-20-


(Continued) "Disability" or "Disabled" with respect to Short Term Disability coverage means you are unable to perform all of the material and substantial duties of your occupation on an Active Service basis because of an Injury or Sickness. "Disability" or "Disabled" with respect to Long Term Disability coverage means: 1. For persons other than pilots, co-pilots, and crew of an aircraft: i. If you are eligible for the 24 Month Own Occupation Benefit,

"Disability" or "Disabled" means during the Elimination Period and the next 24 months of Disability you are unable to perform all of the material and substantial duties of your occupation on an Active Service basis because of an Injury or Sickness; and

ii. After 24 months of benefits have been paid, you are unable to

perform, with reasonable continuity, all of the material and substantial duties of your own or any other occupation for which you are or become reasonably fitted by training, education, experience, age and physical and mental capacity.

2. If you are employed as a pilot, co-pilot or crew of an aircraft: "Disability" or "Disabled" means because of Injury or Sickness

you cannot perform the material and substantial duties of any gainful occupation for which you are or become reasonably fitted by training, education, experience, age and physical and mental capacity.

DOC3-DEF-0001.26 (Cont.)


-21-


(Continued) "Disability Benefits", when used with the term Retirement Plan, means money which: 1. is payable under a Retirement Plan due to Disability as

defined in that plan; and 2. does not reduce the amount of money which would have

been paid as Retirement Benefits at the normal retirement age under the plan if your Disability had not occurred. (If the payment does cause such a reduction, it will be deemed a Retirement Benefit as defined in this plan.)

"Eligibility Date" means the date you become eligible for insurance under this plan. Eligible Classes are shown in the Schedule of Benefits. "Eligibility Waiting Period" as shown in the Schedule of Benefits means the continuous length of time you must serve in an eligible class to reach your Eligibility Date. "Elimination Period" means a period of consecutive days of Disability for which no benefit is payable. Your Elimination Period is shown in the Schedule of Benefits and begins on the first day of your Disability. If you return to work for any 30 or less days during the Elimination Period and cannot continue, Liberty will count only those days the covered Person is disabled to satisfy the Elimination Period. "Family Status Change" means any one of the following events that may occur: 1. your marriage or divorce; or 2. the birth of your child; or 3. the adoption of your child; or 4. the death of your spouse or child; or 5. the loss employment or benefits by your spouse. DOC3-DEF-0003.11/0003.12/0003.13


-22-


(Continued) "Gross Weekly Benefit" or "Gross Monthly Benefit" means your Weekly or Monthly Benefit before any reduction for Benefits from Other Income. "Initial Enrollment Period" means one of the following periods during which you may first enroll for coverage under this policy: 1. If you are eligible for insurance on the policy effective date, a

period before the policy effective date set by the Sponsor and us. 2. If you become eligible for insurance after the policy effective

date, the period which ends 31 days after your eligibility date. "Injury" means bodily impairment resulting directly from an accident and independently of all other causes. Any Disability which begins more than 60 days after an Injury will be considered a Sickness for the purpose of determining benefits under this plan. "Monthly Benefit" means the amount payable by Liberty to you if you are Disabled or Partially Disabled. Benefits for Long Term Disability coverage are determined on a monthly basis. "Partial Disability" or "Partially Disabled" means as a result of the Injury or Sickness, you are: 1. able to perform one or more, but not all, of the material and

substantial duties of his own occupation or any other occupation on an Active Service or a part-time basis; or

2. able to perform all of the material and substantial duties of

his own occupation or any other occupation on a part-time basis.

DOC3-DEF-0003.13


-23-


(Continued) "Physician" means a person who: 1. is licensed to practice medicine and prescribe and administer

drugs or to perform surgery; or 2. is a licensed practitioner of the healing arts in a category

specifically favored under the health insurance laws of the State where the policy is delivered and practicing within the terms of his license.

"Physician" does not mean you or your spouse, daughter, son, father, mother, sister or brother. "Retirement Benefit", when used with the term Retirement Plan, means money which: 1. is payable under a Retirement Plan either in a lump sum or

in the form of periodic payments;

2. does not represent contributions made by you (payments which represent your contributions are deemed to be received over your expected remaining life regardless of when such payments are actually received); and

3. is payable upon: a. early or normal retirement; or b. Disability, if the payment does reduce the amount of

money which would have been paid under the plan at the normal retirement age.

DOC3-DEF-0004.11


-24-


(Continued) "Retirement Plan" means a plan which provides Retirement Benefits to you and which is not funded wholly by your contributions. The term shall not include: a profit-sharing plan, informal salary continuation plan, registered retirement savings plan, stock ownership plan, or a non-qualified plan of deferred compensation. "Schedule of Benefits" means the section of this plan which shows, among other things, the Eligible Classes, the Eligibility Waiting Period, your Elimination Period, your Amount of Insurance, the Minimum Benefit, and your Maximum Benefit Period. "Sickness" means illness, disease, pregnancy or complications of pregnancy. "Sponsor" means the entity to whom the policy is issued. "Sponsor's Retirement Plan" is deemed to include any Retirement Plan: 1. which is part of any Federal, State, Municipal or Association

retirement system; or 2. for which you are eligible as a result of service with the

Sponsor. "Weekly Benefit" means the amount payable by Liberty to you if you are Disabled or Partially Disabled. Benefits for Short Term Disability coverage are determined on a weekly basis. DOC3-DEF-0005.09


-25-

SECTION 3 - ELIGIBILITY AND EFFECTIVE DATES

Applicable to Short Term Disability Who Is Eligible For Coverage? You are Eligible for Coverage if you are in Active Service and in an Eligible Class for Insurance Benefits shown in the Schedule of Benefits. Your Eligibility Date For Insurance Benefits If you are in an eligible class you will qualify for insurance on the later of: 1. this plan's Effective Date; or 2. the day after you complete the Eligibility Waiting Period

shown in the Schedule of Benefits. Your Effective Date Of Insurance 1. Your insurance will be effective at 12:01 A.M. Standard Time in

the governing jurisdiction on the day determined as follows, but only if your Application for insurance is:

a. made with us through your Sponsor; and b. in a form or format satisfactory to us. 2. You will be insured for non-contributory insurance on your

Eligibility Date. 3. You will be insured for contributory insurance on the date you

make written Application for insurance on or before the 31st day after your Eligibility Date.

4. Delayed Effective Date for Insurance - The Effective Date of any

initial, increased or additional insurance for you will be delayed if you are not in Active Service because of Injury or Sickness. The initial, increased or additional insurance will start on the date you return to Active Service.

DOC3-ELG-0001.16/0001.17


-26-


Applicable to Long Term Disability Who Is Eligible For Coverage? You are Eligible for Coverage if you are in Active Service and in an Eligible Class for Insurance Benefits shown in the Schedule of Benefits. Your Eligibility Date For Insurance Benefits If you are in an eligible class you will qualify for insurance on the later of: 1. this plan's Effective Date; or 2. the day after you complete the Eligibility Waiting Period

shown in the Schedule of Benefits. Enrollment You may enroll in or change coverage only during an Initial or Annual Enrollment Period as follows: 1. Initial Enrollment Period

During the Initial Enrollment Period you may enroll in any one coverage or coverage option shown in the Schedule of Benefits. If you do not choose any coverage or coverage option, you will automatically be enrolled in the Base Plan.

2. Annual Enrollment Period

During each Annual Enrollment Period, you may make any one of the following changes in coverage for the next policy year:

a. a decrease in coverage; b. an increase in coverage subject to the Pre-Existing Condition

Exclusion defined herein; or c. keep your coverage at the same level.

DOC3-ELG-0006.03


-27-


(Continued) Enrollment (Continued) 2. Annual Enrollment Period (Continued)

If you fail to enroll for a change in your coverage option during any Annual Enrollment Period, you will continue to be insured for the same coverage option during the next policy year and no change in that coverage can be made during the next policy year.

3. Family Status Change

When you experience a Family Status change, you may enroll for coverage within 31 days of the date of the Family Status Change. When you experience a Family Status Change, you may:

a. decrease your coverage; b. increase your coverage without Evidence of Insurability

subject to the Pre-Existing Condition Exclusion defined herein;

c. keep your coverage at the same level.

You must apply for the change in coverage within 31 days of the date of the Family Status Change. Such changes in coverage must be on account of and consistent with the reason that the change in coverage was permitted.

Your Effective Date Of Insurance 1. Your insurance will be effective at 12:01 A.M. Standard Time in

the governing jurisdiction on the day determined as follows, but only if your Application for insurance is:

a. made with us through your Sponsor; and b. in a form or format satisfactory to us. DOC3-ELG-0007.04


-28-


(Continued) Your Effective Date Of Insurance (Continued) 2. For Coverage Applied For During Initial Enrollment Periods:

You will become insured for non-contributory insurance on your eligibility date. You will become insured for any other contributory coverage on the later of these dates: a. your eligibility date if you enroll before that date; or b. the date you enroll if you do it on or before the 31st day after

your date of eligibility.

If you do not enroll for any contributory coverage on or before the 31st day after your eligibility date, or terminated your insurance while continuing to be eligible, you may not enroll for any contributory coverage until the next Annual Enrollment Period.

3. For Contributory Coverage Applied For During Annual

Enrollment Periods, you will be insured for the selected contributory coverage on the first day of the next policy anniversary.

4. For Coverage Applied For Due To A Family Status Change

You will become insured for the selected coverage on the later of the following dates, provided you enroll or apply for the change in coverage before the 31st day following the Family Status Change: a. the date of the Family Status Change; or

b. the date you enroll or apply for the change in coverage. 5. Delayed Effective Date for Insurance-The Effective Date of any

initial, increased or additional insurance will be delayed for an individual if you are not in active Service because of injury or sickness. The initial, increased or additional insurance will start on the date the individual returns to Active Service.

DOC3-ELG-0008.03


-29-


(Continued) What Happens If There Is A Transfer Of Insurance Carriers? In order to prevent loss of coverage for you because of a transfer of insurance carriers, this plan will provide coverage for you as follows: What Happens If You Are Not In Active Service Due To Injury Or Sickness? This plan will cover you, subject to premium payments, if you were: 1. insured by the prior carrier at the time of transfer; and 2. not in Active Service due to Injury or Sickness on the

Effective Date of the plan. The benefit payable will be in accordance with the provisions of this plan, less any benefit for which the prior carrier is liable. However, in no event will the benefit payable be greater than that which would have been paid under the prior carrier's benefit schedule. What Happens If You Are Disabled Due To A Pre-Existing Condition? If there is a Pre-Existing Condition Exclusion, a benefit may be payable for a Disability due to a Pre-Existing Condition if you: 1. were insured by the prior carrier at the time of transfer; and 2. were in Active Service and insured under this plan on its

Effective Date. The benefit will be determined as follows: 1. We will apply this plan's pre-existing condition exclusion. If

you qualify for a benefit, you will be paid according to this plan's benefit schedule.

DOC3-ELG-0004.06


-30-


(Continued) What Happens If You Are Disabled Due To A Pre-Existing Condition? (Continued) The benefit will be determined as follows: (Continued) 2. If you cannot satisfy this plan's pre-existing condition

exclusion, the prior carrier's pre-existing condition exclusion will be applied.

a. If you satisfy the prior carrier's pre-existing condition

exclusion, giving consideration towards continuous time insured under both policies, you will be paid according to this plan's benefit schedule. However, in no event will the benefit payable be greater than that which would have been paid under the prior carrier's benefit schedule.

b. If you cannot satisfy the pre-existing condition exclusion

of this plan or that of the prior carrier, no benefit will be paid.

DOC3-ELG-0004.07


-31-

SECTION 4 - DISABILITY INCOME BENEFITS

SHORT TERM DISABILITY COVERAGE Disability Benefit When Is Your Disability Benefit Payable? When we receive proof that you are Disabled due to Injury or Sickness and require the regular attendance of a Physician, we will pay you a Weekly Benefit after the end of your Elimination Period. The benefit will be paid for the period of your Disability if you give to us proof of continued: 1. Disability; and 2. regular attendance of a Physician. The proof must be given upon our request and at your expense. For the purpose of determining Disability, the Injury must occur and your Disability must begin while you are insured for this coverage. In addition, a loss of a license for any reason does not, in itself, constitute Disability. Your Weekly Benefit will not: 1. exceed your Amount of Insurance; nor 2. be paid for longer than your Maximum Benefit Period. Your Amount of Insurance and your Maximum Benefit Period are shown in the Schedule of Benefits. DOC3-STD-0001


-32-


SHORT TERM DISABILITY COVERAGE (Continued) Disability Benefit (Continued) How Is Your Amount Of Disability Weekly Benefit Figured? To figure your amount of Weekly Benefit: 1. Multiply your Basic Weekly Earnings by the Benefit

Percentage shown in the Schedule of Benefits. 2. Take the lesser of: a. the amount figured in step (1) above; or b. the Maximum Weekly Benefit shown in the Schedule of

Benefits; and then 3. Deduct your Benefits from Other Income, (shown in the

Benefits from Other Income provision of this coverage), from this amount.

DOC3-STD-0001 (Cont.)


-33-


(Continued) SHORT TERM DISABILITY COVERAGE (Continued) Partial Disability Benefit When proof is received that you are Partially Disabled from an Injury or Sickness Liberty will pay a Partial Disability benefit if you give to Liberty upon request and at your expense, proof of continued (a) Partial Disability, and (b) the required regular attendance of a Physician. "Partial Disability" or "Partially Disabled" means as a result of the Injury or Sickness, which caused Disability, you are: 1. able to perform one or more, but not all, of the material and

substantial duties of your own Occupation or any other occupation on an Active Employment or a part-time basis; or

2. able to perform all of the material and substantial duties of

your own Occupation or any other occupation on a part-time basis.

DOC3-STD-0008.04


-34-


(Continued) SHORT TERM DISABILITY COVERAGE (Continued) Partial Disability Benefit (Continued) Amount of Partial Disability Weekly Benefit If you are eligible for a Partial Disability Benefit according to the terms of this plan, we will pay 50% of your regular Weekly Benefit as shown in the Schedule of Benefits. The Partial Disability Benefit payable will never be more than the Maximum Weekly Benefit shown in the Schedule of Benefits. Return to Work Benefit If you return to Active Service with the Sponsor on a full-time basis within two weeks after Disability Benefits end, a Return to Work Benefit will be payable as shown in the Schedule of Benefits. To be eligible for the return to Work Benefit, you must

1. have received Disability Benefits for the period shown in the Schedule of Benefits; and

2. return to Active Service on a full-time basis with the

Sponsor; and

3. have not received benefits under this provisions for any prior disability while insured under this plan.

DOC3-STD-0008.04 (Cont.)


-35-


(Continued) SHORT TERM DISABILITY COVERAGE (Continued) Benefits From Other Income What Are Your Benefits From Other Income? Your Benefits from Other Income means those benefits shown below: 1. any disability benefits for which you are eligible under Social

Security; 2. any other governmental program or coverage required or

provided by statute (including any amount attributable to your family).

What Happens If You Receive Any Cost Of Living Increases? After the first deduction for each of your Benefits from Other Income, your Weekly Benefit will not be further reduced due to any cost of living increases payable under the Benefits from Other Income provision of this coverage. What Happens If You Receive A Lump Sum Payment? If you receive Benefits from Other Income which are paid in a lump sum, they will be prorated on a weekly basis over the Maximum Benefit Period. What Happens If Your Benefit Period Is Less Than A Week? For any period which a Short Term Disability Benefit is payable that does not extend through a full week, the benefit will be paid on a prorated basis. The rate will be 1/7th per day for such period of Disability. DOC3-STD-0002.05


-36-


(Continued) SHORT TERM DISABILITY COVERAGE (Continued) Benefits From Other Income (Continued) When Will Your Short Term Disability Benefit Be Discontinued? Your Weekly Benefit will cease on the earliest of: 1. the date you are no longer Disabled; or 2. the date you die; or 3. the end of your Maximum Benefit Period DOC3-STD-0002.05 (Cont.)


-37-


(Continued) SHORT TERM DISABILITY COVERAGE (Continued) Successive Periods of Disability What Happens If You Return To Work And Become Disabled Again? If you return to work and become Disabled again, you may qualify for Successive Periods of Disability. With respect to this coverage, "Successive Periods of Disability" means a Disability which is related or due to the same cause(s) as a prior Disability for which a Weekly Benefit was payable. A Successive Period of Disability will be treated as part of your prior Disability if, after receiving Disability Benefits under this coverage, you: 1. return to your Own Occupation on an Active Service basis

for less than six continuous months; and 2. perform all the Material and Substantial duties of your Own

Occupation. Benefit payments will be subject to the terms of this coverage for your prior Disability. If you return to your Own Occupation on an Active Service basis for six continuous months or more, the Successive Period of Disability will be treated as a new period of Disability. You must complete another Elimination Period. If you become eligible for coverage under any other group Short Term Disability coverage, this Successive Period of Disability provision will cease to apply to you. DOC3-STD-0004.13


-38-


LONG TERM DISABILITY COVERAGE Disability Benefit When Is Your Disability Benefit Payable? When we receive proof that you are Disabled due to Injury or Sickness and require the regular attendance of a Physician, we will pay you a Monthly Benefit after the end of your Elimination Period. The benefit will be paid for the period of your Disability if you give to us proof of continued: 1. Disability; and 2. regular attendance of a Physician. The proof must be given upon our request and at your expense. For the purpose of determining Disability, the Injury must occur and your Disability must begin while you are insured for this coverage. In addition, a loss of a license for any reason does not, in itself, constitute Disability. Your Monthly Benefit will not: 1. exceed your Amount of Insurance; nor 2. be paid for longer than your Maximum Benefit Period. Your Amount of Insurance and your Maximum Benefit Period are shown in the Schedule of Benefits. DOC3-LTD-0001


-39-


LONG TERM DISABILITY COVERAGE (Continued) Disability Benefit (Continued) How Is Your Amount Of Disability Monthly Benefit Figured? To figure your amount of Monthly Benefit: 1. Multiply your Basic Monthly Earnings by the Benefit

Percentage shown in the Schedule of Benefits. 2. Take the lesser of: a. the amount figured in step (1) above; or b. the Maximum Monthly Benefit shown in the Schedule of

Benefits; and then 3. Deduct your Benefits from Other Income, (shown in the

Benefits from Other Income provision of this coverage), from this amount.

The Disability Benefit payable will never be less than the Minimum Monthly Benefit shown in the Schedule of Benefits. DOC3-LTD-0001 (Cont.)


-40-


(Continued) LONG TERM DISABILITY COVERAGE (Continued) Partial Disability Benefit When Are Benefits Payable Under Our Partial Disability Provision? When proof is received that you are Partially Disabled because of an Injury or Sickness, you may be eligible to receive a Partial Disability Benefit under Liberty’s Partial Disability provision. To be eligible to receive such benefits, you may be employed in your Own Occupation or another occupation and must satisfy the Elimination Period. A Monthly Benefit will be paid for the period of Partial Disability if proof is given to Liberty upon request, and at your expense, of continued: 1. Partial Disability; and 2. regular attendance of a Physician.. For the purposes of determining Partial Disability, the Injury must occur and Partial Disability must begin while the Covered Person is Insured for this coverage. In addition, a loss of a license for any reason does not, in itself, constitute Partial Disability. Amount of Partial Disability Benefit The Monthly Benefit will be calculated as follows If you are eligible for a Partial Disability benefit according to the terms of the plan, Liberty will pay 50% of the your regular Monthly Benefit as shown in the Schedule of Benefits less any Benefits from Other Income (shown in the Benefits from Other Income provision of this coverage). The Monthly Benefit payable will never be less than the Minimum Monthly Benefit shown in the Schedule of Benefits, or more than the Disability Benefit payable under this coverage. DOC3-LTD-0007.07


-41-


(Continued) LONG TERM DISABILITY COVERAGE (Continued) Return to Work Benefit If you return to Active Service with the Sponsor on a full-time basis within two weeks after Disability Benefits end, a Return to Work Benefit will be payable as shown in the Schedule of Benefits. To be eligible for the return to Work Benefit, you must

1. have received Disability Benefits for the period shown in the Schedule of Benefits; and

2. return to Active Service on a full-time basis with the

Sponsor; and

3. have not received benefits under this provisions for any prior disability while insured under this plan.

DOC3-LTD-0007.07 (Continued)


-42-


(Continued) LONG TERM DISABILITY COVERAGE (Continued) Mental Illness and Alcohol or Drug Abuse Limitations What Limitations Will Apply For Mental Illness and Alcohol or Drug Abuse? The Benefit for Disability due to Mental Illness and Alcohol or Drug Abuse will not exceed 24 months of Monthly Benefit payments unless you meet one of these situations. 1. You are in a Hospital or Institution for Mental Illness and

Alcohol or Drug Abuse at the end of the 24 month period. The Monthly Benefit will be paid during the confinement. If you are still Disabled when you are discharged, the Monthly Benefit will be paid for a recovery period up to 90 days. If you become reconfined during the recovery period for at least 14 days in a row, benefits will be paid for the confinement and another recovery period up to 90 more days.

2. You continue to be Disabled and become confined for the

Mental Illness and Alcohol or Drug Abuse: a. after the 24 month period; and b. for at least 14 days in a row.

The Monthly Benefit will be payable during the confinement

for the Mental Illness and Alcohol or Drug Abuse. The Monthly Benefit will not be payable beyond the Maximum Benefit Period. Benefits are payable for the duration of the confinement.

Benefits are payable for up to 24 months for outpatient treatment. "Hospital" or "Institution" means a facility licensed to provide care and Treatment for the condition causing your Disability. "Mental Illness" means mental, nervous or emotional diseases or disorders of any type. DOC3-LTD-0011.02


-43-


(Continued) LONG TERM DISABILITY COVERAGE (Continued) Benefits From Other Income What Are Your Benefits From Other Income? Your Benefits from Other Income means those benefits shown below: 1. The amount for which you are eligible under: a. Workers' or Workmen's Compensation Law; b. occupational disease law; c. any compulsory benefit act or law; or d. any other act or law of like intent. 2. The amount of any disability benefits which you are eligible

to receive under any governmental retirement system as a result of your job with the Sponsor.

3. The amount of Disability and/or Retirement Benefits under

the United States Social Security Act, the Canada Pension Plan, the Quebec Pension Plan, or any similar plan or act, for which:

a. you receive or are eligible for; and b. your spouse, child or children receive or are eligible for

because of your Disability; or c. your spouse, child or children receive or are eligible for

because of your eligibility for retirement benefits. Note: For Agents and Sales Managers, the 20% additional coverage

available under the 70% plan will not be reduced from benefits from Other Income. For General Agents and General Managers the additional coverage available under the Buy-Up Plan will not be reduced from Benefits from Other Income.

These Benefits from Other Income, except Retirement Benefits must be payable as a result of the same Disability for which Liberty pays a benefit. DOC3-LTD-0013.05


-44-


(Continued) LONG TERM DISABILITY COVERAGE (Continued) What Happens If You Receive Any Cost Of Living Increases? After the first deduction for each of your Benefits from Other Income, your Monthly Benefit will not be further reduced due to any cost of living increases payable under the Benefits from Other Income provision of this coverage. This provision does not apply to increases received from any form of service. What Happens If You Receive A Lump Sum Payment? If you receive Benefits from Other Income which are paid in a lump sum, they will be prorated on a monthly basis over the time period for which the sum is given or the Maximum Benefit Period, whichever is less. What Happens If Your Benefit Period Is Less Than A Month? For any period which a Long Term Disability Benefit is payable that does not extend through a full month, the benefit will be paid on a prorated basis. The rate will be 1/30th per day for such period of Disability. How Can Your Benefit Period Be Extended? Your Maximum Benefit Period is shown in the Schedule of Benefits. However, the benefit will be extended beyond the end of your Maximum Benefit Period if you attain the age specified in the benefit duration while Disabled and have not received 12 Monthly Benefit payments. In this event, the benefit period will be extended during the continuance of your Disability until 12 monthly payments have been paid. DOC3-LTD-0014.20


-45-


(Continued) LONG TERM DISABILITY COVERAGE (Continued) When Will Your Long Term Disability Benefits Be Discontinued? Your Monthly Benefit will cease on the earliest of: 1. the date you are no longer Disabled; or 2. the date you die; or 3. the end of your Maximum Benefit Period; or DOC3-LTD-0014.21


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(Continued) LONG TERM DISABILITY COVERAGE (Continued) Successive Periods of Disability What Happens If You Return To Work And Become Disabled Again? If you return to work and become Disabled again, you may qualify for Successive Periods of Disability. With respect to this coverage, "Successive Periods of Disability" means a Disability which is related or due to the same cause(s) as a prior Disability for which a Monthly Benefit was payable. A Successive Period of Disability will be treated as part of your prior Disability if, after receiving Disability Benefits under this coverage, you: 1. return to your Own Occupation on an Active Service basis

for less than six continuous months; and 2. perform all the material and substantial duties of your Own

Occupation. Benefit payments will be subject to the terms of this coverage for your prior Disability. If you return to your own occupation on an Active Service basis for six continuous months or more, the Successive Period of Disability will be treated as a new period of Disability. You must complete another Elimination Period. If you become eligible for coverage under any other group Long Term Disability coverage, this Successive Period of Disability provision will cease to apply to you. DOC3-LTD-0015.10


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(Continued) LONG TERM DISABILITY COVERAGE (Continued) Three Month Survivor Benefit What Happens To Your Benefit If You Die? We will pay a lump sum benefit to your Eligible Survivor when proof is received that you died: 1. after your Disability had continued for 180 or more

consecutive days; and 2. while receiving a Monthly Benefit. The lump sum benefit will be an amount equal to three times your Last Monthly Benefit. "Eligible Survivor" means your spouse, if living, otherwise your children under age 26. If payment becomes due to your children, payment will be made in equal shares to: 1. the children; or 2. a person named by us to receive payment on your children's

behalf. This payment will be valid and effective against all claims by others representing or claiming to represent your children.

"Last Monthly Benefit" means the Monthly Benefit paid to you immediately prior to your death without any reduction for earnings received from service. DOC3-LTD-0016.25


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(Continued) LONG TERM DISABILITY COVERAGE (Continued) Minimum Indemnity For Accidental Dismemberment And Loss Of Sight When Is Your Minimum Indemnity Benefit For Accidental Dismemberment And Loss Of Sight Payable? If Injury results in any of the losses listed in the Schedule below, the Disability Monthly Benefit will be paid to you for the number of monthly payments shown in this Schedule. The loss must: 1. result from an Injury caused by an accident which occurred

while you were insured for this benefit; 2. result from that Injury directly and independently of all other

causes; and 3. occur within 100 days after the accident. If you die before all of these payments have been made, the balance remaining at the time of your death will be paid to your estate.

SCHEDULE

Minimum Number of For loss of Monthly Payments

Sight of Both Eyes.................................... 46 Hands...................................................... 46 Both Feet................................................. 46 One Hand and One Foot............................ 46 One Hand and Sight of One Eye................46 One Foot and Sight of One Eye..................46 One Hand or One Foot............................... 23 Sight of One Eye....................................... 23* Thumb and Index Finger of Either Hand............................................. 12 DOC3-LTD-0023


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(Continued) LONG TERM DISABILITY COVERAGE (Continued) Minimum Indemnity For Accidental Dismemberment And Loss Of Sight (Continued) The maximum number of monthly payments payable to you for all losses suffered in any one accident shall be limited to that one loss for which the greatest number of monthly payments is provided in the above Schedule. Loss of hands and feet means loss by severance at or above the wrist or ankle joint. Loss of sight means total and irrecoverable loss of sight. Loss of thumb and index finger means actual severance at or above the knuckles joining each to the hand. A benefit may be payable for a period in excess of the number of months indicated in the above Schedule provided that you are Disabled. *Note: The minimum number of payments for loss of sight in one

eye has been changed from 15 to 23. DOC3-LTD-0023 (Cont.)


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SECTION 5 - EXCLUSIONS

GENERAL EXCLUSIONS What Disabilities Are Not Covered? This plan will not cover any Disability due to: 1. war, declared or undeclared or any act of war; 2. intentionally self-inflicted injuries, while sane or insane; 3. active Participation in a Riot; 4. your committing of or the attempting to commit an

indictable offense. 5. periods of incarceration; 6. elective cosmetic surgery, unless cosmetic surgery is

necessary as a result of injury, illness, deformity or other medically necessary condition, regardless of when such injury, illness, deformity or other medically necessary condition began.

With respect to this provision, Participation shall include promoting, inciting, conspiring to promote or incite, aiding, abetting, and all forms of taking part in, but shall not include actions taken in defense of public or private property, or actions taken in defense of the person of the insured, if such actions of defense are not taken against persons seeking to maintain or restore law and order including, but not limited to police officers and firemen. With respect to this provision, Riot shall include all forms of public violence, disorder or disturbance of the public peace, by three or more persons assembled together, whether or not acting with a common intent and whether or not damage to persons or property or unlawful act or acts is the intent or the consequence of such disorder. DOC3-EXC-0001.25


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SECTION 5 - EXCLUSIONS

(Continued) LONG TERM DISABILITY COVERAGE Pre-Existing Condition Exclusion What Happens If Your Disability Results From A Pre-Existing Condition? This policy will not cover any Disability or Partial Disability: 1. which is caused or contributed to by, or results from a Pre-

Existing Condition; and 2. which begins in the first 12 months after your Effective Date. "Pre-Existing Condition" means a condition resulting from an Injury or Sickness for which you are diagnosed or received Treatment within 12 months prior to your Effective Date. "Treatment" means consultation, care or services provided by a Physician including diagnostic measures and taking prescribed drugs and medicines. DOC3-EXC-0003


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SECTION 6 - TERMINATION PROVISIONS

When Will Your Insurance End? You will cease to be insured on the earliest of the following dates: 1. the date this plan terminates, but without prejudice to any

claim originating prior to the time of termination; 2. the date you are no longer in an eligible class; 3. the date your class is no longer included for insurance; 4. the last day for which your required contribution has been

made; 5. the end of the payroll period following the date service

terminates. Cessation of Active Service will be deemed termination of service, except the insurance will be continued for you if you were absent due to Disability during:

a. your Elimination Period; and b. any period during which premium is being waived. 6. the date you cease Active Service due to a labor dispute,

including any strike, work slowdown, or lockout. We reserve the right to review and terminate all classes insured under this plan if any class(es) cease(s) to be covered. Military Leave of Absence under the uniformed Service Employment and Reemployment Rights Act (USERRA)- Applicable to General Manager Only The Sponsor may continue the Covered person’s coverage (s) by paying the required premium, if the Covered Person is given a Military leave of absence. The Covered Person’s coverage will not continue beyond the end of the policy month following 12 months from the date the leave of absence begins. DOC3-TER-0001.34


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SECTION 6 - TERMINATION PROVISIONS

(Continued) What Happens If You Leave The Group Or Your Service Ends Because Of A Plant Closing Or Partial Closing? (Applicable to MA Residents only) If you leave the group covered by this policy, you will remain insured for a period of 31 days, unless during such period you are entitled to similar benefits. In addition, if you leave the group covered by this policy because your service is terminated due to plant closing or covered partial closing, you will remain insured under this policy for a period of 90 days, unless during such period you are entitled to similar benefits. DOC3-TER-0001.35


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SECTION 7 - GENERAL PROVISIONS

How Will Statements Made In Your Application Affect Your Coverage? In the absence of fraud, all statements made in any signed Application are considered representations and not warranties (absolute guarantees). No representation by the Sponsor in applying for this plan will make it void unless the representation is contained in the signed Application. Who Has The Authority For Interpretation Of This Plan? We shall possess the authority, in our sole discretion, to construe the terms of this plan and to determine benefit eligibility hereunder. Our decisions regarding construction of the terms of this plan and benefit eligibility shall be conclusive and binding. What Happens If Your Age Is Misstated? If your age has been misstated, an equitable adjustment will be made in the premium. If the amount of the benefit is dependent upon your age, the amount of the benefit will be the amount you would have been entitled to if your correct age were known. A refund of premium will not be made for a period more than 12 months before the date we are advised of the error. Who Will Pay Premiums During A Period For Which Benefits Are Payable? Your premium payments are waived during any period for which benefits are payable. If coverage is to be continued, premium payments may be resumed following a period during which they were waived. DOC3-GNP-0001.10


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When Can This Plan Be Contested? The validity of this plan shall not be contested, except for non-payment of premiums, after it has been in force for two years from the date of issue. The validity of this plan shall not be contested on the basis of a statement made relating to insurability by you after such insurance has been in force for two years during your lifetime, and shall not be contested unless the statement is contained in a written instrument signed by you. What Happens When There Are Canadian Residents Covered? If you are domiciled in Canada: (a) premium and benefit amounts will be deemed to be expressed in Canadian currency; (b) plan provisions concerning your rights are subject to applicable provincial statutes; and (c) with respect to benefits, an action under this plan may be brought in any court in the province where you are domiciled. How Will This Plan Affect Workers' Compensation? This plan and the coverages provided are not in lieu of, nor will they affect any requirements for coverage under any Workers' Compensation Law or other similar law. When Must We Be Notified Of A Claim? Notice of your claim must be given to us within 30 days of the date of the loss on which your claim is based, if that is possible. If that is not possible, we must be notified as soon as it is reasonably possible to do so. When we have the notice of your claim, we will send you our claim forms. If the forms are not received within 15 days after notice of your claim is sent, you can send us proof of claim without waiting for the form. DOC3-GNP-0001.10/0002.12


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(Continued) When Must We Receive Proof Of Claim? Proof of your claim must be given to us. This must be done no later than 30 days after the end of your Elimination Period. Failure to furnish such proof within such time shall not invalidate nor reduce any claim if it was not reasonably possible to furnish such proof within such time. Such proof must be furnished as soon as reasonably possible. Proof of your continued Disability or Partial Disability, when applicable, and regular attendance of a Physician must be given to us within 30 days of the request for the proof. The proof must cover, when applicable: a. the date your Disability or Partial Disability started; b. the cause of your Disability or Partial Disability; and c. the degree of your Disability or Partial Disability. DOC3-GNP-0002.12/0003.14


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(Continued) When Must Payment Of Claim Be Made? When we receive satisfactory proof of your claim, the benefit payable under this plan may be paid at least monthly, depending on the coverage for which your claim is made, during any period for which we are liable. Any balance remaining unpaid upon the termination of the period of liability will be paid immediately upon receipt of due written proof. Who Are Claims Paid To? The benefit is payable to you. But, if a benefit is payable to your estate, or if you are a minor, or you are not competent, we have the right to pay up to $2,000 to any of your relatives or any other person whom we consider entitled thereto by reason of having incurred expense for your maintenance, medical attendance or burial. If we, in good faith, pay the benefit in such a manner, we will not have to pay such benefit again. What Are Our Examination Rights? We, at our own expense, will have the right and opportunity to have you, whose Injury or Sickness is the basis of a claim, examined by a Physician or vocational expert of our choice. This right may be used as often as reasonably required. What Are Our Rights Of Recovery? If a benefit overpayment on any claim occurs, it will be required that reimbursement be made to us within 60 days of such overpayment, or we have the right to reduce future benefit payments until such reimbursement is received. We have the right to recover such overpayments from you or your estate. DOC3-GNP-0003.14 (Cont.)


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(Continued) When Can Legal Proceedings Begin? You or your authorized representative cannot start any legal action: 1. until 60 days after proof of claim has been given; nor 2. more than one year after the time proof of claim is required. How Will We Conform With State Statutes? Any provision of this plan which, on its Effective Date, is in conflict with the statutes of the governing jurisdiction of this plan is hereby amended to conform to the minimum requirements of such statute. What Are Our Rights Of Subrogation? When your Injury appears to be someone else's fault, benefits otherwise payable under this plan for loss of time as a result of that Injury will not be paid unless you or your legal representative agrees: 1. to repay us for such benefits to the extent they are for losses

for which compensation is paid to you by or on behalf of the person at fault;

2. to allow us a lien on such compensation and to hold such

compensation in trust for us; and 3. to execute and give to us any instruments needed to secure

the rights under 1. and 2. above. Further, when we have paid benefits to or on your behalf, we will be subrogated to all rights of recovery that you have against the person at fault. These subrogation rights will extend only to recovery of the amount we have paid. You must execute and deliver any instruments needed and do whatever else is necessary to secure those rights to us. DOC3-GNP-0003.14/0004


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