Short Term Disability - Tidewater Fleet Supplytidewaterfleetsupply.com/employees/Short Long Term Disability.pdf · Short Term Disability 1. ... submits an application or files a claim

r==\ Fleet Supply"

Short Term Disability

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

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

3. 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.

4. Full-time employees may elect to enroll in the short-term disability program,subject to the conditions in 3 above. An employee may elect to cover up to60% of their normal income. An amount less than 60% may also be elected.

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

6. In general, the coverage is for the 7th day of accident or the 7th day of illnessand continues for a maximum of twenty-six (26) weeks. You must be under adoctor's care. The complete terms and conditions are contained in theinsurance document.

7. 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 during open enrollment only or upon terminationof employment.

8. 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 Birth Sex Soc Sec NumberMo Day Yr M D F D

Requested Eff DateMo Day Yr

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 NameTidewater Fleet Supply

Employer/MCP #25741

Salary: $ OccupationAnnual Q Monthly |_]

Are you currently able to perform the duties of your occupation? Yes No DApplicant'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

Dnannnnc

Dnnnnnoc

STNDSTND

Zz

017935-D4017806-D31

1z=lndividuat; 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 D 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 Ct No Ocounseling) 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 Q No Q

1-0-. 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

A126WA

Tidewater Fleet SupplyShort Term Disability

Policy #G-108-105

Rates as of :

AnnualIncome$$$$$'$$$$$$.$.$$$$$$$$$$$$.$$$$$$$$$$$"$•$$$$$$

8/1/2004

MonthlyBenefit

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

10,000.0011,000.0012,000.0013,000.0014,000.001-5,000,0016,000.0017,000.0018,000.0019,000.0020,000.0021,000.0022,000.0023,000.0024,000.0025,000.0026,000.0027,000.0028,000.0029,000.0030,000.0031,000.0032,000.0033,000.0034,000.0035,000.0036,000.0037,000.0038,000.0039,000.0040,000.0041,000.0042,000.0043,000.0044,000.0045,000.00

$$$$$'$$$$$$•$-$$$$$1$1$1$1$1$1$1$1.$1$1$1$1$1$1$1$1$1$1$1$t$2

200.00250.00300.00350.00400.00450.00500.00550.00600.00650.00700.00750,00-800.00850.00900.00950.00,000.00,050.00,100.00,150.00,200.00,250.00,300.00,350,00-,400.00,450.00,500.00,550.00,600.00,650.00,700.00,750.00,800.00,850.00,900.00,950VOO,000.00

$2,050.00$2$2$2$2

,100.00,150.00,200.00,250.00

MonthlyPremium$$$$$$$$$$$•$-$$$$$$$$$$$•$-$$$$$$$$$$$•$-$$$$$$

4.806.007.208.409.60

10.8012.0013.2014.4015.6016.8018,00-19.2020.4021.6022.8024.0025.2026.4027.6028.8030.0031.2032.40-33.6034.8036.0037.2038.4039.60'40.8042.0043.2044.4045.6046.8048.0049.2050.4051.6052.8054.00

Rate Factorper $100:

EmployeeDeductionBl-Weekly

$$$$$$$$$$$.$.$$$$$$$$$$$$$$$$$$$$$$$'$$$$$$$

0.750.941.131.321.511.69-1.882.072.262.452.642.823.013.203.393.583.773.954.144.334.524.714.905.085.275.465.655.846.036.216.406.596.786.977.167.347.537.727.918.108.298.47

EmployeeDeductionMonthly$$$$$$$$$$$$.

$$$$$$$$$$$.$.

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

1.632.042.452.863.263.674.084.494.905.305.716.1-26.536.947.347.758.168.578.989.389.79

10.2010.6111,0211.4211.8312.2412.6513.0613.4&13.8714.2814.6915.1015.5015.9116.3216.7317.1417.5417.9518.36

$ 2.40

American Fidelity Short Long Term DisibilityShort Term 7/30/2014


Policy SG-108-105

Rates as of :

Annualincome$$$$$$$$$$$$.$$$$$$-$$$$$$$$$$$$$$$$$$$$$$$$

46,000.0047,000.0048,000.0049,000.0050,000.0051,000,00.52,000.0053,000.0054,000.0055,000.0056,000.0057,000.0058,000.0059,000.0060,000.0061,000.0062,000.0063,000,00-64,000.0065,000.0066,000,0067,000.0068,000.00•69,000.0070,000.0071,000.0072,000.0073,000.0074,000.0075,000.0076,000.0077,000.0078,000.0079,000.0080,000.0081,000.0082,000.0083,000.0084,000.0085,000.0086,000.0087,000.00

8/1/2004

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

MonthlyPremium$$$$$•$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$

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


EmployeeDeductionBi-Weekly

$$$$$.$.$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$

8.668.859.049.239.429.609.799.98

10.1710.3610.5510.7310.9211.1111.3011.4911.681-1,86.12.0512.2412.43

•12.6212.8012.99-13.1813.3713.5613.7513.9314.1214.3114.5014.6914.8815.0615.2515.4415.6315.8216.0116.1916.38

EmployeeDeductionMonthly$$$$$•$•$$$$$$$$$$$•$•$$$$$$$$$$$"$$$$$$$$$$$$$

18.7719.1819.5819.9920.4020,8421.2221.6222.0322.4422.8523.2623.6624.0724.4824.8925.3025.7026.1126.5226.9327.3427.7428.1-5-28.5628.9729.3829.7830,1930.6031.0131.4231.8232.2332.6433.0533.4633.8634.2734.6835.0935.50

$ 2.40



Po Key #6-108-105

Rates as of:

AnnualIncome$$$$$$$$$$$$•$$$$$$$$$$$•$$$$$$$$$$$$$$$

88,000.0089,000.0090,000.0091,000.0092,000.0093,000,0094,000.0095,000.0096,000.0097,000.0098,000.009S,OOO.OQ

100,000.00101,000.00102,000.00103,000.00104,000.00105,000.00106,000.00107,000.00108,000.00109,000.00110,000.00I'TIYOiDO.UO112,000.00113,000.00114,000.00115,000.00116,000.00117,000.00118,000.00119,000.00120,000.00121,000.00122,000.00123,000.00124,000.00125,000.00

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.UQ$ 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$$$$$$$$$$$•$$$$$$"$$$$$$'$•$$$$$$$$$$$$$$

105.60106.80108.00109.20110.40111.60112.80114.00115.20116.40117.60148.SO-120.00121.20122.40123.60124.80126.00'127.20128.40129.60130.80132.00133.20134.40135.60136.80138.00139.20140.40141.60142.80144.00145.20146.40147.60148.80150.00


EmployeeDeductionBi-WeekJy

$$$$$$$$$$$•$•$$$$$$$$$$$"$$$$$$$$$$$$$$$

16.5716.7616.9517.1417.3217.5117.7017.8918.0818.2718.4518.6418.8319.0219.2119.4019.5819.7719.9620.1520.3420.5320.712D.9D21.0921.2821.4721.6621.8422.0322.2222.4122.6022.7922.9723.16-23.3523.54

EmployeeDeductionMonthly$$$$$$$$$$$-$-$$$$$$$$$$$"$$$$$$$$$$$$ •$$$

35.9036.3136.7237.1337.5437.9438.3538.7639.1739.5839.9840,3940.8041.2141.6242.0242.4342.8443.2543.6644.0644.4744.8845.2945.7046.1046.5146.92

-47.3347.7448.1448.5548.9649.3749.7850.1850.5951.00

$ 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 DisibilityShort Term . 4 7/30/2014

Tidewater Fleet SupplyLong Term DisabilityPolicy # G-1tre-T05

Rates as of :

Annual

$$$$$$$$$$$$$$$$$?$$$$$$$$$$$-$$$$$$$$$$$$

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

10,000.0011,000.0012,000.0013,000.0014,000.0015,000.0016,000.0017,000.0018,000.0019,000.0020,000.002T.rjoa.oa22,000.0023,000.0024,000.0025,000.0026,000.0027.000-.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$$$$$$$$$$$$$$$$$1$1$1$1$1$1$1$1$1

200.00250.00300.00350.00400.00450.00500.00550.00600.00650.00700.00750.00800.00850.00900.00950.00,000.00,050;oo,100.00,150.00,200.00,250.00,300.00,350.00,400.00

$1,450.00$1$1$1$-1$1$1$1$1$1$1$2$2$2$2$2

,500.00,550.00,600.00,650.00-,700.00,750.00,800.00,850.00,900.00,950.00,000.00,050.00,100.00,150.00,200.00

MonthlyPremium$$$$$$$$$$$$$$$$$$$$$$$$$$$$$-$.$$$$$$$$$$$

2.803.504.204.905.606.307.007.708.409.109.80

10.5011.2011.9012.6013.3014.0014.7015.4016.1016.8017.5018.201-8.9019.6020.3021.0021.7022.4023.10-23.8024.5025.2025.9026.6027.3028.0028.7029.4030.1030.80



$$$$$$$$$$$$$$$$$$'$$$$$$$$$$$-$-$$$$$$$$$$$

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

10.5011.2011.9012.6013.3014.00T4.7015.4016.1016.8017.5018.2018.90-19.6020.3021.0021.7022.4023,1-0.23.8024.5025.2025.9026.6027.3028.0028.7029.4030.1030.80

$ 1.40

American Fidelity Short Long Term DisibilityLong Term 7/30/2014

Tidewater Fleet SupplyLong Term DisabilityPolicy #G-108-105

Rates as of :

Annual

$$$$$$$$$$$$•$$$$$'$$$$$$$.$$$$$$$•$$$$$$$$$$

Income45,000.0046,000,0047,000.0048,000.0049,000.0050,000.0051,000.0052,000.0053,000.0054,000.0055,000.0055,000.0057,000.0058,000.0059,000.0060,000.0061,000.0062,000.0063,000.0064,000.0065,000.0066,000.0067,000.00ea.QOO.OQ-69,000.0070,000.0071,000.0072,000.0073,000.0074,000.0075,000.0076,000.0077,000.0078,000.0079,000.0080,000,00-81,000.0082,000.0083,000.0084,000.0085,000.00

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$$$$$$$$$$$$$$$.$$$$$$$$•$-$$$$$$$$$$$$$$$$$

31.5032.2032.9033.6034.3035.0035.7036.4037.1037.8038.503912039.9040.6041.3042.0042.7043.4044.1044.8045:5046.2046.9047.6048.3049.0049.7050.4051.1051.8052.5053.2053.9054.6055.3056,0056.7057.4058.1058.8059.50



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

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

14.5414.8615.1815.5115.8316.1516.4816.8017.1217.4517.77raoff18.4218.7419.0619.3819.7120-.0320.3520.6821.0021.3221.6521.9722.2922.6222.9423.2623.5823.9124.2324.5524.8825.2025.5225.8526.1726.4926.8227.142746


$$$$$$$$$$$$•$$$$$$$$$$$$$$$$$$$$$$$•$-$$$$$

31.5032.2032.9033.6034.30

.35.0035.7036.4037.1037.8038.503912039.9040.6041.3042.0042.7043.40-44.1044.8045.5046.2046.9047.60-48.3049.0049.7050.4051.1051.8052.5053.2053.9054.6055.3056,0056.7057.4058.1058.8059.50

$ 1.40


Tidewater Fleet SupplyLong Term DisabilityPolicy #G-108-105

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

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

MonthlyPremium$$$$$$$$$$$'$$$$$$.$.$$$$$$$$$$$.$.$$$$$$$$$$

60.2060.9061.6062.3063.0063.70'64.4065.1065.8066.5067.2067.9068.6069.3070.0070.7071.4072.10-72.8073.5074.2074.9075.6076.3077.0077.7078.4079.1079.8080.5081.2081.9082.6083.3084.0084.7085.4086.1086.8087.50



$$$$$'$$$$$$$$$$$$$-$$$$$$$$$$$.$-$$$$$$$$$$

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


$$$$$$•$$$$$$$-$$$$-$-$$$$$$$$$$$.$.$$$$$$$$$$

60.2060.9061.6062.3063.0063.7064.4065.1065.8066.5067.2067.90-68.6069.3070.0070.7071.4072.10.72.8073.5074.2074.9075.6076.3077.0077.7078.4079.1079.8080,50-81.2081.9082.6083.3084.0084.70-85.4086.1086.8087.50

$ 1.40


Documents

Short Term Disability - Tidewater Fleet Supplytidewaterfleetsupply.com/employees/Short Long Term Disability.pdf · Short Term Disability 1. ... submits an application or files a claim