Unum Provident Disability Program Booklet

UNUM PROVIDENT
SUPPLEMENTAL DISABILITY BENEFIT PLAN
CSX Transportation
Plan No. 11220-1 (M-948-ASO)
UNUM PROVIDENT CONTACTS:
Sr. Disability Benefit Specialist:
Disability Benefit Specialist:
Claims Manager:
Kim Porter
Daryle Edmonds
Dan Vatt
1-800-858-6843
1-800-858-6843
1-800-858-6843
EXT. 45625
EXT. 46609
EXT. 44066
Coverage: Conductor and Trainmen employees only.
To speak with a UNUM Provident Representative regarding a general claim dial: 1-800-822-9103
To fax information to UNUM provident, including filing a claim by fax dial: 1-800-447-2498
TO CERTAIN EMPLOYEES OF THE
CSX TRANSPORTATION, INC.
REPRESENTEDBYTHE
UNITED TRANSPORTATION UNION
One of the most difficult problems confronting a worker is that of protecting himself
against loss of income during periods of disability caused by accident or sickness.
The plan outlined in this booklet has been especially designed to give a disabled eligible
employee an income for up to 12 months in addition to benefits available under the
Railroad Unemployment lnsurance Act.
Please study this booklet carefully, so that you will become acquainted with the benefits
to which you are entitled.
The Provident Life and Accident lnsurance Company are pleased to participate as the
Administrator of this Benefit Program.
TABLE OF CONTENTS
Page
IMPORTANT INFORMATION WITH RESPECT TO ELIGIBILITY
Qualifying Employees ........................................................................................ 4
Eligibility for Benefits.......................................................................................... 4
When Is a Qualifying Employee Covered? .................................................. 4
When Does a Qualifying Employee Become
Eligible for Benefits? ................................................................................... 5
DEFINITIONS ............................................................................................................. 6
MONTHLY BENEFIT FOR TOTAL DISABILITY........................................................ 7
Indemnity Limits ................................................................................................. 7
Exclusions and Limitations................................................................................. 7
Schedule of Benefits .......................................................................................... 8
TERMINATION OF COVERAGE .............................................................................. II
CLAIM INFORMATION............................................................................................. 12
Notice of Disability ........................................................................................... 12
Proof of Claim .................................................................................................. 12
Payment of Claim............................................................................................. 12
Supplementary Plan Description...................................................................... 14
How To File A Claim ........................................................................................ 19
QUESTIONS AND ANSWERS ................................................................................. 20
IMPORTANT INFORMATION WITH RESPECT TO ELIGIBILITY
Qualifying Employees
Benefit Program No. M-948-AS0 is applicable only to Qualifying Employees.
A Qualifying Employee is a train service employee of the CSXT who is in active train
service on a portion of CSXT subject to a supplemental sickness benefit agreement with
the United Transportation Union.
ELIGIBILITY FOR BENEFITS
When Is A Qualifying Employee Covered?
If you are a Qualifying Employee and have a minimum of six months of continuous
active service on a portion of CSXT covered by a supplemental sickness benefit
agreement, you will be covered for each month in which you rendered compensated
service to or received vacation pay from CSXT or in which you did not render
compensated service solely as a result of disability caused by accidental bodily injury or
sickness.
No Employee shall be covered (a) after the date on which his employment relationship
is terminated; (b) after the date he is granted a leave of absence; (c) after commencing
work on a regular or permanent basis for CSXT on a position not covered by a
supplemental sickness benefit agreement with the United Transportation Union (train
service employees); or, (d) for a longer period than 12 months during any one period of
disability.
IMPORTANT INFORMATION WITH RESPECT TO ELIGIBILITY
(Continued)
Qualifying Employees
An Employee will be considered in active service if he has a continuous employment
relationship with the CSXT on a regular, relief, or extra position.
When Does a Qualifying Employee Become Eligible for Benefits?
An Employee shall be eligible for the benefits described in this booklet if he is unable to
work in train service solely as a result of disability caused by accidental bodily injury
occurring or sickness commencing while he is covered. The disability must be certified
by a duly licensed physician or surgeon. Recertification may be required periodically in
cases involving prolonged disabilities.
The Employees eligible for such benefits are hereinafter referred to as "Eligible
Employees."
DEFINITIONS
1.
The term "total disability" as used herein means the complete
inability of an Employee, because of injury or sickness, to perform each and
every duty pertaining to his occupation or employment.
Period of Total Disability - A period of total disability means the period of time
during which a Covered Employee is totally disabled, as defined above, whether
from one or more causes, beginning with the first full day of total disability
following cessation of active work for the Employer and ending on the date such
Employee ceases to be totally disabled.
The term "hospital" as used herein means an institution which meets all the
following tests:
(a)
It is engaged primarily in providing medical care and treatment of sick and
injured persons on an in-patient basis at the patient's expense and
maintains diagnostic and therapeutic facilities for surgical and medical
diagnosis and treatment of such persons by or under the supervision of a
staff of duly qualified physicians;
It continuously provides 24 hour a day nursing service by or under the
(b)
supervision of registered graduate nurses and is operated continuously
with organized facilities for operative surgery; and
It is not, other than incidentally, a place of rest, a place for the aged, a
(c)
place for drug addicts, a place for alcoholics or a nursing home.
3.
The term "Other Income Benefits" as used herein means income benefits under:
the Railroad Unemployment Insurance Act;
(a)
(b)
the Railroad Retirement Act;
the Federal Social Security Act; and,
(c)
any plan, fund or other arrangement, by whatever name called, providing
(d)
benefits for loss of time from employment because of disability pursuant to
any compulsory benefit act or law of any government.
4. The term "average monthly earnings" as used herein means the average of the
Employee's actual gross wages received from CSXT during the 12 calendar
months immediately preceding the month in which disability commences.
MONTHLY BENEFIT FOR DISABILITY
If an Eligible Employee shall be disabled as a result of accidental bodily injury or
sickness, the Administrator will pay to the Employee for the period for such disability a
benefit as provided herein.
BENEFIT LIMITS - Benefits will be paid commencing with the fifth full day of disability
and will be paid for not more than 12 months during any one period of disability,
provided that no payment shall be made:
for disability for which the Employee is not under treatment by a duly
(1)
qualified physician or surgeon as certified by the physician or surgeon;
during
the first four days of an injury or sickness;
(2)
for disability due to intentionally self-inflicted injuries;
(3)
for disability for which the contributing cause was the commission or
(4)
attempted commission by the Employee of an assault, battery or felony;
for
disability due to war or any act of war, insurrection, riot or rebellion;
(5)
for
any day on which an Employee eligible to receive benefits under the
(6)
Disability provisions of the Railroad Unemployment Insurance Act is
denied such benefits for any reason including failure by the Employee to
make application for benefits;
after
the date the employment relationship ceases;
(7)
for disability which commences before the effective date of the Plan;
(8)
after the date of the employee's death or the date he ceases to be
(9)
disabled; or
(10) after the date the employee is furloughed.
MONTHLY BENEFIT FOR DISABILITY
(Continued)
In determining the amount of monthly benefits payable, an Employee age 65 or over
shall be considered eligible to receive extended or accelerated sickness benefits under
the Railroad Unemployment Insurance Act if such employee would have been eligible to
receive such benefits if under 65 years of age.
SCHEDULE OF BENEFITS
The following SCHEDULE OF BENEFITS is applicable for periods of disability
commencing on and after June 1,2009:
(i)
The amount of monthly benefit payable for each full month of total
disability shall be determined by the Employee's average monthly
earnings for the 12 month period preceding disability, subject to a
maximum of:
(a)
$1,005.70 for each of the first six month of any one period of
disability; or
$1,273.87 for each of the 7th through 12th months of any one
(b)
period of disability.
The $1,005.70 shall be increased by $134.09 with respect to the first two
months of any one period of disability while the Employee is confined as
an in-patient in a hospital.
Benefits will be pro-rated whenever less than a full calendar month is
involved.
A covered employee during his initial RUlA registration period after all
certification requirements are met will receive:
(ii)
Benefits for the 5th thru the 14th day of disability at the applicable basic
benefit amount plus
(iii)
An amount equal to the total RUlA benefit that would have been payable
for days of sickness except for RUIA's "waiting period" requirement.
MONTHLY BENEFIT FOR DISABILITY
(Continued)
SCHEDULE OF BENEFITS
(Continued)
(iv)
The maximum monthly benefit shall be $1,005.70 during any part of the
7th through 12th month during any one period of disability during which
the Employee is eligible to receive disability benefits under the Railroad
Unemployment lnsurance Act.
The monthly benefit will be reduced to the extent that it, plus any
other income benefit available to an employee in the same month,
exceeds the lesser of $1,881.03 or 70% of the employee's average
monthly earnings in the 12 months preceding disability.
(v)
When the benefits are reduced because of sickness benefits payable
under the Railroad Unemployment lnsurance Act ($59 per day at the time
this booklet was issued), the monthly benefits payable under the Benefit
Program are based upon average monthly earnings for the 12-month
period immediately preceding disability. The monthly RUlA benefit amount
is calculated by multiplying the daily rate by 21.75.
Lower average monthly income than shown above will result in additional
reduction in the monthly benefit.
MONTHLY BENEFIT FOR DISABILITY
(Continued)
SCHEDULE OF BENEFITS
(Continued)
Retroactive Payment of Other Income Benefit. If an employee receives any other
income benefit on a retroactive basis for any part of a period of disability for which
benefits were paid under this Benefit Program, the Administrator will have the right to
recover the amount of benefits paid under this Benefit Program in excess of what the
employee would have received had the retroactive payments been made when the
benefits were paid.
Liability Cases. In case of a disability for which the employee may have a right of
recovery, benefits will be paid under this Benefit Program pending final resolution of the
matter so that the employee will not be exclusively dependent upon Railroad
Unemployment lnsurance Sickness Benefits or other existing benefits. However, the
benefits under this program are not to duplicate recovery for loss of wages.
Accordingly, benefits paid under this Benefit Program will be offset against any claim for
loss of wages the employee may have against the Company and may be recovered by
the Company if lost wages are recovered from third parties. As a condition for payment
of Benefits, Provident, the Administrator, may require the employee to assign to it the
right to recover wages, to the amount of benefits paid, from third parties. Upon
recovery, the employee will reimburse the Administrator for benefits paid under the
Benefit Program.
Non-Governmental Plan for Sickness Insurance. Effectiveness of the Supplemental
Sickness Benefit Plan is conditioned upon a favorable ruling from the Railroad
Retirement Board that such Plan qualified as a "non-governmental plan for sickness
insurance" under Section i(j) of the Railroad Unemployment lnsurance Act.
TERMINATION OF COVERAGE
Your coverage under the Plan will terminate on the earliest of the following dates:
(a)
The date of termination of the Benefit Program;
(b)
The date the Benefit Program is amended to terminate the
coverage with respect to the class of Employees of which you are a
member; or
(c)
The date you cease to be a Covered Employee as defined on Page 5.
CLAIM INFORMATION
NOTICE OF DISABILITY
A Notice of Disability form is included in this booklet. It may be used to report a claim for
benefits under this Benefit Program. You may also obtain Notice of Disability forms from
the Administrator's claim processing office or your supervisor. When you have been
disabled and under the care of a physician for five days, complete the enclosed Notice
of Disability Form and mail it promptly to the Administrator's claim processing office.
PROOF OF CLAIM
Upon receipt of the Notice of Disability form, Provident will immediately furnish an
attending Physician's Statement. This form contains detailed instructions for completion.
PAYMENT OF CLAIMS
Benefits will be paid upon receipt of written proof on the Administrator's forms, or if such
forms are not furnished by the Administrator within 15 days after demand therefore,
then upon receipt of written proof covering the occurrence, character and extent of the
event for which claim is made, the Administrator may require as part of the proof of
claim, bills with respect to hospital confinement and to all other charges incurred. The
Administrator will make any investigations necessary of claims and will make all
payments in settlement of such claims.
The Administrator has the right to require an examination of the person of the Covered
Employee by a licensed physician when and as often as it may reasonably require
during the pendency of the claim, to the extent that such examination is necessary to
the investigation of the pending claim.
Proof of loss on which claim may be based should be furnished to the Administrator no
later than 90 days after the date of such loss.
If any time limitation applicable to the Benefit Program with respect to furnishing proof of
loss or bringing of an action at law or in equity is less than the minimum permitted by
the law of the state in which the Covered Employee resides at the date of the accident
causing the injury on which claim is based or at the date of commencement of sickness
disability or of other loss on which claim is based, such limitation is extended to agree
with the minimum period permitted by such law.
CLAIM INFORMATION
(Continued)
All benefits will be paid immediately after receipt of the due proof of loss, or upon the
request of the Employee, and subject to due proof of loss. The accrued monthly benefit
for which proof of loss has been furnished will be paid each month and any balance
remaining unpaid at the termination of such period will be paid immediately after receipt
of due proof.
All benefits will be payable to the Employee and any accrued benefits unpaid at his
death shall be payable to his Estate.
SUPPLEMENTARY PLAN INFORMATION
The following information, together with this booklet, constitutes the Summary Plan
Description required by the Employee Retirement Income Security Act of 1974 to be
distributed to Employees covered under this Benefit Program.
1.
Name of Plan: Supplemental Sickness Benefit Plan covering certain employees
of CSX Transportation, Inc., represented by the United Transportation Union.
2.
Name, Address and Telephone Number of the Plan Sponsor who is the agent for
service of legal process of the Benefit Program:
CSX Transportation, Inc.
50 Water Street
Jacksonville, FL 32202
AC 904 - 359-2345
3.
Employer Identification Number: 54-6000720
4.
Type of Administration: A S 0
5.
Benefit Program records are maintained on a policy year basis ending December
31st each year.
6.
Source of Contributions: Employer
7.
Claim Procedures and Payment of Benefits:
Claim for benefits under the Benefit Program is to be submitted to the
Administrator as provided in your booklet. Payment of claim under the Benefit
Program will be made by the Administrator. If your claim for benefits under the
Benefit Program is denied, the Administrator will provide notice to you in writing
of the denial within 90 days after receipt of the claim setting for the specific
reasons for such denial; specific reference to pertinent plan provisions on which
denial is based; a description of any additional information needed to perfect a
claim and an explanation of why such information is needed; and appropriate
information as to steps to be taken if you wish to have your claim reviewed.
SUPPLEMENTARY PLAN INFORMATION
(Continued)
You or your duly authorized representative have the right to request review of
your claim by the Administrator. You may request a review upon written
application to the Administrator within 60 days of receipt of the claim denial. You
may review pertinent documents and submit issues and comments in writing.
Ordinarily the Administrator will make a final review and notify you in writing
within 60 days. This notice shall contain specific reasons for the decision with
references to appropriate plan provisions. If special circumstances warrant
additional time for review, you will be notified in writing prior to the extension. In
no case will the extension be more than an additional 60 days.
The Administrator's liability for claims review extends only to the benefits
provided under the plan of coverage listed in Item 1. The Administrator will not
review claims for any other benefits unless a separate contract specifically
provides for this.
8.
An Employee you are a participant in the Benefit Program and are entitled to
certain rights and protections under the Employee Retirement Income Security
Act of 1974. ERISA provides that all plan participants shall be entitled to:
Examine without charge, at the Plan Sponsor's office all Benefit Program
documents, including contracts, and copies of all documents filed by the
Benefit Program with the U.S. Department of Labor, such as annual
reports and plan descriptions.
Obtain copies of all Benefit Program documents and other Benefit
Program information upon written request to the Benefit Program Plan
Sponsor. The Plan Sponsor may make a reasonable charge for copies.
Receive a summary of the Benefit Program's annual financial report. The
Benefit Program Plan Sponsor is required by law to furnish each
participant with a copy of this summary financial report.
SUPPLEMENTARY PLAN INFORMATION
(Continued)
In addition to creating rights for Benefit Program participants, ERISA imposes duties
upon people who are responsible for the operation of the Employee Benefit Program.
The people who operate your Benefit Program, called "fiduciaries" of the Benefit
Program, have a duty to do so prudently and in the interest of you and other Benefit
Program participants and beneficiaries.
No one may fire you or otherwise discriminate against you in any way to prevent you
from obtaining a benefit or exercising your rights under ERISA. If your claim for a benefit
is denied in whole or in part you must receive a written explanation of the reason for the
denial. You have the right to have the plan reviewed and your claim reconsidered. If you
are not satisfied with the final claims decision, you may file suit in Federal or State
Court.
Under ERISA, there are steps you can take to enforce the above rights. For instance, if
you request materials from the Benefit Program and do not receive them within 30 days,
you may file suit in a Federal Court. In such a case, the court may require the Benefit
Program Plan Sponsor to provide materials and pay you up to $1 10 a day until you
receive the materials, unless the materials were not sent because of reasons beyond
the control of the Plan Sponsor. If you have a claim for benefits which is denied or
ignored, in whole or in part, you may file suit in a state or federal court. If it should
happen that Benefit Program fiduciaries misuse the Benefit Program's money, or if you
are discriminated against for asserting your rights, you may seek assistance from the
U.S. Department of Labor, or you may file suit in a Federal Court. The court will decide
who should pay court costs and legal fees. If you are successful the court may order the
person you have sued to pay these costs and fees or, if it finds your claim is frivolous
the court may order you to pay the costs and fees. If you have any questions about your
plan, you should contact the Benefit Program Plan Sponsor.
If you have any questions about this statement or your rights under ERISA, you should
contact the Benefit Program Plan Sponsor or the nearest Area Office of the U.S. LaborManagement Service Administration, Department of Labor.
The information contained in this Summary Plan Description is only a summary of
several rights, benefits and administrative procedures contained in your Benefit
Program. In case of any conflict, specific terms in the plan document will control over
the summary.
IMPORTANT NOTICE FOR
EMPLOYEESREPRESENTEDBY
UNITED TRANSPORTATION UNION
ON
CSXT (FORMER B&OlB&OCT, C&O (PROPER) C&O (PMIHV)), WM, A&WP AND
CERTAIN EMPLOYEES AT CONSOLIDATED GREATER RICHMOND TERMINAL
CSXT and the United Transportation Union have completed agreements to provide
covered employees with a Supplemental Sickness Benefit Plan effective January 1,
1990 which provides monthly benefits payable during illness or injury and loss of time
from work.
This new agreement applies to Train Service Employees represented by the United
Transportation Union on the above-named portions of CSXT and covers disability
commencing on or after June 1, 2009, provided the following requirements have been
met:
Employee has completed six months of continuous active service with
(a)
CSXT under the collectively bargained agreement with the United
Transportation Union to which he is subject.
(b)
Employee is in active train service subject to the collectively bargained
agreement with the United Transportation Union.
(c)
Employee is eligible for sickness benefits as provided by the Railroad
Unemployment Insurance Act.
(d)
Employee is unable to work in train service solely because of illness or
injury as certified by a licensed physician.
(e)
Employee has met a four-day waiting period from the date of
commencement of illness or injury.
(f)
Employee is not subject to a wage continuation program as a result of an
on-duty personal injury.
Plan benefit amounts are determined by an employee's average monthly earnings in the
12-month period immediately preceding disability, subject to a monthly maximum of
$1,005.70.
The above brief description of benefits available is furnished in order to make
employees aware of the existence of the Supplemental Sickness Benefit Plan. If there
is any discrepancy between this notice and Plan documents, the Plan documents will
govern.
IMPORTANT NOTICE FOR
EMPLOYEESREPRESENTEDBY
UNITED TRANSPORTATION UNION
ON
CSXT (FORMER B&OlB&OCT, C&O (PROPER) C&O (PMIHV)), WM, A&WP AND
CERTAIN EMPLOYEES AT CONSOLIDATED GREATER RICHMOND TERMINAL
(Continued)
The Provident Life and Accident Insurance Company located at One Fountain Square,
Chattanooga, Tennessee 37402 is the administrator of the Plan. Booklets describing
the Plan will be distributed in the near future. If employees need to file a claim prior to
receipt of the booklet they may request a claim form from their Supervising Officer.
HOW TO FILE A CLAIM
For Certain Employees of
CSX TRANSPORTATION
Represented by the UTU
SUPPLEMENTAL SICKNESS BENEFIT PLAN
When you are disabled, your claim will receive prompt handling if you will do the
following:
(1)
See your doctor immediately.
(2)
Obtain and fill in the green NOTICE OF DISABILITY (Form F-68667) and
mail to Provident as soon as you know you will be disabled for more than
4 days.
Double check your Social Security Number and Employee ID Number
that you show on the notice form. A "wrong number" will delay your claim.
It is important that the "Notice of Disability" form be sent promptly so that
Provident can obtain certification from both your employer and the
Railroad Retirement Board. This will enable Provident to pay your claim
immediately when proof of your disability is received.
(3)
Obtain and fill in the U. S. RAILROAD RETIREMENT BOARD
"Application for Sickness Benefits" form, have your doctor complete the
RAILROAD RETIREMENT BOARD "Statement of Sickness" form, and
promptly mail both of those forms to the Bureau of Unemployment and
Sickness Insurance, U. S. Railroad Retirement Board, 844 Rush Street,
Chicago, Illinois 60611.
This is IMPORTANT because unless you file your claim with RUlA
promptly, your Supplemental Sickness Benefit Payment will be delayed.
(4)
The blue "PROOF OF DISABILITY" (Form F-68387) should be completed
by you and your doctor at the end of each 30 day period of disability or at
the end of your disability, whichever comes first.
Address of Claim Paying Office:
Provident Life and Accident Insurance Company
Railroad Disability Claims
P. 0.Box 180135
Chattanooga, TN 37401-7135
Telephone Number: 1-800-542-4231
FAX: 1-423-294-7857
SUPPLEMENTAL DISABILITY BENEFIT PLAN
BENEFIT PROGRAM M-948-AS0
The following questions and answers are presented for the purpose of giving you a
better understanding of your Supplemental Disability Benefit Plan.
Q.
A.
How and where can I obtain claim forms?
Write to the Provident claim office located at:
Provident Life and Accident lnsurance Company
Railroad Disability Claims
P. 0 . Box 180135
Chattanooga, Tennessee 37401-7135
Q.
Why is it important that the green "Notice of Disability" Form F-68667 be
completed and sent to the Provident office as soon as I know disability will
extend beyond 4 days, rather than waiting until the end of my disability or the end
of the first 30 days of disability?
Giving prompt notice will speed up your claim payment. After your "Notice of
Disability" form is received, Provident will certify your eligibility from both your
employer and the Railroad Retirement Board. If you give prompt notice, chances
are that both your employer and the Railroad Retirement Board will have
furnished certification by the time Provident receives your "Proof of Disability"
Form F-68387 which is to be completed by you and your doctor.
A.
A.
When should I send Provident the blue "Proof of Disability" form which is to be
completed by me and my doctor?
At the end of the first 30 days or the end of your disability, whichever comes first.
Q.
A.
Do I have to be under the care of a physician to claim disability benefits?
Yes.
Q.
Under the terms of the Benefit Program, is it necessary to file for disability
benefits under the Railroad Unemployment lnsurance Act in order to collect
benefits under the Supplemental Disability Benefit Plan?
Yes. You should obtain and fill in the U. S. Railroad Retirement Board
"Application for Sickness Benefits" form, have your doctor fill in the Railroad
Retirement Board "Statement of Sickness" form, and promptly mail both of those
forms on the Bureau of Unemployment and Sickness Insurance, U. S. Railroad
Retirement Board, 844 Rush Street, Chicago, Illinois 60611.
Q.
A.
SUPPLEMENTAL DISABILITY BENEFIT PLAN
BENEFIT PROGRAM M-948-AS0
(Continued)
Is it necessary for one to actually be paid RUlA benefits in order to qualify for
disability benefits under the Supplemental Disability Benefit Plan?
If you are "late" filing for RUlA benefits, you could be penalized and disability
benefits may not be payable under RUlA until the date you can actually file. If
this happens, you will also lose disability benefits under the Supplemental
Disability Benefit Plan, because Supplemental Benefits are not payable for any
day for which you are denied RUlA benefits unless the reason for the denial is
one of the following:
You have exhausted your RUlA benefits during a benefit year, or
(1)
(2)
You are a "Qualified Employee" under RUIA, but are denied
benefits because you are receiving annuity benefits under Railroad
Retirement, Social Security, or military services, etc.
In addition to being a "Qualified Employee" under RUIA, what other requirements
must I meet in order to be eligible for benefits under the Supplemental Disability
Benefit Plan?
Generally speaking, an employee is a "Qualified Employee" under the
Supplemental Disability Plan when he meets all of the following requirements:
Is a train service employee of the CSXT who is in active train
(1)
service on a portion of CSXT subject to a Supplemental Sickness
Benefit Agreement with the United Transportation Union;
and
has a minimum of six months of continuous active train service
(2)
on a portion of CSXT covered by a Supplemental Sickness Benefit
Agreement with the UTU.
Suppose I am a "Qualified Employee" under the Supplemental Disability Benefit
Plan, but my service is interrupted because of disability, furlough, leave of
absence or discipline. If I return to work for the same railroad within 12 months,
when will I again become a "Qualified Employee"?
On the first day you render compensated service under a UTU Trainmen's
schedule agreement.
How often are benefit payments made by Provident under the Supplemental
Sickness Benefit Plan?
Monthly.
How long are benefits payable?
Up to 12 months in connection with any one period of total disability.
SUPPLEMENTAL DISABILITY BENEFIT PLAN
BENEFIT PROGRAM M-948-AS0
(Continued)
Is 12 months the most I can ever draw for disability under the Supplemental
Sickness Benefit Plan?
No. If you are paid the full 12 month limit for a period of disability and later have
a new period of disability which starts while you are a "Qualified Employee," you
may qualify for additional disability benefits under the Supplemental Sickness
Benefit Plan.
What determines the amount of the monthly benefit I receive under the Plan?
The amount is determined by the employee's average monthly earnings for the
12 month period preceding disability subject to certain maximums.
Will my monthly benefits under the Supplemental Disability Benefit Plan be
increased if I exhaust my benefits under RUlA in less than 12 months?
Yes, your monthly benefits under the Plan will be increased an additional $200
per month but not to exceed the lesser of $1,273.87 or 70% of your average
monthly earnings in the 12 months preceding disability.
Will my disability benefits under the Supplemental Disability Benefit Plan be
reduced if I apply for and receive a disability annuity under the Railroad
Retirement Act?
Your Supplemental Disability Benefit Plan benefits will be reduced only if your
total benefits exceed the lesser of $1,881.03 or 70% of your average monthly
earnings for the 12 months preceding disability.
I have another disability policy for which I pay the entire premium. Will this
reduce my Supplemental Sickness Plan benefits?
No.
Are disabilities due to pregnancy covered?
Yes.
Are disabilities for employees over age 65 but actively working covered?
Yes. Benefits will be allowed to eligible employees up to 12 months.
Does the law require Provident to report Supplemental Disability Benefit
Payments to the Internal Revenue Service?
Yes. Public Law 96-601 requires that benefit payments made on or after May 1,
1981, be reported and that each employee be furnished with a W-2 form showing
the amount of benefits he or she was paid each year.
SUPPLEMENTAL DISABILITY BENEFIT PLAN
BENEFIT PROGRAM M-948-AS0
(Continued)
Q.
A.
Q.
A.
Does the law require Provident to withhold Railroad Retirement Tier I taxes from
Supplemental Sickness Benefits?
Yes. Public Law 97-123, which became effective January 1, 1982, requires that
Railroad Retirement Tier I taxes be withheld from benefit payments made prior to
the end of six months from the end of the month in which an employee last
worked. The employer is required to pay a matching share of Railroad
Retirement tax withheld from Supplemental Sickness Benefit Payments. State
Income Tax must also be withheld if applicable.
Does this Plan provide replacement of benefits that are not paid by the RRB for
the first Registration Period during a Benefit Year?
Yes. The Plan provides replacement at the current daily level once during each
Benefit Year, i.e., from July 1 through June 30 of the following year.
NOTICE O F DISABILITY
Supplemental S i c k n e s s Benefit Plan
Provident Life and Accident Insurance Company
P.O. Box 180135
Chattanooga, TN 37401-7135
RAILROAD D l S A B l L l N CLAIMS
Customer Service Telephone Number:
ph: 1-800-822-9103 Fax: 1-800-447-2498
Employee'sAddress (Number)
3 Please indicate if new address
Name of Employer
(Street)
IF YOU BECOME DISABLED. YOU AND YOUR AllENDiNG
PHYSICIAN(S) SHOULD FULLY COMPLETE ALL PARTS
IMMEDIATELYANDRETURN TO UNUM.
(city)
(state)
(Zip)
,
1 Telephone Number I
) I
I
Dale Em~loved
. .
Indicate which Organization represents you: i3 Maintenance ot Way
5 Firemen & Oilers
C Machinists
E Electricians
Location Last Worlted
'!Sheet Metal Workers
fl Carmen
C Boilermakers, etc.
Department Last Worked
CiSignalmen
L? Other
1 Rate of Pav.(oer
hrJver monlh) Indicate Occuoation Class:
Date You Last Worked
.
fl i.~echanicor comparable or higher rated position
$
O 2. Helper or comparable position
When Did You Become Disabled?O AM
Occupation
3. Lower rated oosition
Date
Time
Indicate
of Disability
Supelvisor's Name
Telephone No.
fl Accident (Comolete Part ill fl Sickcause1
(
1
Have You Returned To Work?
Telephone No.
I . Name 01 Ail Trealing Physicians
U Yes-if so, give date
(
I
t
O Nwif not, when do you expect to return to work?
2.
Have you received vacation pay since your last day worked7 O Yes O No
(
)
if yes. give date(s)
I
gse
3.
(
)
I Do vou currenllv hold a medical certiiication?
I u 'DOT o CRANE other
Date of First Treatment
.I?
.
Yes 1'- No
..
Have you completed a total of at least 12 calendar months of
Did you work forme Employer named above (or take vacation
employment with one or more participating railroads? C Yes O N wilh pay) in the month beforevou became disabled? E Yes
--
1 Were vou at work when accldent haooened?
1 O Yes 0 No If yes. forwhom?
Date Of Accldent
D NO
Explain How Accident Happened?
1
Was a railroad on-trackvehicle involved?
Did injury result from a traffic awident?
I Will a Liability claim be made?
Benelits under the Railroad Unemployment Insurance Act:
1. Have you appliedforsickness benefits underthe Railroad Unemployment Insurance Act? =! Yes 5 No
My benefits have been exhausted forthis benefit year.
2. 11 not, why not? P Am not qualified under the Act.
D Other (explain)
Other lncome Benevis:
Are any of the 'Other Income BenefitClisled below available to you whiiedisabled? L Yes 2 No (Ifyes,checkeachofthefollowingwhich
is applicable, and show monthly amounts payable).
3 Railroad Retirement Act-Disability Annuity
O Social Security Act (Are Benefits for Age o
C Military Pension (Are Benefits for Years of Service or Disability?
1 ......................... $
3 Wage Continuatio
$
$
..
$
.......................................................................................6
C Advancement f
$
F-68625 (12102) Prinled In U.S.A.
10
(4107)(0ver)
1. Name of Empioyee
2. Social Secum Number
3. Diagnosis and concurrent condaions
(If diagnosis code other than ICD9' used, give name):
4. Dates of Treatment
(If previous form submitted to this carrier.
you need show only dates since last report)
First:
3. Dates of Hospital Confinement
Admitted
5. Has patient had surgaryloutpatient procedures? (if so, date
Discharged
1
6. Frequency of Treatment
7. Is patient receiving physical therapy? D y e s
No it "Yes" iwJicat%Rame and address of IaCil@flheraQist
8. Date symptoms first appeared or accident happened.
9. Date patient first consulted you for this condition.
10.Patient ever had same or similar condiion?
Yes
No If "Yes" when and describe
11.Patient still under your care for this condition? OYes
No if 'No', has patient been refened to anotter physician?
12,Patient was continuously unable lo perform the regular duties of hisher own occupation.
From
To
13.11 patient was released to restricted duty, please indicate all restrictions and applicable dates.
14.11 still disabled, date patient should be able to return to work
Date Completed
P h y ~ l r i aName
h
(Pllnt)
Sinalure
OBwen
Tarpner's Account No.
X
treet Address
Ciy or Town
State or Province
Zip Code Telephone No.
Fax NO.
Any person who knowingly and with intent to defraud any insurance company or other person hies a statement of claim containing any materiiiiy false
information, or conceals for lhe purpose of misleading; information concerning any fact materiel thereto, commits a fraudulent insurance act which is a
crime, in Florida, a felony of the third degree.
The undersigned certifies Mat the information disclosed above is a correct declaration of facts upon which claim is based lor benefits and furltier hereby
acknowledges Me limitations and provisions of the plan.
AUTHORIZATIOW
Solely to assist Provident Lifeand Accident Insurance Company in administering an insurance claim. I hereby authorize any providar of health care inciuding but not limited to any institution, or person possessing information concerning:
-
--
to permitthe abocnamed insurance company and its representative, insurance suppottGnization, reinsurancecompanies or other persons performing
business or ieaaise~icesin connection with the claim, to view, coov. be furnished cooies or be aiven details of allsuch Dhvsicai or mental medical-record
information including but not limited to drug, alcohol or psychiatrictreatment or condition, askell as information reg'aiing employment income, other
insurance coverage, andlor any otherwise personal or privileged information, including but not limited to any other claim for insurance benefits, or any
records concerning civil or criminal proceedings.
Any copy of the authorization shall have the same authority as the original.
I understand I, or my authorized representative, may reeeive a copy of this authorizatlon upon request. This authorization is valid for the duration of the
claim.
Signature
Unum is a registered irademark and marketing brand of Unum Group and its insuringsubsidiaries.
Date