PILOT TRAVEL CENTERS LLC

OCCUPATIONAL INJURY
BENEFIT PLAN

PJLOT TRAVEL CENTERS LLC
OCCUPA rrONAL INJURY BENEFIT PLAN
TABLE OF CONTENTS

ARTICLE 1

1.1
1.2
1.3
1.4
ARTICLE 2

2.1
2.2
2.3
2.4
2.5

2.6
2 .7
2.8

2.9
2.10
2.11
2.12
2.13
ARTICLE 3

3.1
3.2
3.3
3.4

ARTICLE4

4.1
4.2
4.3
4.4
4.5

4.6
ARTICLE 5

5.1
5.2

5.3
5.4
5.5

ESTABLISHMENT OF THE PLAN ............ , ......:........ ,......., ............................................... 1
ADOPTION OF PLAN .................................................................................................................. 1
LEGAL STATUS ............................................. ......................... ,..........................................:....... 1
PRIOR ARRANGEMENTS ....................... ,............................... ................................. ,................. 1
NO ADMISSION OF LIABILITY ................................................................................ ................. 1

DEFINITIONS AND CONSTRUCTION ................................ ,..... ,...................................... 1
BENEFITS ......... , .................... " ...... ,................. " ................................... ,....... ,............................. 1
CARRIER .............. ........... ....... . " .................... ', ......................·................ ", .................................. 2
COMPANY ..................... ,......................... .... .... ... ........ ... ,............ ........ ,........ ,..... ,.......... " .... ,........ 2
EFFECTIVE DATE ,', ...... ,... ,........ ,.................. ." ... ............... "........·................... ,...... " .................. ,.2
EMPLOYEE(S)" ...................... ,..... ,............... ,." ......... ......... ,.. .,., .... ,.................................... ,...... 2
EMPLOYER ........... ,"', .... ,......... ,., ...................................... ,.... ",.. ,........................... ,.............. " .... 2
ENROLLMENT DATE .... ,..... ........ ,.......... ,....... " .................... ...................................................... 2
ERISA ............ ,..... ,.. ...... ,...... ,...................... " .................. ,.................................... " ..................... 2
PARTICIPANT " ... "',' ..................... ,, ................. ,.. ,..... ,.................. ,,, .......... ,, .............................. 2
PLAN ." .... " .......... ,.................. ......... ,................ ,."." .... ,,, ................ ,,., ...,,, ....... " .......................... 2
PLAN ADMINiSTRATOR ....... "., ............. ,......... ,.. " .... " .........·.......... ,...... ,............. ,....... " ...... " .... 3
PLAN yEAR" ........ ,...... ,..... ,................ ,., .................... ........................................... ,.................... 3
POLlCY(IES) ................... ,............ ,..... ,........ ,..... " ..... ,." ... " ............ ,.................... ,.. " ...... ,........... ,3

ELlGIBILlTY AND PARTICIPATION ................................................... ,............................ 3
GENERAL PROVISIONS ... ,................... " ....... ,.. " .............. ,' ,.......... ",'" ................ ,..... ,... .. ........ 3
REQUIREMENTS ." ., ..... ,., ....... , .... ,.' ............... ' ....... ......... ................. ... ..... ,...... ....... ........... ,.. ,... 3
PARTICiPATION ......... .. .................. ................................ ... ..... ,." ., ......... ,... ,.... ..... ,..... ...... ,.... ,.... 5
TERMINATION OF PARTICiPATION .................. .................................................................... 5

BENEFITS POSSIBLE UNDER THE PLAN ..................................................................... 5
LISTING OF POSSIBLE BENEFITS ...... ........................................ " ........................................ 5
INSURANCE POLICIES .... .. . ,.. .. ... ............... .... ,............... , ............... " .......... ........................... 6
FUNDING OF BENEFITS ... .... ........ _... ...... ................. ................................................. ............ 7
MAXIMUM BENEFITS .... .. ........ ,.... ...... . .... _....................... .. ....................................... ....... 7
NOT A WORKER'S COMPENSATION POLiCy ........ ......... ,...... ................. ......................... 7
ADDITIONAL RESTRiCTIONS ............ ....... . ..................... .......... _....................................... 7

OPERATIONAL PROVISIONS ............................................ ,." ......................................... 7
REPORTING .............. , .... ... , ..... ,......................................................... ........ . .. ......... .... _...... . 7
DRUG SCREEN .... .............................. .... ...... ..................... ... .. , ............. ........................... 8
MEDICAL TREATMENT .. .. ............... ... ............... ........ ... ........................... .... ... , .. ...... _.. 8
SECOND OPINION .. . .. .. ........ " ..... .... , .. . ' ...... ........ ............................. ................. ....... 8
INCAPACiTY.. .. .. .................. ............ . ..... ...... ................ " . .. .. ........ " ... ... " .................... 8
(i)

 5.6
5.7
5.8
5.9
ARTICLE 6
6.1
6.2
6.3
6.4
6.5
6.6
6.7
6.8
6.9
6.10
6.11
6.12
6.13
ARTICLE 7
7.1
7.2
7.3
7.4
7.5
7.6
ARTICLE 8
8.1
8.2
8.3
8.4
8.5
8.6
8.7
8.8
8.9
8.10
8.11
8.12
B.13
ARTICLE 9
9.1
9.2
ARTICLE 10
10.1
10.2
10.3

WEEKLY CONTACT ........ ........ ........ ............... ... .......... ................ ........................................... .,9
SOCIAL SECURITY .................................. _....... ..... ................ ,........ ............................. ,............ 9
FAILURE TO RETURN ...... .. ......... ............................ " ..............·............................................... 9
COORDINATION OF BENEFITS: SUBROGATION .. ............................................................... 9
CLAIMS ...........................................................................................................................10
CLAIM PROCEDURE ......................................................... .................................................... 10
NOTICE OF DENIAL .......................................... ..................................................................... 10
TIMING OF THE NOTICE OF DENIAL. ........ .......... . " ................................................ ,............. 11
WHEN A CLAIM IS RECEiVED ...................... ......................................................................... 12
MANNER OF GIVING NOTICE .. .. .......................... ;.................... ,..................................... ,...... 12
DEFINITION OF CLAIM INVOLVING URGENT CARE .............................;.......... ,.................. 12
APPEAL PROCEDURE ...................... ............... ,............................... ,...... ·................................... 13
RIGHTTO RECONSiDERATION .... .......................................................... ,...... .... ;.................. 13
RIGHT TO SUBMIT COMMENTS ........................................................................................... 13
RIGHT TO REVIEW DOCUMENTS ......................................................................................... 13
DECISION BY PLAN ADMINiSTRATOR ................................................................................. 13
CONTENTS OFTHE PLAN ADMINISTRATORS NOTIFICATION ................................., ....... 13
RIGHT TO BRING CIVIL ACTION .......................................................................................... 14
ADMINISTRATION OF THE PLAN .................................................................................14
PLAN ADMINISTRATOR .................. ,........................... ,....................;......... " ........................... 14
DISCRETIONARY RIGHTS AND DUTIES .. ,................. ~ ..........................., .......: .. " ..........;........ 14
DOCUMENTS ................... ,.... " ......... ........ ,............ " ................. ,............. ,............ " .................. 15
INDEMNIFICATION ..... ............................................................,.......................................... .......... 16
SPONSOR ................................................................................................................................. 16
THIRD PARTY REViEW ....... ................................. ,................................ ,................................ 16
MiSCELLANEOUS .......................................................................................................... 16
SAFETY ............................ ...................... ... ... .. .......................................................................... 16
NO GUARANTEE OF EMPLOyMENT ....... .................... ,................ ,....................................... 16
RIGHTS TO EMPLOYER'S ASSETS ...................................................................................... 16
COMMUNiCATIONS ...................... ............... ...................................... ..................................... 17
NO WAIVER OR ESTOPPEL ................................................ ,................................................. 17
EMPLOYER NOT AN AGENT OF CARRIER .......................................................................... 17
ENTIRETY .............................................................................................................................. 17
HEIRS ...................................................................................................................................... 17
HEADINGS ................................ ,.. ................................................................. ,............ ,.......... 17
GENDER ........................................ .................................. ....................................................... 18
CONTROLLING LAW ......................... .. . .......... ..... ........................ ......................................... 18
SEVERABILITY ....................... '" .. ........... .. ..... ,............................ .......................................... 18
OFFSET .. .. ...... .. ................................. .. ..... .... ......................................................................... 18
ADOPTION OF PLAN BY AFFILIATED CORPORATION ............................................. 18
AFFILIATED CORPORATION ... .......... . ....... ..... . .. ..... ............. ,....................... ......... 18
OBLIGATION ., ..... ..... ..................................... ..................... ............ .. ... _........ .................. .. .. 18
AMENDMENT AND TERMINATION ...............................................................................19
PRIOR ARRANGEMENTS .... ............ ............................................................................ 19
AMENDMENTS.... ...... ...... ..
.... ............ .. .. .. .................. .......... ....... ...................... 19
RIGHT TO TERMINATE .. ...... " .. ...... " ... ............. ............................. ...................... 19

(ii)

 PilOT TRAVEL CENTERS LlC
OCCUPATIONAL INJURY BENEFIT PLAN
ARTICLE 1
ESTABLISHMENT OF THE PLAN
1.1
Adoption of Plan. Pilot Travel Centers LLC (the "Company") hereby
establishes an Occupational Injury Benefit Plan for its Employees as of the Effective Date.
1.2
Legal Status. This Plan is intended to constitute an employee welfare benefit
plan under the Employee Retirement Income Security Act of 1974, as amended, and has
been reduced to writing in order to comply with that act.

Prior Arrangements. This Plan shall supersede any other ERISA Plans or
1.3
prior similar arrangements for providing the Benefits hereinafter described.
1.4
No Admission of Liability. This Plan is ad op ted by the Company in an effort
to provide prompt -payment of covered expenses incurred by the Participant which are
eligible for reimbursement under tile Policies and to limit the Company's liability when a
Participant is injured. In no event shall any payment LInder thIs Plan or any of the Policies
constitute or be treated as an admission of <ln y liability or responsibility by an Employer,
Plan Administrator o[ any employee or agent of any of the foregoing, in any respect, for any
injury, accident, illness or other event giving rise to a claim hereundeL

ARTICLE 2
DEFINITIONS AND CONSTRUCTION
2.1
Benefits means the payment for necessary medical care required as a result
of an accidental work related on-the-job injury or illness, as described in this Plan; and
salary continuance Benefits for periods of disability resulting from an accidental work

OCCUPATIONAL INJURY BENEFIT PLAN

Page 1

 related on-the-job injury or illness, as described in this Plan, as well as death,
dismemberment, and paralysis Benefits, if any, as described in this Plan, less any
applicable state or Federal taxes .
2.2
hereunder.

Carrier means an insurance company which issues one or more Policies

2.3

Company means Pilot Travel Centers LLC and any successors thereto .

2.4

Effective Date means 9/1/2006 .

2.5
Employee(s) means an individual employed by an Employer as a common
law employee . The term "Employee" shall not include leased employees, independent
contractors or persons who serve only as directors of the Company or an Employer unless
the Employer has expressly agreed in writing to such coverage .
2.6
Employer mea ns the Co mpany and any affiliate which shall adopt this Plan;
provided, howeve r, th at except as otherwise provided herein, the Company and each
affiliate Wllich adopts this Plan shall be deemed an Employer only with respect to its own
Employees. Unless and until an affiliate sh all adopt this Plan, "Employer" shall have the
same meaning as ItCompany."
.
Enrollment Date means the following date on which an eligible Employee
2.7
may commence or recommence participa1ion in the Plan: The date on which the employee
commences or recomme nces employm ent.
2.8
ERISA means the Employee Retirement Income Security Act of 1974, and
the regulations adopted thereunder, as either may be amended from time to time .
Participant means an Employee who meets the requirements and
2,9
participates in the Plan.
2,10 Plan means the Pilot Travel Centers LLC Occupational Injury Benefit Plan,
the Plan set forth herein, as amended from time to time.

OCCUPATIONAL INJURY BENEFIT PLAN

Page 2

 2.11 Plan Administrator means the Compan y or such other person(s) or entities
utilized by the Company or Carrier.
2.12 Plan Year means the twelve month period ending on December 31. The first
Plan Year shall begin on the Effective Da te and may be less than twelve months.
2.13 Policy(les) means one or more contracts of insurance issued by a Carrier to
provide one or more Benefits under the PIa n and in effect.

ARTICLE 3
ELIGIBILITY AND PARTICIPATION
3.1
General Provisions. This Plan shall apply to an accidental on -the-job injury
or illness sustained in the course and scope of employment and in the furtherance of the
business of lh~ Comp.any by a Par\lcipan t whose principa l place of employ ment is located
in the State of Texas. T his Plan specifies the only Be nefits for which a Participant is eligible
In the event of sllch Inj ury or illness·. Provision of BenefiLs to a Participant pursua nt to tllis
Plan shall not constitute an admission of liability on the part of the Compa ny for the injury or
illness to a Participant. The Plan Administra tor rese rves the right \0 cond itio n paymen t of
any Benefits hereunder on the Participant (or Ilis es tate or beneficiary) execu tin g a waiver
and release form to this effect.
3.2
Requirements. A Participant's entitlement to continuing Benefits under this
Plan may be forfeited, suspended, or discontinued if the PartiCipant fails to comply with or
satisfy any of the requirements or provisions of this Plan. Without limiting the foregoing,
and by way of example only, a Participant shall not be entitled to Benefits under this Plan if:

i.

The injury or illness or alleged injury or illness is (i) not an injury or
illness covered by this Plan, (ii) determined by the Plan Administrator
to be intentional or feigned, or (iii) determined by the Plan
Administrator to be an attempt to defraud the Company.

ii.

The injury or illness is not reported immediately to the supervisor or
designee.

OCCUPATIONAL INJURY BENEFIT PLAN

Page 3

 ii i.

Tile P,)rl1cipant ,LJlilizes a I)eaitl'l care provideroll1er than an au thorized
hea lth care provider. No physician or med ical facility is an agent of
the company. Although benefits under this pran are conditiona l on
yo ur use of on ly approved physicians and facilities, you remain
ent itled to seek any medical care you deem appropriate from any
provider of your clloice.

iv.

The Participant fails to follow the treatment and advice prescribed by
the health care provider.

v.

The Participant refuses or fails to obtain a second opinion , if
requested to do so by the Plan Administrator.

vi.

The Participant fails to give the Company a progress report by
contacting the Company office each week while receiving lost time
compensation .

vii.

The Participant fails to report to his/her supervisor for work
immediately upon being released in whole or in part by the health care
provider to return to work .

viii.

The Plan Administrator determines that the Participant was under the
influence of drugs or alcohol at the time of the injury or illness.

ix.

The Plan Administrator determines that the injury or illness was
caused by horseplay, scuffling, fighting, altercation or other
inappropriate behavior.

x.

The Plan Adm inistrator detennines (at an y point in time) that tile injury
or ill ness was caused, in wllole or in pa rt. by the Participrlnl'S Violation
of reasonab le sarety rules and/or practices, including , but not limited
to, any written safely po licies of the COmpany, or was caused by 1118
Part icipant's fail ure to obtain available assistance provid ed lor I,is
benefit \0 accomplish a particular lasl( or to properly utilize available
appropriate eq Lupmenl or applfances.

OCCUPATIONAL INJURY BENEFIT PLAN

Page 4

 xi.

The on-the-job injury or illness arises from or is aggravated by a
preexisting condition that is not otherwise covered hereunder.

xii.

If tile Participant becomes employed by another employer while
receiving Benefits under this Plan .

xiii.

If the Participant fails. to provide a complete statement, affidavit, or
deposition upon request by the Plan Administrator concerning the
irlcident which the Participant believes resulted in an injury.

xiv.

If the Participant was untruthful in regard to any aspect of the required
information supplied as part of the employment process including,
without limitation, information as to physical or mental abilities to
perform tile job .

xv.

If the Participant refuses to submit to drug and/or alcohol testing .

3.3
Participation. Ea.ch employee who meets all the requirements of the Plan is
eligible to pa rticipate in the Plan. However, in.ltial receipt and continuing receipt of B~nefits
is continge nt upon compliance with the te rms and conditions of this Plan .
3.4 . T ermina tion o f Participa tion. An employee will cease to be a Participan t in
the Plan as of the earlier of (i) the elate th.e Plan is term inated, (ii) the policy providing
Benefits is canceled or terminated for any reason, includIng non-paymen t of premiums,
(iii) the date employment ceases, or (iv) the da te the Parlicipanl ceases to be eligible for
any other reason under the Plan.

ARTICLE 4
BENEFITS POSSIBLE UNDER THE PLAN
4.1

Listing of Possible Benefits.
a.

The following Benefits may be available through the Plan :

i.

Occupational Accident Medical Benefits,

OCCUPATIONAL INJURY BENEFIT PLAN

Page 5

 ii. Accidental Death and Dismembemlcnt (AD&D), andlor
iii . Wage Replacement Benefits.
b. . Each of such Benel1ts, if any, wiD be provided solely through one or
more Policies. THE PROVISIONS AND BENEFITS OF EACH SUCH POLICY

ARE INCORPORATED HEREIN BY REFERENCE. NOTHING CONTAINED IN
TillS PLAN SHALL BE CONSTRUED AS A REPRESENTATION OR PROMISE
OF BENEFITS TO BE PROVIDED OTHER THAN THROUGH SUCH
POLICIES, IF ANY.
4.2

Insurance Policies.

a.
The Company shall select the Carrier(s) who shall write the
Policy(ies) providing Benefits under the Plan . the COlllrnll lY mEl)' clwllgc 'Imi el's, modify
or tcnninate coverage of any Policy, and l. h: slIch olh'r ,ction with ros pccl La each
Policy as it shall deem appropliate, without notj c to Iii' Participl1 nt The ompany hall
be deemed the owner of each such Policy UTI li IllAy cx..::rcise all rights and privj] ges of
ownership.
b.
The limitations and exclusions of cover<1ge provided by the
Policy(ies), jf any, purchased hereunder (including <Illy limitations pertaining to the

coordination of duplicate or ovedu pping coverage) shall be in addition to any such
Iimit<llions and excJusions herein mld shall be applicabJe to the Benefits hereunder
BeneJits paid sh<lJl not exceed the Maximum Benefits provision of paragraph 4.4 of tlris
Plan.
c.
Any insurance pllrchased now or in [he future under the Plan may
provide for ditJerent levels of coverage, deductibles, exclusions, limitatIons, premilll1s
and benefits.

d.
All Benefits are subject to acceptance by the Carr.iers. H' a Carrier
rejects or limits coverage, the Pm·ticipanl shall have no recourse against the Plan or illly
Employer for any ben efit otherwise payable if the coverage had been granted. The
Employer shall have no obligation to obtClin supplemental or allemative coverage.

OCCUI'ATIONAL IN.nm.Y llENEFIT PLAN

Page 6

 e.
IF FOR ANY REASON THE INSURANCE CARRIER TERMINATES
OR CANCELS THE POLICY OR THE COMPANY FOR ANY REASON TERMINATES OR
CANCELS THE POLICY, INCLUDING NON-PAYMENT OF PREMIUM, THERE SHALL
BE NO BENEFITS. THE EMPLOYER SHALL HAVE NO OBLIGATION TO OBTAIN
OTHER SUPPLEMENTAL OR ALTERNATIVE COVERAGE.
4.3
Funding of Benefits. The premiums applicable to Policies purchased under
the Plan are to be paid by the Employer.
4.4
Maximum Benefits. The maximum amount of aggregate Benefits under this
Pla n is $250,000. Aggregate Benefits means the sum total of §l1 Benefits, such as medical,
dea th, dismemberment, salary continuance, and/or paralysis Benefits. All Benefits
available under this Plan are not payable to the extent said Benefits are in excess of the
above amou nt.
4,5
NotaW orker's C om pe nsation Policy. Each of the Employers has rejected
coverage (become a non-subscriber) under the Texas Workers' Compensation Act. THIS
IS NOT A POLlCY OF WORKERS' COMPENSATION INSURANCE. THE COMPANY
DOES NOT BECOME A SUBSCRIBER TO THE WORKERS' COMPENSATION SYSTEM
BY PURCHASING INSURANCES AS DESCRIBED HEREIN.

4.6
Additional Restrictions. The Plan Administrator may from time to time
impose such additional restrictions on the availability of Benefits as is necessary to comply
with applicable law, Company policy, or the restrictions of any Carrier which underwrites
any Benefit under the Plan .

ARTICLE 5

OPERATIONAL PROVISIONS
5.1
Reporting. A Participant mus t im l11ediatety report a llYaccidenta l on-lhe-Job
injury or illness to his supervisor or designee . The Parlicipa nl must report every injury or
illness, regardless of the nature or severity . Failure 10 irnrnedialely report an injury or
illness nlaysubJect the PartiCIpant todisc.ipiinary action up to and including termination .

OCCUPATIONAL INJURY BENEFIT PLAN

Page 7

 5.2
Drug Screen.
be requested by the Company,

Upon reporting

5.3
Medical Treatment.
conducted as follows :

811

injury or illness, n drug screen may

The Participnnt's treatment and care will be

J.
If the Participmlt and the Participant's supervisor determine that
only routine first aid is required to treat a Participant's injury, the
Participant will be treated from tile location first aid kit and will then
relum to work.

ii.
If additional or more extensive medical assistance is required, the
Participant will be sent to a health care provider selected from a list of
authorized health care providers maintained by the Company. Participants
will be required to accept referrals within this approved refen'ul network in
order that the cost of treatment for the injlll'Y or illness will be maintained
by the Company. If a Pi:lrticip<illt chooses to go to a pbysician of his or her
choice, the Company will not be responsible for 1l1e expenses incurred by
the Participant in so doing. In addition, the Company reserves the right to
require that a Participant undergo an initial and subsequent evaluations by
an authorized health care provider prior to allowing the Participant to
retum to work after em injury or iJlness.
5.4
Second Opinion.
The Plan Administrator may require a second or
additional medical opinions relating to any on-the-job injury and any recommended
surgery, whether in-patient or ollt-patient surgery, as part of the prescribed treatment for
an injury or illness.
5.5
Incapacity.
After initial treatment, the authorized physician may
instruct the Participant not (0 retUl11 to work pending further treatment and until released
at a later date. DUling this period of incapacity ("incapacity"), the Participant may not
resume any duties for the Company unti.1 released in whole or in part by the authorized
physician to retUll) to work. The Participant must report for work immediately after being
released in whole or in part by the authorized physician to retUJ1) to work.

OCCUPATIONAL INJURY BENEFIT PLAN

Page 8

 5.6
Weekly Contact. A Pa rti cipant must contact the Company's office weekly
while receiving Sa lary Continu ance Benefits to report on his or her progress and expected
recovery time. Fa ilure to do so will ca use the Participant's entitlement to continuing
Benefits under this Plan to be discontin ued.
5.7
Social Security. If the Participant receives or is entitled to receive Social
Security disability Benefits for the same period of time for which salary continuance
Benefits are payable hereunder, the weekly benefit provided hereunder will be reduced by
the total amount of such Social Security disability Benefits.
5.8
Failure to Return. If, after treatment, whether emergency or long term, the
authorized physician releases the Participant to return to work, and the Participant fails to
return, all medical payments and salary continuance Benefits will immediately cease .

5.9

Coordination of Benefits: Subrogation.

a.
No person claiming benefits under the Plan shall have a right to
recover, from all sources, an amount in excess of the claims which may be filed under the
Plan . Accordingly, benefits payable under the Plan shall be reduced to the extent provided
in any of the Policies to the extent needed so that the sum of the reduced benefits and
reimbursements payable from all sources do not exceed the total amount of the
Participant's claims. In determining whether coverage under the Plan is primary, the terms
of the Policies shall control.
b.
In addition, the Plan shall be subrogated with regard to claims it pays
under the Plan. Therefore, if a Participant recovers, or has the right to recover, monies
from any third party, including coverage under an insurance policy Dr a claim against any
third party including the Employer, whether through litigation, arbitration , or otherwise, the
Plan may, at its option, make a claim for the funds previously paid on behalf of the
Participant. The Plan shall have a lien on any amounts which a Participant recovers from
any third party . Each Participant shall be required to cooperate fully in the exercise of the
Plan's subrogation rights, and shall do nothing after incurring an injury, claim or other loss
to prejudice su ch rights, but shall assist in the PIan's efforts to secure such rights. In the
event that the Plan is unable to subrogate against any third party, the Participant shall
reimburse the Plan for any amounts recovered by it to the extent that the Participant has
previously received payment from a third party.

OCCUPATIONAL INJURY BENEFIT PLAN

Page 9

 c.
The Plan's right to coordination of benefits and subrogation shall be
subject to the terms of the Policies . Nothing contained in this Section shall be deemed to
limit or restrict the right of any Carrier to seek subrogation, reimbursement, or coordination
of benefits under any Policy.

ARTICLE 6
CLAIMS
6.1
Claim Procedure. When a Benefit is due, the Participant should submit his
claim to the person or office designated by the Plan Administrator to receive claims . Under
normal circumstances, a final decision shall be made as to a claim within 15 days after
receipt of the claim. If the claim is for urgent care, a final decision shall be made as to the
claim within 72 hours after receipt of the claim. If a claim is denied during the claims
period, the Plan Administrator must notify the Participant in writing. The denial must
include the specific reasons for it, the Plan provisions upon which the denial is based, and
the claims review procedure. If no action is taken during the claims period, the claim is
treated as if it were denied on the last day of the claims period.
6.2
Notic e of Denial. In the event that a claim for Benefits is to be denied in
whole or in part, then the Third Party Administrator shall provide the Participant or the
Participant's representative with written or electronic notification of the Plan's adverse
determinatioll. The notice of denial shall contain the following:
i.

the specific reason for the adverse determination;

ii.

reference the specific Plan provisions (including any internal rules,
guidelines, protocols, criteria, etc .) on which the determination is
based;

iii.

a description of any additional material or information necessary for
the Participant to perfect the claim for appeal and an explanation of
why that material or information is necessary;

iv.

a description of the Plan's review procedures and the time limits
applicable to those procedures;

OCCUPATIONAL INJURY BENEFIT PLAN

Page 10

 v.

a statement of the Participant's right to bring a civil action under
section 502(a) of ERISA following an adverse benefit determination
upon review; and

vi.

in the case of an adverse benefit determination involving a claim for
urgent care, a description of the expedited review process applicable
to urgent claims.
.

If the notice of denial of a claim fo r Benefits re late t a claim involving urgent
care, the notice may be provided to the Particip ant or the Participan t's representative orally,
provided that a written or electronic notification is furnlsh ed 10 the Participant or the
Participant's representative no later than 3 days after the oral notification.

6.3
Timing of the Notice of Denial. The deadline for providing the notice of a
claims denial depends on-the type of claim being denied and the reason the claim is being
denied, as set forth below.
a.
If the claim is being denied because the Participant or the Participant's
representative did not follow the Plan's procedure for submitting the claim, the Third Party
Administrator must notify the Participant or the Participant's representative of the correct
procedure within five days after the claim is received. Exception for Urgent Care: If the
claim is for urgent care, the notification must be given within 24 hours after the claim is
received.
b.
If the claim is being denied because the Participant or the Participant's
representative followed Plan procedures but did not submit sufficient information for the
TI1ird Party Administrator to determine whether the claim is covered or payable by the Plan,
lhe Third Party Administrator shall notify the Participant or the Participant's representative
of the additional information needed within five days after receipt of the claim, and the
Participant or the Participant's representative shall be given 45 days after the date the
notice is received to provide the missing information. The Third Party Administrator shall
then review the additional information and notify the Participant or the Participant's
representative within 15 days after the additional information is received of the Plan's
determination with regard to the claim. If no additional information is received during the
45-day response period, the Third Party Administrator shall send a notice of claim denial
within 15 days after the end of the 45-day period. Exception for Urgent Care: If the claim is
for
urgent
care,
the

OCCUPATIONAL INJURY BENEFIT PLAN

Page 11

 Third Party Administrator shall notify the Participant or the Participant's representative of
tl1e additional information needed within 24 hours after the claim is received, and the
Participant or the Participant's representative shall be given 48 hours to provide the missing
information . The Third Party Administrator shall then review the add itional information and
notify the Participant or the Participant's representative within 48 hours after the additional
information is received of the Plan's determination with regard to the claim. Ifno additional
information is received during the 48-hour response period, the Third Party Administrator
shall provide a notice of denial of the claim within 48 hours after the end of the response
period .
If the Participant or the Participant's representative has followed Plan
c.
procedures and has submitted sufficient information for a determination to be ma'de, but the
Third Party Administrator has determined that the claim is to be denied, then the deadline
for the Th ird Party Administrator to provide the notice of denial is 15 days after the receipt
of the claim. Exception for Urgent Care : If the claim being denied is for urgent care, then
the deadline for providing the notice of denial is 72 hours after receipt of the claim.

6.4 When a Claim is Received. The Plan will be deemed to have received a
claim for Benefits if a claim or a Participant's representative makes a written
communication, except in the case of urgent care, in which case the claim may be
communicated orally, reasonably calculated to bring a request for a claim to the attention of
the Third Party Administrator.
6.5
Ma nner of Giving Notioa. Notice given in writing sha ll either bese nl by first
class mail or by hand delivery. Notice may only be givenelectron icaliy (the lis, by ema il) If
the Third Pa rty Admi nistra tor insures tha t the message is re ceived by using lhe relu rnreceipt electronic mail feature and if the Participant is advised in the text of the nofice of llle
Participant's right to receive, free of charge a paper copy of the notice.

6,6
De finition of Claim Involving Urgent Ca re. "Urgent care" means medical
care orlreatmen t w ith respect to w hioh tile application of tile perio ~5 ror making non-urge nt
care cJetermina llons: (i) could serioLis ly jeopa rdize the life or hea lth of the Pc rticipant or the
ability of the Participant 1'0 regain maximum fuhctio n, Of, (11) WO Uld, in til e opinion of a
physician familiar with th e Participant's medica l cone/itio n, subJecl lhe Parlicipanl to severe
pain lha t cannot be adequately managed with out the care or treatment being applied for.
Wileiller a claim should be trea ted as an "Urgen t care " c1airn can eilher be determined by
a phYSician with l~t1Owledge of lhe Participan t's medicat condition or by an individual ac1ing
on ehalf tile Pla n, provided that individual applies the jlJdfjrnent of a reasonable individual
wt10 is no l a trained hoa lth pro fessiona l.

OCCUPATIONAL INJURY BENEFIT PLAN

Page 12

 6.7
Appeal Procedure. Once an initial denial is issued, the T I,ird Party
Administrator shall not give any further consiueralion to the claim. The Participant may
then appeal the initial claim denial. If a claim has been denied , tile Participant or the
Participant's representative has the right to appeal the deni~l l , as described be low .
S.B
Right to Reconsideration. Within 180 days after the date of the notice of
denial is received, the Participant, or the Participant's representative, may request further
review of the original claim by filing a written request for reconsideration with the Plan
Administrator, by hand delivery or first class mail. Exception for Urgent Care: If an appeal
relates to an urgent care claim, the appeal may be verbal.

6.9
Rig ht to S ubmit Comments . W ithin 180 days after llle date Ihe notice of
denial is received, in addition to having tile original claim reviewed, the Participanl or lIle
Participant's I'epres.entatlve may al'sa subm it written comments, documents, records, and
other informaLlon related to til e cla im , even if the Participant had not previously submitted
those documents or information.
6.10 Right to Review D o cum ~ nts. During the period that a claim is being
reconsidered, the Partlcipanl or the P"rticipant's representative may have access to and
copies of all documents,. records, an d Ot1ler information relevant to the claim that has been
denied.
6.11 Decis ion by Plan Adminis trat or. The Plan Administrator shall notify the
Participant or the Participant's rep resentative of the Plan Administrator's findings within 30
days after receipt of the request for review o f tile claim. Exception for Urgent Care: If the
claim being reviewed involves urgent care, the Plan Administrator shall notify the
Participant or the Participant's representative of the Plan Administrator's finding within 72
hours after receipt of the request for review.
6.12 Contents of the Plan Administrat o r's No tificatio n. If, upon review, the
claim is again den ied, the Plan Administrator slla ll prov ide a written notice of the denial
containing:

i.

the specific reasons for the adverse determination;

Ii.

reference to the specific Plan provisions (including any internal rules,
guidelines, protocols, criteria. etc.) on which the benefit determination
Is based;

OCCUPATIONAL INJURY BENEFIT PLAN

Page 13

 iii ,

n stll icmen t lh,it the Participant is entitled to receive, upon
reql1est,
reasonable UCCCS$
to and copies of, (llJ
documents and records re!eViJnl to the review of the claim,
and the identities, of allY experts
including any reports,
whose advice was obtained;

IV ,

a statement that if the Participant disagrees with the benefit
determination, the dispute shall then be submitted to binding
arbitration as required by the "Mandatory Arbitration Plan
for the Resolution of Work Related Injury or Illness Claims
of Texas Employees" which is "Amendment 1 to the Pilot
Travel Centers LLC OccupatioJlal lnjuTY BeneJit Plan".

ARTICLE 7
ADMINISTRATION OF THE PLAN
7.1
Plnn Administrator.
The Company may appoint a Plan Administrator
other tban the Company to administer this Plan. The Plan Administrator shall serve lIntil
its resignatiol1, d~alh or removal. 'Dle Plan Administrator may resign at any time by
mailing 01' delivering a written resignation to the Company. The Plan Administrator may
be removed by lhe Company~ with or without cause, 'nle vacancy may be filled by the
Company trom lime to time.

7.2
Discretionary Rights and Duties.
The Plan Administrator is <1
Jiduciary. The Plan Administrator has the exclusive responsibility for the general
adminislration of the Plan, and has the discretionary power and authority necessary to
accomplish thaI purpose, including but 110t limited to the following lights, powers, und
authorities:

1.

To nmke rules lor administeJing the Plan;

OCCUl'ATJONAL INJURY BENEFIT PLAN

Page 14

 ii.

To construe all provisions of the Plan;

iii.

To correct any defect. supply any omiSSion, or reconcile any
inconsistency which may appear in the Plan;

iv.

To determine all questions relating to eligibility, and all ather matters
relating to entitlement to Benefits;

v.

To resolve all controversies relating to the administration of the Plan
and any questions he believes are advisable for the proper
administration of the Plan;

vi.

Direct the Third Party Administrator, if any , in all maliers relating to the
processing of claims and payment o f Pla n Be nefits; pro vided ,
however, such matters delegated to the Third Party Administrator
shall constitute ministeria l o r non-discretionary respon sibilities; and

vii.

Delegate any clerical or recordation duties of the Plan Administrator
as the Plan Administrator believes is advisable to properly administer
the Plan.

viii.

Plan Administrator (or its delegatee) may investigate all accidents,
injuries, and illnesses, and promulgate, implement, and enforce
workplace safety rules and standards.

The action of the Plan Administrator in exercising a/l of the rights, powers and authorities
set out in this Section, when performed in good faith and in its sole judgment, shall be final,
conclusive and binding upon all parties.

7.3
Documents. The Plan Administra to r shall make available to each Participant
for his examination, those records, documents and otll er data req uired under ER ISA, but
only at reasonable times during business hours. No Parlicipan t has the righ t to examine
any data or records reflecting information pertaining to any other Participant. T he Plan
Administrator is not required to make any oth e r da la or records avail ble other than those
required by ERISA.

OCCUPATIONAL INJURY BENEFIT PLAN

Page 15

 7.4
Indemnification. The Plan Administrator shall not be liable for any act or
omission of its own unless required by ~RISA or another applicable state Dr federal law
under which liability cannot be waived . The Company shall indemnify the Plan
Administrator from any and all losses, costs, expenses, and damages arising out of the
Plan Administrator's administration ofthis Plan unless the Plan Administrator is determined,
by a nonappealable final order of a court of competent jurisdiction, to have been guilty of
gross negligence or willful misconduct.
.
7.5
Sponsor. For all purposes of ERISA, the Plan Administrator is the Sponsor.
The Plan Administrator has the final responsibility for compliance with all reporting and
disclosure requirements imposed under all applicable federal or state laws and regulations.
7.6
Third Party Review. The Carrier or the Company may, at its discretion,
utilize a third party to review and provide services regarding medical costs and to oversee
the medical treatment and progress of a Participant.

ARTICLE 8
MISCELLANEOUS
8.1
Safety. The Particip ant must report to his or her immediate supervisor any
fau lty equipment, hazardous cond itions, damaged property, blocked passageways or exits
or any other co nditions which may be a safety haza rd to Employees, customers and others.
FCl ifure 10 ob serve all safety rules may subject a Participant to disciplinary action, and the
Partioipan t's entiUemenl [0 continu ing Benefits under this Plan may be forfeited,
suspe nded, or -d iscc>ntin uec!.
8.2
No Guarantee of Emplovment. Nothing contained in this Plan shall be
construed as a contract of employment between the Employer and any Employee, or as a
right of any Employee to be continued in the employment of tile Employer, or as a limitation
of the right of the Employer to discharge any of its Employees, wilh or without cause.

B.3
Rights to Empl oyer's Assets . No Participant or beneficiary shall have any
right to, or interes t. in, any asse ts of tile Employer for claims arising under the Plan . All
payments of benefits as provlded for in this Plcm shall be made solely from the Policies and
neither the Employers nor the Plan Administrator shall be liable therefor in any manner.

,
OCCUPATIONAL INJURY BENEFIT PLAN

Page 16

 8.4
Communications. All elections, requests, notices, and instructions and other
communications from a Participant or other person to the Employer or Plan Administrator
shall be mailed by first-class mail or delivered to such location as sha lf be specified by the
Company, and shall be deemed to have been given ~n I delivered Mly Llf}on actu I receipt
thereof by the Company or Plan Administrator at slIch Ibcation, as applicable. All notices,
statements, reports, and other communications from the Empl"oyer or Plan Adminis tra tor to
any Pariicipant 'Dr oill er person req uired or permitted under the Plan shall be deemed to
h.ave been duly given when delivered to, or when mailed by first-class mail, postage
prepaid, and addressed to, sllch Pmlicipant or other person at address last appearing on
the re.cords of Ih e Employer.
B.5
No Waiver or Estoppel. No term, condition, or provision of the Plan or any
Policy shall be deemed to have been waived, and there shall be no estoppel against the
enforcement of any provision of the Plan or any Policy, except by written instrument of the
party charged with such waiver or estoppel. No such written waiver shall be deemed a
continuing waiver unless specifically stated . Each such waiver shall operate only as to the
specific term or condition waived and shall not constitute a waiver of such term or condition
for the future or as to any act other than that specifically waived.
8.6
Employer Not an Agent of Carrier. Neither the Company, any Eniployer,
nor the Plan Administrator shG, 1I be deemecl to be an agent of any Carrier nor to be
authorized to interpret any proviSion of the Policies. No Carrier shail be bound by any
statement made by the Company, Employer, or Plan Adminis tratpr wiU, respect to any
j3enefit provided under a Policy issued by any sucll Carrier.
8.7
Entirety. This Plan, the Policies, and the individual applications executed by
the Participants, including documents in support thereof, or altering information or effect of
any such applications, shall constitute the entire agreement between the Employer and the
Participants. Such agreement may not be changed, except in writing.
B.8
Heirs. This Plan shall be binding upon the heirs, executors, administrators,
successors, and assigns of the parties, including the Company and each Participant, estate
of a Participant, and beneficiary of a Participant, present and future.
8.9
Headings. The headings and captions herein are provided for reference and
convenience only, shall not be considered part of this Plan, and shall not be used in
construction of this Plan.

OCCUPATIONAL INJURY BENEFIT PLAN

Page17

 B.10 Gender. Except where otherwise clearly indicated by context, the masculine
and the neuter shall include the feminine and the neuter, the singular shall include the
plural, and vice-versa.
8.11 Controlling Law. This Plan isan "employee welfa re benefit plan" as defined
in Section 3( 1) of the ER ISA, as a plan main tain ed for the purpose of providing one or more
ot'medical, surgical, or hospital care, disability, dea th, or dismemberment Benefits in the
event of an Injury. This Plan shall be governed, construed , and enforced according to
Federal law to the maximum extent available.
8.12 Severability. If any provision of the Plan is determined to be void by any
court of competent jurisd iction, the Plan will continue to operate, and for the purposes of
the jurisdiction of that court only, will be deemed not to include the prOVision determined to
be void.
8.13 Offset. Any Benefits paid under this Plan are for the reduction of the
Company's liability, if any, and shall be construed as an offset by an Arbitrator or court of
law. Benefits paid under this Plan shall not be considered payment from a collateral source
as that term is defined by statute, case law, or judicial decision.

ARTICLE 9
ADOPTION OF PLAN BY AFFILIATED CORPORATION
9.1
Affiliated Corporation. An affiliated corporation or franchisee may adoptthis
Plan by a certified resolution or consent of its board of directors agreeing to be bound as a
Company by the terms. conditions and limitations in this Plan, as applied to,its Participants,
except as to those terms, if any, specifically described in the adopting resolutions or
agreement.
Obligation. The Company shall not be liable for any obligations under the
9.2
Plan of an adopting affiliated corporation or franchisee; and an adopting affiliated
corporation shall not be liable for any obligations of the Company under this Plan .

OCCUPATIONAL INJURY BENEFIT PLAN

Page 18

 ARTICLE 10
AMENDMENT AND TERMINATION
10.1 Prior Arrangements.
This Plan shall supersede any prior similar
arrangements for providing the Benefits hereinafter described.
10.2 Amendments. The Company has the sole right to make from time to time
any amendment or amendments to this Plan as it shall deem appropriate without notice to
Participants.
10.3 Right to Terminate. The Company may terminate the Plan at any time
without notice to the Participants. In the event of the dissolution, merger, consolidation or
reorganization of the Company, the Plan shall terminate unless the Plan is continued by a
successor to the Company in accordance with a resolution of its board of directors.
IN WITNESS WHEREOF, the Company has caused this Plan to be adopted as of
9/1/2006.

Pilot Travel Centers LLC

OCCUPATIONAL INJURY BENEFIT PLAN

Page 19

 PILOT TRAVEL CENTERS LLC
ACTIONS AND AFFIRMATIONS REGARDING THE IMPLEMETA TlON
OF PILOT TRAVEL CENTERS LLC'S OCCUPATIONAL INJURY BENEFIT

PLAN
The undersigned, as the authorized representative, instructed by PILOT
TRA VEL CENTERS LLC; a limited liability company fomled in the State of Delawme
and doin g business in the State of Texas; to reject tJle Texas Workers' Compensation
statute effective September I, 2006 and instructed to adopt and implement an
occupational injury benefit plan for the Texas employees of Pilot Travel Center LLC
effective September 1, 2006; takes the following actions and adopts the following :
As the authorized representative; instructed by PILOT TRAVEL CENTERS LLC,
to reject the Tex8s Workers' Compensation statute effective September 1, 2006
and instructed to adopt and implement an occupational injury benefit plan for the
Texas emp loyees of Pilot Travel Center LLC effective September 1, 2006; J
hereby adopt the PILOT TRAVEL CENTERS LLC OCCUPATIONAL INJURY
BENEFIT P LAN in tbe fonn attached hereto, to become effective as of ) 2:00
a.m. , 9/)/2006.
As the authorized representative; instructed by P1LOT IRA VEL CENTERS
LLC; to reject the Texas Workers' Com pens<1tion stall lte effective September 1,
2006 and instructed to adopt and impJemcni an occllpati onaJ il~ lIry bene fil plan
for the Texas employees of Pilot Travel Center LLC eJleclive September 1, 2006;
I affirm, that Pilot Travel Centers LLC, a limited li ability company, shaJJ serve as
Administrator of the Plan for all purposes undeT t11e Employee Retirement lncome
Security Act of 1974 (ER1SA);
As the authorized representative; instructed by PILOT TRAVEL CENTERS
1,LC; to reject the Texas Workers' Compensation statute effeclive September 1,
2006 and instructed to adopt and implement .m occupational illju ry bene fil plan
for the Texas employees of Pilot Travel Center LLC effective Septem ber 1, 2 006~
J further aHinn, th at any representative of the COmpallY. anth orized 10 do so by
the Company, may execute the Plan and any and nil other documell(s necessary
and \0 file My fonns with the Department of LabOr or 11l terna.1 Revenue Serv ice
which m8Y be required .

 EXHIBIT 

AMENDMENT 1 TO
PILOT TRAVEL CENTERS LLC SUMMARY PLAN DESCRIPTION OF
THE OCCUPATIONAL INJURY BENEFIT PLAN
MANDATORY ARBITRATION PLAN FOR RESOLUTION OF WORK
RELATED INJURY OR ILLNESS CLAIMS OF TEXAS EMPLOYEES
This Plan is the exclusive and mandatory way for an Employee and the Company to resolve
their disputes arising from a work related injury or illness.
Neither the Employee nor Company may bring a lawsuit in any state or federal court
against tbe other regarding a work related injury or illness or the severity of alleged
damages arising from a work related injury {lr illness.
1.0]

Arbitration is the process wherein a legally recognized dispute is decided by an
individual or individuals chosen by the parties to the dispute, rather than by a judge or
jury. Arbitration has the advantage of being less formal, of resolving disputes quicldy
and at less expense. The decision of the arbitrator is final and binding on the "Company"
and the "Employee."
Arbitration shall be the sole and exclusive process by whicll any legally recognized
claim, controversy, dispute or difference arising fi'om a work related injury or illness may
be resolved.

1.02

I\.s used in this Plan, "Employee" means any applicant for employment, actual employee
or rnmlcr employee. nljs shall also include any individual, child, dependent, spollse,
relative, executor, es tate or guardian which would have the legal standing required to
bring H lawsui l for drunages arising out ofa claim .

1.03

As lIsed in this Plan, "Company" means tbe employer and any, present or former, officer,
director, shareholder, co-worker, atlomey, agent or client of the Company. This
definition shall also include any parent company, holding company, subsidimy or any
other entity which has or had an economic interest in the Company.

1.04

As lIsed in this Plan, "Claim," "Controversy," "Di~pl1te' or "D ifference" means any
claim, dispute, disagreement, contention, or grie vallce Il r.ising from a work re lated injllry
or illness wbich an Employee has wilh the Company, or the Company has with 1he
Employee, which could !lonnally be mflde tJ1C basis or a lawsuit in a Stntc or Fedeml
Court. This pertains only (0 those claims, controversies, disputes or di tferences for work
related injuries and illnesses.

 This Plan DOES NOT provide lor resolution of disputes arising from any claim, dispute,
disagreement, contention or grievance other them those arising from a work related injury
or illness.
1.05

All employees, by applying for, accl:lp! i ll/5 Dr by c0111i l1 uing emploYlDent nrtcr the
implementation of this Plan, sha/J be requireu l{) subm it any I gai ly recognized d ail1l for
a work related injury or iJlness to arbi1 rulioll, rtll hcr thru, to li tiga ti on, according to th is
Plan and the rules established for ils enfo rcemenl. Tilt: Company shill! also b reCJ uired to
proceed to arbitration on all work related inj ury OJ' illness ma lleI'S bro ughl for arbj trnti01l
by an employee. The duty imposed on both Ihe COn'l) allY and E mployee to arbit mte nil
legally recognized claims arising from a work related injury or illness shall continue
beyond and not be affected by, the termination of an employee's employment.

1.06

The company shall have no righi, once the fac l S giv ing rise to n WOrk related illj ury 0 1'
illness have occurred, to amend this Plan () r o therwise elV id its obljgalioll ll) p roceed (0
arbitration if requested to do so. The compallY !,;/loll have lhe ri ghl Lo amend this Plo.n,
provided that no Plan amendment shnll be effcl:livc un til len (J 0) d<1Ys after it has been
communicated to all cunent employees. No nmlldrnent' clI n am'ol LI ennen! worl, relit le I
injury or illness claim.

1.07

No employee or group of employees shall have the right to seek class-wide relief for any
work relaLed injury or illness claim.

1.08

Remedies ava iJabl e to the em ployee Or company in arbitration shall be the same as would
be flvallable had Ull~ n:Hltter been bro ught in .coll1'l. All defenses Lhat would be available to
th e empJoyee 0r ~Oll1pany in litigat ion regarding work related injuries 01' illnesses shall be
avail able in nrbllrutioll. The arbi lrato r ~ Ii[lll have the right to consider alJ evidence and
ci)"cumslances deemed relevant to the dispute in arriving at the decision.

1.09

Despite the implementation of this Plan, emp loymenL with tbe Com pany is nod shall
remain "at wilL" Employees retain the ri ghL to terll1i na1e lheir employmenl, with or
withouL cause, and the Company similarly retni ns lhe ri!1,b Lto te)mina le employment w itb
or without notice and with or without cause. Nei ther thi s Plrul nor any provi!\ion
conLained herein is intended in any way to affec t. or change th e " at wiIJ " em ployment
relationship. Neither the employee's right to J roeeed Lo arbi lm lioll 1101' Ule Company's
obligation 10 proceed to arbitration shall be: affected by a termination of employment.

1.10

The Federal Arbitration Act (FAA) shall apply to and govern any matter submitted to
arbitration pursllant to this Plan . Tn the event, or to the extent, that the Fec/ernl
Arbitration Act Illay be detennilled to be inapplicable, and only in such an event, the
Texas General Arbitration AcL shall apply.

1.11

The rules governing arbitration proceedings shall be set forth , and as from time to time

anJended by the American Mediation Association, Dall as, Texas.
The American Mediation Association fiLing fee shall be paid by the party seeking
resolution under ihjs Plan . If any party refuses to pay any required fee, [hen this shall
represenl fl refllsal to arbitraLe per this Plan, and Lhe other parly may requ est a summary
ruling J/-om the arbitrator.

 Prior to initiation of arbitration, the employee and company shall attempt to resolve thc
c1ispllte by informal intcl1HlI disclission. If lhe dispute ewmat be resolved, thcn either
party may contact the American Mediation Association.
1.12

The arbitrator shall have expertise and expelience in resolving work injury disputes or
claims. Such individual must be available to hear a matter and render a decision without
undue del Ely.
The arbitrator shall have the same all thority as a llial judge, sitting without a jury, to
make factual detcI111inations and 10 app ly govcming low to the facts as determined. The
arbitrator shall have no 'authority to ignore or modify ru1Y provision of this Plan or to
apply any legal, quasi-legal Or equitable stand ards excep t those embodied in or as
generally accepted as part of the governing law.

I. I3

The Company and Employee shall attempt to sel eci a mutually acceptab le arbitrator. Is
an arbitrator cannot be selected within thirty (30) days of the deman d tor arbi tratjon, {h e
Amelican Mediation Association shall slIbmH to each party a Ijst of fiv e (5) qualified
persons, along with information on their backgrounds ami C] ua li-lications. The parties
may (hen agree on a person . ]f the parties fail to Hgree OJ) an arbit.rator, euch pany w.iU
rank the arbitrator candidates from one to jive (one being the preferred) and retUnl [he
rankings to the American Mediation Association . The candidate whose lol'll score is Lile
lowest shall be the arbitrator. 1n the event of a tie score, Ule Amelican Mediation
Association shall select the arbilrator.

If a party fails to return their nmkings within thirty (30) days of receipt, then that party
agrees to the appointment of ~my persoll on the list. If neither party returns the list within
the time limit, then the American Mediation Association may appoint any person on the
list.
1.14

The parties agree iJ1at the person appointed as arbitrator is an independent contractor and
not an agent or employee of the American Mediation Association.
The parties agree that neither the American Mediation Association nor any arbitrator or
mediator shall be necessary or permissible parly in any judicial proceeding related to an
arbitration or mediation.
The parties agree thai neither an employee or associate of the Am erican Mediation
Association, arbitrator or mediator shall be called as a witness, consultant or expert in any
pending or future proceeding related to the subject matter of the dispute.
The parties agree tbal the Americall Mediation Association, its employees, associates and
all arbitrators or mediators shall have immunity or defense from any liability to the same
extent 8S any judge tJ1a l presides over a court proceeding. The parties further agree that
the American Med'iation Association, i1s employees, associates, arbitmtors and mediators
shall not be li abl e to any party for any act or omission concerning a dispute. The totul
damages recoverable for any claim that a party cannot waive shall be equal to the fee paid
by a party to the America!) Mediation Association.

1. J 5

Except where it may be shown that the arbitrator's award was proclII'ed by fraud or
cOlTuption, or where the arbitrator has demonstrated evident partially or misconduct
sufficient to substantially prejudice the rights of one or more of the parties, or where the

 arbitrator's ~lw[lrd shows manifest disregard for the goveming law or for Ihis Pion, the
awm'u rendered by the arbitrator shall be final, binding and unappealable.
Eflorts to confirm, modify or vacate an arbitrator's award in court shall be conducted
according to the provisions of the Federal Arbi tration Act ~md the trial judge in such court
shall have limited jurisdiction sufficient only to enforce this AJbitration Plan and the
orders of the selected arbitr<ltor.
J.16

Except as may be modified herein, the time limit for requesting arbitration shall be the
same time limit specified under law as the statute of limitations period for work injllrY
claims; as if the work injury claims had been asserted in u court of law. Reqlfests for
arbitration not timely made in accord,mce with the applicable stahlte of limitations shall
be forever ban-ed .

1.17

Unless so ordered by the arbitrator, and only upon a showing of good cause, no more than
three (3) depositions, excluding depositions of expert witnesses, may be taken by any
pruty. No single deposition may exceed iour (4) hours. Interrogatories may be utilized
by any party. Each party is allowed two (2) sets oflnterrogutories requiring DO more than
twenty (20) separate responses per set (subset req\lcsts sucb as I A, IB or questions
requesting multiple answers shall each count as one response). The arbitrator shall have
sole aUlhorily to deLenn.ine which discoY~ry py;o cedt ll"(:~$ are necessary and nPI1l' priate in
the case to reduce the lime, cosl Olld expense of tJ1C~ discovery process, whi le sti JI
aJConlil'l g each pqrty a fai)" opportunily to prepare it s case. Requests for PrmiuetioJ1 JUDY
be utilizcd by any party lIpon approval by the arbitrator. Reqlle ·ts for Admission may be
utili zed by tIny pflrty L1pon appr vol by the arbitrator. Unless a grcAt'er lime is allowed by
the r€Cjue5ling party, Jl1t crr0g~Lori es, Requests l"or Prociuclioll and Requests for
Admission sllaIJ be rulswered or objected to within thirty (30) {hlYS [rom the date of
service. The arbilmtor may impose sanctions and take such other actions in connection
therewith as deemed necessary to the same extent a judge could pursuant to the Federal
Rules of Ci vi I Procedure.
Both parties retain the right to file dispositive motions on the work injw'Y claim asseliecl
pursuant to lhc guidelines ortlle Federal Rules of Civil Procedme.

1.18

Costs and fees charged by the arbitrator sha ll be home eqllolly by Lhc patti "5. The
arbitrator sball have the discretion, upon written re.quer.l of allY party, ami 1'01' g od cuuse
shown, to reapportion the arbitration rees (except attorney fct!s) aud ';,0 'Is ill any mnnner
whicb the arbitrator deems equitable, e.'cept thal in IlO event shall un mployce be
assessed more than one-half of the arbitration fees ( xcept tltomey fees) and t: sts.

1.19

The consideration supporting the company's obligation to arbitrate, as well as the
employee's obligation to cU'bitmte, includes the mutual promise given to the other, to
submit all work related injury or illness claims or disputes to arbitration, rather than
litigate them in COllrt or in some other forum.
The company's obligation to submit aIJ legally recognized work related injury or illness
claims or disputes to arbi1ration upon the timely request of any employee is contractual
and oven-ides allY statement within its policies which may be construed to the contrary.

 1.20

This Plan shall, without any acl'ion required, automatically amend to comply with any
applicable slate Supreme Court, U.S. Court of Appeals or U.S. Supreme Court decision
regarding the enforceElbility of arbitration pllli1s.
Any issue or dispute conceming work related injuries or illnesses shall be subjecl to
arbitration as provided herein. The arbitrator, and not any federal, stale or 10CElI court or
agency shall have authority to decide any such issue or dispute. The decision of the
arbitrator on any such issue or dispute shall be finsl and binding upon the parties.

1.21

No promise or sgreement regarding this Mandatory Arbitration Plan that is not expressly
contained in this document sllall be binding on the company or employee. No oral
promise or representation shall in any way amend this Plan.

1.22

This Plan shall be the primary Elrbitration plan to resolve disputes regarding work

injury/illness claims.
Effective Date: Si~)\.!lJ.J'..,.9

.Q.J'.... \ \

\

:l D 0

6

Company Name: PILOT TRA VEL CENTERS LLC
A,rthorized
Signalure:

~esenrruPl

T,' s,<J'<'U.X>"- ~--"*" \~~ ~

I I>- - ~~

w &._