tidewater fleet supply llctidewaterfleetsupply.com/employees/disability application.pdf ·...

Tidewater Fleet Supply LLC

Short Term Disability

Effective April 1,2000

1. This is the short-term disability policy of Tidewater Fleet Supply LLC. It iseffective April 1,2000.

2. This policy supplements but does not replace the Leave Without Pay -Disability Policy stated in the Employee Handbook.

3. Tidewater Fleet Supply LLC has made arrangements with American FidelityAssurance Company to provide short-term (26 weeks maximum) disabilityinsurance to our employees.

4. This coverage is available on the same basis as our Group Health & DentalPlan.

a) Full-time employees are eligible to participate on the first day of themonth after they have been employed sixty (60) calendar days.

b) Full-time employees work at least thirty-two (32) hours per week.

5. Full-time employees may elect to enroll in the short-term disability program,subject to the conditions in 4 above. An employee may elect to cover up to60% of their normal income. An amount less than 60% may also be elected.

6. Tidewater Fleet Supply LLC will pay for two-thirds (66%) of the cost of thiscoverage.

7. In general, the coverage is for the first day of accident or the eighth day ofillness and continues for a maximum of twenty-six (26) weeks. You must beunder a doctor's care. The complete terms and conditions are contained inthe insurance document.

8. The short-term disability program is voluntary. You are not required toparticipate. Should you choose to participate and later change your mind,you may stop participation effective with the first of the month following.

9. This program represents the only short-term disability payment to anyemployee. There will be no other payment from Tidewater Fleet Supply LLCother than the two-thirds (66%) of the premium.

GROUPAPPLICATION

AMERICAN FIDELITY ASSURANCE COMPANY2000 N. Classen Blvd Oklahoma City, Oklahoma 73106

1. PROPOSED INSURED Last NameINFORMATION:

First Name Full Middle Name Suffix

Age Date of BirthMo Day Yr

Sex Soc Sec Number Requested Eff Date] F D MoDayYr

Date of EmploymentMo Day Yr

Residence Address: Number & Street (Not a P.O. Box) Work Phone # Home Phone #

City State Zip Country of Citizenship

Mailing Address (if different than Residence) City State Zip

Employer Name Employer/MCP # Salary: $_Tidewater Fleet Supply 25741 AnnualAre you currently able to perform the duties of your occupation?

MonthlyOccupation

Yes D NoApplicant's E-mail Address:2. BENEFITS APPLIED FOR:

Billing Persons Plan PREMIUM:Product New/Chg Distribution ID Covered1 Plan Code Amount Employee Employer Mode Total

S/T DisbL/T Disb

nnnnnnncnnnnnnnc

STNDSTND

ZZ

017935-D4017806-D31

^Individual; y=lndividual & Spouse; x=lndividual, Spouse & Child(ren); v=lndividual & Children; s=Spouse TOTAL3. BENEFICIARY:First Name Middle Name Last Name Relationship to Insured Country of Citizenship

4. ELECTION: I hereby enroll, add or change, as checked above, group insurance coverage(s) for which I am eligible. Iauthorize my employer to deduct my contributions, if any, from my pay.5. ACKNOWLEDGMENT: I understand and agree that:. The information in this application will be used to determine my eligibility for insurance; the statements and answers

shown in this application (first page and, if applicable, the second page) are true and complete; the Company may relyupon such answers as the basis of my contract; and no coverage will take effect until the application is approved by theCompany, the first premium is received, and a Certificate is issued.

. If applying for disability income coverage, OTHER INCOME I AM ENTITLED TO RECEIVE WILL, IF APPLICABLE,REDUCE MY MONTHLY BENEFIT. I SHOULD READ MY CERTIFICATE FOR MORE DETAILED INFORMATIONREGARDING HOW OTHER INCOME WILL REDUCE MY BENEFIT.

• "Pre-Existing Conditions" may not be covered; and I should read my Certificate for a more detailed explanation of thePre-Existing Condition exclusion, if any.

• BROCHURE(S) # APSB-21986(VA) HAS/HAVE BEENEXPLAINED TO ME, AND I HAVE RECEIVED A COPY/COPIES; OR, I HAVE HAD ACCESS TO AND THEOPPORTUNITY TO PRINT THE BROCHURE(S). (Please initial): |

6. FRAUD NOTICE: Any person who, with the intent to defraud or knowing that he is facilitating a fraud against anInsurer, submits an application or files a claim containing a false or deceptive statement may have violated the state law.

AGENT SIGNATURE (where required by law) Date

Agent #

A1264VA

SIGNATURE (Applicant)

GROUP AMERICAN FIDELITY ASSURANCE COMPANYAPPLICATION 2000 N. Classen Blvd Oklahoma City, Oklahoma 73106

PROPOSED INSURED'S NAME:

HEALTH HISTORY:7. Within the past 5 years, have you received a diagnosis, taken medication and/or had

treatment by a member of the medical profession for any of the following:

Cancer (other than basal or squamous cell skin cancer), heart and/or circulatory disorder,peripheral vascular disease (PVD), stroke or transient ischemic attack, liver or kidneydisorder/disease (excluding stones), pulmonary disease, diabetes requiring insulin, rheumatoid Yes CD No darthritis, epilepsy, ulcerative colitis, Crohn's disease, organ transplant, systemic lupuserythematosus, disorder of blood cells or blood clotting disorder, seizures, Acquired ImmuneDeficiency Syndrome (AIDS), AIDS-Related Complex (ARC), or Human Immunodeficiency Virus(HIV), Chronic Fatigue Syndrome (CFS), fibromyalgia, alcohol or drug addiction or abuse, orneurological disorder (excluding headaches or migraines).

8. Within the past 12 months, have you:

Received advice from a medical provider, taken medication, incurred an expense, undergonetests, or received treatment (including, but not limited to, spinal manipulation, physical therapy, or Yes D No Dcounseling) for a condition related to: (a) your back, neck or spine; (b) a mental or nervouscondition; or (c) had surgery recommended that has not yet been performed or received a referralfor surgery consultation?

9. Are you currently pregnant? Yes d No D

10. The undersigned applicant and agent, if applicable, certify that the applicant has read, or had read to him, thecompleted application and that the applicant realizes that any false statement or misrepresentation in the applicationmay result in loss of coverage under the policy.

I also understand that additional investigation could occur at time of claim and any misrepresentation contained hereinrelied on by the Company may be used to reduce or deny a claim and/or void the coverage if such misrepresentationmaterially affects the acceptance of the risk.

Date

Agent Signature Applicant Signature

A1264VA

Help Us Help the Environment

Electronic delivery of policy documents can offer you access to the most up-to-date documents keepingthem safe so that you can have access to them at any time.

If you would like to receive and manage your American Fidelity Assurance Company Policy Documentsonline electronically, please read the Consent to Electronic Delivery of Policy Documents and place yourinitials in the space provided below.

Consent to Electronic Delivery of Policy Documents

I hereby request and agree to Electronic Delivery of Policy Documents ("Consent"), if available, by AmericanFidelity Assurance Company (AFA).

Policy DocumentsI understand that: (1) Policy Documents will be hosted on a secure Web site; (2) I will receive an e-mail from AFAto the e-mail address that I have designated below containing instructions and AFA's web address; (3) ElectronicDelivery is in lieu of regular U.S. Mail delivery; (4) Electronic Delivery is sufficient to meet all requirements underthe Policy; (5) paper copies of any and all electronically delivered Policy Documents are available to me upon myrequest; and (6) if I have executed more than one Consent, only my last election will be in effect.

Systems RequirementsI understand that in order to receive Policy Documents electronically, I must use a valid e-mail address, anInternet connection, and a computer that meets the following minimum requirements: Internet Explorer 6.0 or laterand Adobe® Reader® 8.0 or newer, available free on www.afadvantage.com or www.adobe.com.

Revocation of ConsentI understand that either party may revoke this Consent unilaterally at any time with ten (10) days prior notice tothe other party. The Certificateholder/Policy Owner may revoke by calling, toll-free: 1-800-654-8489; or by writingto: American Fidelity Assurance Company, 2000 N. Classen Blvd., Oklahoma City, Oklahoma 73106. Uponrevocation of this Consent, AFA will communicate all future Policy Documents via regular U.S. Mail to the lastknown designated address of the Certificateholder/Policy Owner.

Transmittal of Policy DocumentsI understand that I am responsible at all times, as the Certificateholder/Policy Owner, to notify AFA in writing ofany and all changes associated with the transmittal of Policy Documents. That I, as the Certificateholder/PolicyOwner, agree that I will hold AFA harmless with respect to any and all delivery errors caused by my failure toprovide current and valid information for the receipt of Policy Documents.

in the box below, I Q agree |~~| d° not agree to the Electronic Delivery of my Policy Documents.

INITIAL ABOVE DATE

Name and designated electronic transmittal e-mail address of the Certificateholder/Policy Owner:

PRINTED NAME E-MAIL ADDRESS

M-3311

Tidewater Fleet SupplyShort Term Disability

Policy # G-108-105

Rates as of :

AnnualIncome$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$

4,000.005,000.006,000.007,000.008,000.009,000.00

10,000.0011,000.0012,000.0013,000.0014,000.0015,000.0016,000.0017,000.0018,000.0019,000.0020,000.0021,000.0022,000.0023,000.0024,000.0025,000.0026,000.0027,000.0028,000.0029,000.0030,000.0031,000.0032,000.0033,000.0034,000.0035,000.0036,000.0037,000.0038,000.0039,000.0040,000.0041,000.0042,000.0043,000.0044,000.0045,000.00

8/1/2004

Monthly MonthlyBenefit$ 200.00$ 250.00$ 300.00$ 350.00$ 400.00$ 450.00$ 500.00$ 550.00$ 600.00$ 650.00$ 700.00$ 750.00$ 800.00$ 850.00$ 900.00$ 950.00$1,000.00$1,050.00$1,100.00$1,150.00$1,200.00$1,250.00$1,300.00$1,350.00$1,400.00$1,450.00$1,500.00$1,550.00$1,600.00$1,650.00$1,700.00$1,750.00$1,800.00$1,850.00$1,900.00$1,950.00$2,000.00$2,050.00$2,100.00$2,150.00$2,200.00$2,250.00

Premium$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$

4.806.007.208.409.60

10.8012.0013.2014.4015.6016.8018.0019.2020.4021.6022.8024.0025.2026.4027.6028.8030.0031.2032.4033.6034.8036.0037.2038.4039.6040.8042.0043.2044.4045.6046.8048.0049.2050.4051.6052.8054.00

Rate Factorper $100:

EmployeeDeductionBi-Weekly

$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$

0.750.941.131.321.511.691.882.072.262.452.642.823.013.203.393.583.773.954.144.334.524.714.905.085.275.465.655.846.036.216.406.596.786.977.167.347.537.727.918.108.298.47

EmployeeDeductionMonthly$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$

1.632.042.452.863.263.674.084.494.905.305.716.126.536.947.347.758.168.578.989.389.79

10.2010.6111.0211.4211.8312.2412.6513.0613.4613.8714.2814.6915.1015.5015.9116.3216.7317.1417.5417.9518.36

$ 2.40

American Fidelity Short Long Term Disibility.xlsShort Term 8/26/2010


Policy # G-108-105

Rates a*

AnnualIncome$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$

5 of:

46,000.0047,000.0048,000.0049,000.0050,000.0051,000.0052,000.0053,000.0054,000.0055,000.0056,000.0057,000.0058,000.0059,000.0060,000.0061,000.0062,000.0063,000.0064,000.0065,000.0066,000.0067,000.0068,000.0069,000.0070,000.0071,000.0072,000.0073,000.0074,000.0075,000.0076,000.0077,000.0078,000.0079,000.0080,000.0081,000.0082,000.0083,000.0084,000.0085,000.0086,000.0087,000.00

8/1/2004

Monthly MonthlyBenefit$2,300.00$2,350.00$2,400.00$2,450.00$2,500.00$2,550.00$2,600.00$2,650.00$2,700.00$2,750.00$2,800.00$2,850.00$2,900.00$2,950.00$ 3,000.00$ 3,050.00$3,100.00$3,150.00$ 3,200.00$3,250.00$ 3,300.00$ 3,350.00$3,400.00$3,450.00$ 3,500.00$ 3,550.00$3,600.00$3,650.00$ 3,700.00$ 3,750.00$3,800.00$3,850.00$3,900.00$3,950.00$4,000.00$4,050.00$4,100.00$4,150.00$4,200.00$4,250.00$4,300.00$4,350.00

Premium$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$

55.2056.4057.6058.8060.0061.2062.4063.6064.8066.0067.2068.4069.6070.8072.0073.2074.4075.6076.8078.0079.2080.4081.6082.8084.0085.2086.4087.6088.8090.0091.2092.4093.6094.8096.0097.2098.4099.60

100.80102.00103.20104.40



$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$

8.668.859.049.239.429.609.799.98

10.1710.3610.5510.7310.9211.1111.3011.4911.6811.8612.0512.2412.4312.6212.8012.9913.1813.3713.5613.7513.9314.1214.3114.5014.6914.8815.0615.2515.4415.6315.8216.0116.1916.38

EmployeeDeductionMonthly$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$

18.7719.1819.5819.9920.4020.8121.2221.6222.0322.4422.8523.2623.6624.0724.4824.8925.3025.7026.1126.5226.9327.3427.7428.1528.5628.9729.3829.7830.1930.6031.0131.4231.8232.2332.6433.0533.4633.8634.2734.6835.0935.50

$ 2.40



Policy #6-108-105

Rates as of :

AnnualIncome$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$

88,000.0089,000.0090,000.0091,000.0092,000.0093,000.0094,000.0095,000.0096,000.0097,000.0098,000.0099,000.00

100,000.00101,000.00102,000.00103,000.00104,000.00105,000.00106,000.00107,000.00108,000.00109,000.00110,000.00111,000.00112,000.00113,000.00114,000.00115,000.00116,000.00117,000.00118,000.00119,000.00120,000.00121,000.00122,000.00123,000.00124,000.00125,000.00

8/1/2004

MonthlyBenefit$4,400.00$4,450.00$4,500.00$4,550.00$4,600.00$4,650.00$4,700.00$4,750.00$4,800.00$4,850.00$4,900.00$4,950.00$ 5,000.00$ 5,050.00$5,100.00$5,150.00$5,200.00$5,250.00$5,300.00$5,350.00$ 5,400.00$5,450.00$ 5,500.00$ 5,550.00$5,600.00$5,650.00$ 5,700.00$5,750.00$5,800.00$5,850.00$5,900.00$ 5,950.00$6,000.00$6,050.00$6,100.00$6,150.00$6,200.00$6,250.00

MonthlyPremium$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$

105.60106.80108.00109.20110.40111.60112.80114.00115.20116.40117.60118.80120.00121.20122.40123.60124.80126.00127.20128.40129.60130.80132.00133.20134.40135.60136.80138.00139.20140.40141.60142.80144.00145.20146.40147.60148.80150.00



$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$

16.5716.7616.9517.1417.3217.5117.7017.8918.0818.2718.4518.6418.8319.0219.2119.4019.5819.7719.9620.1520.3420.5320.7120.9021.0921.2821.4721.6621.8422.0322.2222.4122.6022.7922.9723.1623.3523.54

EmployeeDeductionMonthly$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$

35.9036.3136.7237.1337.5437.9438.3538.7639.1739.5839.9840.3940.8041.2141.6242.0242.4342.8443.2543.6644.0644.4744.8845.2945.7046.1046.5146.9247.3347.7448.1448.5548.9649.3749.7850.1850.5951.00

$ 2.40



Policy #G-108-105

Rate FactorRates as of: 8/1/2004 per $100: $ 2.40

Employee , EmployeeAnnual Monthly Monthly Deduction DeductionIncome Benefit Premium Bi-Weekly Monthly

American Fidelity Short Long Term Disibility.xlsShort Term 4 8/26/2010

Tidewater Fleet SupplyLong Term DisabilityPolicy # G-108-105

Rates as of :

Annual

$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$

Income4,000.005,000.006,000.007,000.008,000.009,000.00

10,000.0011,000.0012,000.0013,000.0014,000.0015,000.0016,000.0017,000.0018,000.0019,000.0020,000.0021,000.0022,000.0023,000.0024,000.0025,000.0026,000.0027,000.0028,000.0029,000.0030,000.0031,000.0032,000.0033,000.0034,000.0035,000.0036,000.0037,000.0038,000.0039,000.0040,000.0041,000.0042,000.0043,000.0044,000.00

8/1/2004

MonthlyBenefit$ 200.00$ 250.00$ 300.00$ 350.00$ 400.00$ 450.00$ 500.00$ 550.00$ 600.00$ 650.00$ 700.00$ 750.00$ 800.00$ 850.00$ 900.00$ 950.00$1,000.00$1,050.00$1,100.00$1,150.00$1,200.00$1,250.00$1,300.00$1,350.00$1,400.00$1,450.00$1,500.00$1,550.00$1,600.00$1,650.00$1,700.00$1,750.00$1,800.00$1,850.00$1,900.00$1,950.00$2,000.00$2,050.00$2,100.00$2,150.00$2,200.00

MonthlyPremium$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$

2.803.504.204.905.606.307.007.708.409.109.80

10.5011.2011.9012.6013.3014.0014.7015.4016.1016.8017.5018.2018.9019.6020.3021.0021.7022.4023.1023.8024.5025.2025.9026.6027.3028.0028.7029.4030.1030.80



$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$

1.291.621.942.262.582.913.233.553.884.204.524.855.175.495.826.146.466.787.117.437.758.088.408.729.059.379.69

10.0210.3410.6610.9811.3111.6311.9512.2812.6012.9213.2513.5713.8914.22

EmployeeDeductionMonthly

$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$

2.803.504.204.905.606.307.007.708.409.109.80

10.5011.2011.9012.6013.3014.0014.7015.4016.1016.8017.5018.2018.9019.6020.3021.0021.7022.4023.1023.8024.5025.2025.9026.6027.3028.0028.7029.4030.1030.80

$ 1.40

American Fidelity Short Long Term Disibility.xlsLong Term 8/26/2010


Rates as of :

Annual

$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$

Income45,000.0046,000.0047,000.0048,000.0049,000.0050,000.0051,000.0052,000.0053,000.0054,000.0055,000.0056,000.0057,000.0058,000.0059,000.0060,000.0061,000.0062,000.0063,000.0064,000.0065,000.0066,000.0067,000.0068,000.0069,000.0070,000.0071,000.0072,000.0073,000.0074,000.0075,000.0076,000.0077,000.0078,000.0079,000.0080,000.0081,000.0082,000.0083,000.0084,000.0085,000.00

8/1/2004

MonthlyBenefit$2,250.00$2,300.00$2,350.00$2,400.00$2,450.00$2,500.00$2,550.00$2,600.00$2,650.00$2,700.00$2,750.00$2,800.00$2,850.00$2,900.00$2,950.00$ 3,000.00$3,050.00$3,100.00$3,150.00$ 3,200.00$ 3,250.00$3,300.00$ 3,350.00$3,400.00$3,450.00$3,500.00$ 3,550.00$ 3,600.00$ 3,650.00$ 3,700.00$3,750.00$3,800.00$3,850.00$ 3,900.00$ 3,950.00$4,000.00$4,050.00$4,100.00$4,150.00$4,200.00$4,250.00

MonthlyPremium$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$

31.5032.2032.9033.6034.3035.0035.7036.4037.1037.8038.5039.2039.9040.6041.3042.0042.7043.4044.1044.8045.5046.2046.9047.6048.3049.0049.7050.4051.1051.8052.5053.2053.9054.6055.3056.0056.7057.4058.1058.8059.50



$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$

14.5414.8615.1815.5115.8316.1516.4816.8017.1217.4517.7718.0918.4218.7419.0619.3819.7120.0320.3520.6821.0021.3221.6521.9722.2922.6222.9423.2623.5823.9124.2324.5524.8825.2025.5225.8526.1726.4926.8227.1427.46


$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$

31.5032.2032.9033.6034.3035.0035.7036.4037.1037.8038.5039.2039.9040.6041.3042.0042.7043.4044.1044.8045.5046.2046.9047.6048.3049.0049.7050.4051.1051.8052.5053.2053.9054.6055.3056.0056.7057.4058.1058.8059.50

$ 1.40



Rates as of :

Annual

$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$

Income86,000.0087,000.0088,000.0089,000.0090,000.0091,000.0092,000.0093,000.0094,000.0095,000.0096,000.0097,000.0098,000.0099,000.00

100,000.00101,000.00102,000.00103,000.00104,000.00105,000.00106,000.00107,000.00108,000.00109,000.00110,000.00111,000.00112.000.00113,000.00114,000.00115,000.00116,000.00117,000.00118,000.00119,000.00120,000.00121,000.00122,000.00123,000.00124,000.00125,000.00

8/1/2004

Monthly MonthlyBenefit$4,300.00$4,350.00$4,400.00$4,450.00$4,500.00$4,550.00$4,600.00$4,650.00$4,700.00$4,750.00$4,800.00$4,850.00$4,900.00$4,950.00$ 5,000.00$5,050.00$5,100.00$5,150.00$5,200.00$5,250.00$ 5,300.00$ 5,350.00$ 5,400.00$ 5,450.00$5,500.00$5,550.00$5,600.00$ 5,650.00$ 5,700.00$ 5,750.00$ 5,800.00$ 5,850.00$ 5,900.00$5,950.00$6,000.00$6,050.00$6,100.00$6,150.00$6,200.00$6,250.00

Premium$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$

60.2060.9061.6062.3063.0063.7064.4065.1065.8066.5067.2067.9068.6069.3070.0070.7071.4072.1072.8073.5074.2074.9075.6076.3077.0077.7078.4079.1079.8080.5081.2081.9082.6083.3084.0084.7085.4086.1086.8087.50



$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$

27.7828.1128.4328.7529.0829.4029.7230.0530.3730.6931.0231.3431.6631.9832.3132.6332.9533.2833.6033.9234.2534.5734.8935.2235.5435.8636.1836.5136.8337.1537.4837.8038.1238.4538.7739.0939.4239.7440.0640.38


$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$

60.2060.9061.6062.3063.0063.7064.4065.1065.8066.5067.2067.9068.6069.3070.0070.7071.4072.1072.8073.5074.2074.9075.6076.3077.0077.7078.4079.1079.8080.5081.2081.9082.6083.3084.0084.7085.4086.1086.8087.50

$ 1.40
