Case 3:14-cv-00200-DCG Document 1 Filed 05/28/14 Page 25 of 110 SIL VERoptions Work Injury Plan Third Amended SUMMARY PLAN DESCRIPTION for Employees (Plan #503) C sponsored and tm4ed solely by V.'. Silver, Inc. Includes all amendments through 05/15/2012 Supersedes and replaces a!! prior work i,fwy summaiy plan descriptions 0 000001 Case 3:14-cv-00200-DCG Document 1 Filed 05/28/14 Page 26 of 110 SILVERoptions Work Injury Plan IMPORTANT NOTICE: If You Need Help or Have Questions This booklet is a summaty in English of your rights, obligations and benefits under the SILVERoptions Work injury Plan ("SJLVERoptions" or "Plan"). If you have difficulty understanding any part of this booklet, please contact the SlLVERoptIona Benefits Admlnkfrater (the "Benefits Admmnisfrazor") office at 9059 Doniphan Dr., Vinton, Texas 79821. Office hours are from 8:00 a.m. to 5:00 p.m, Monday through Friday, except on holidays. If you need Occupatlona.1 Rasitheare, you must get Pro-Approval from the Benefit. Administrator. Call the telephone numbers below for further information end follow instructions, or you may not receive full coverage. ( C; Call the Benefits Administrator (915) 886-3553 ext. 131 If no answer, on weekends, or after hours call Security at (915) 886-3553 NOTIFICACION IFIPORTANTE: Si tasted necesita ayuda o tiene pregwstas rmen Este folleto en un en ixigles do sus derechos, obligaciones y bexieficios os par SlLVERoptions Work Injury Plan ("SlLVERoptions Plan"). Si usted tiene dificultad entediendo cuniquler porte do eat. folieto, por favor pongase en contacto con an Mmlnktrador do Beneficios. Sn oflcina so ubica en ci 9059 Dothpban Drive, Vintor, Texas 79821. Sushoxasbbllessonde8:0Oa.m.a5:00p.m.de1unes*viCSOOfleXCePddfl& festivos. Recuerde qus pam obtener cobertura bajo Plan, ofted dab. de obteocr proaproboclôn do Is Admlnlstrtdor do Beneficlos, port recibir cu*lquler servIclo o atteaclon medico. Part mayor informacidn llama a su Adminisirador do Beneflcios o a los oficiales do seguiidad do Plan. Sus nunieros telefonicos so encuentran en esta pagina. SILViRoptlonS Surnany Plan Desniptk*i 0 Copyright 2012 Canstangy. Biostur& Smith, Ortog1 LIP 1:) ( 000302 Case 3:14-cv-00200-DCG Document 1 Filed 05/28/14 Page 27 of 110 SILVERoptlons Work Injury Plan YOUR SAFETY & HEALTH IS OUR PRIORiTY W. Silver, Inc. (the "Company") is committed to providing a safe workplace for all ofourenrployees. With your help, and the help of every employee, the Company is committed to preventing accidents and occupational incidents, injuries and diseases. It is everyone's responsibility to use common sense, good judgment end to know and follow the Company's safbty rules and your supervisor's directions and instructions In order to prevent accidents end occupational Incidents, injuries arid diseases. Please see the Company's safety rules and policies for details. WORK INJIJRY BENEFIT COVERAGE Your employer, W. Silver, Inc., baa voluntarily established this SLLVERoptions Work Injury Plan (the "Plan"). The Plan provides legally enforceable "no-faulr benefits for covered Employees when (a) an Occupational Incident is the Main Cause of an Occupational Injury or Disease, or (b) Active Service for the Company Is the iole cause of Cumulative Trauma, all as specified in the Plan Document. As allowed by Texas law, W. Silver, Inc. ended its workers' compensation insurance as of June 10, 2002 and established a work ijuay benefit plan In Its place.. The Company provides coverage through Ibis Plan for Occupational Injuries, Dlsemeu end Cumulative Trauma occurring after the Plan's Effective Dale and during the Term of the Plan. The Plan is not workers' compensation insurance. CALL THE BENEFITS ADMINISTRATOR FOR HELP C The Company Is committed to making sure that you receive appropriate and timely hesithoare (If needed) if you are mnjwed. The Benefits Miulnistrator wilt help you with your claim, any questions and will schedule all medical treatment or evaluation (as needed) and aft follow-ups. During Business Bonn....................................... .(915) *86-3553 ext. £31 lIne answer, on weekends, or altar bonn' ............... (915) *86-3553 REM1?DER OF MANDATORY BINDJNG ARBITRATION The Company agrees with all employees (since June 1, 2001) that all legal actions arising from the employment relationship and arj work injuries, diseases, accidents and incidents, whenever occurring, wilt be submitted to final and binding arbitration Instead of to ajury trial. This mandatory condition of employment is explained In the current Arbitration sad Jury Waiver Agreement (the "Arbitration Agreement"). The Arbitration Agreement is 5c'paiC from the Plan and this Summary Plan Description and it applies to alt Employees and the Company as a condition of the employment relationship. A copy of the Notice of Arbitration and Jury Waiver Agreement Is attached to this Smuniry as En. "B." You have been given a copy of the current Arbitration sad Jury Waiver AgreCaseat which explains all the tents about arbitration. You can request an additional copy from the Company's Human Resources office or from the Benefits Administrator at any time. SlLVERoptiorrs Summary Plan Description LLP B4O0t3& OCc *2012 C O nfl : Case 3:14-cv-00200-DCG Document 1 Filed 05/28/14 Page 28 of 110 QkOver4ewofm.SILYERovdo,3P1w. The next 3 pages are a quick overview of the SlLVERoptions Plan (also referred to as "StiVERoptions" or the "Plan"). AU W. Silver, Inc. employees have the choice to be covered by "SlLVEP Benefris" or "GOLD Benefits' (GOLD oftrs more benefits), as Summarized in Table 1: What te required to qualify Timely report an Incident which is not excluded from coverage and is Mainly Caused by your Active Service an the Course and Scope of employment. for these benefits? you vohuitarliy elect Gold Benefits by mini the Post-Incident Waiver (Es. "),yoi will be eligible for the Iditlonal benelius below: Iledleal B.neftts 100% of Pre-Approved Hesithosie that is Medically Neceesaiy (at Designated Fee Guidelines), not excluded from coverage and provided by a Designated Provider. 'me as Silver Benefits, plus: Coven: Current employees only. HospItalIzatIon: Seem-private room only. Current and former employees. Private room (if needed and requested). MeL Duration: Earlier of DOTS or 30 days after incident (wOrsa you rign the'Waivurto get Gold Bcaefns). of your v.ge rats (no weekly cap) Wages dii 1) 'Eoiatinuous not s, 0. Wile Ic5 itt. Munoed a) When applicable: toMMI5 or anytime duringthc first nq99t- Max. Duration: _Dilflgflrt4ays after Incident Date. bit Time Wages None ($600!wk cép) (inluw you ilgo the Walvaic get Gold Bcncttb). Wages (unIon you sige the tdlöf6Oworkshlfts per. 'AWW for weebs 14 end thercato 0 When applicable: Man. Duration: Dáthor Walce to get Gold Bcne1'tr). AWW (capped at$600/wcek larMl1I ruin l560weekaflerDOL to 100% of $600,000based on 1'one WaIver to get Gold $5,000 Mod. (unlnosym* sign the Walverto get Gold cnocfin). 'DUT Dma OJTGPINUIeerOn See detaIICd deScription of bSneflts for exclusions, limitations, 7,' ( C ) SILVEROptIOVJ Sianma' Plan Description BinolakSalth, LI.? eComvtØe2O)2 Cgy. and requirements niãcusryfor / Case 3:14-cv-00200-DCG Document 1 Filed 05/28/14 Page 29 of 110 (I Qukk Overview ofthe SIL VERopIlos.s Plan ROW TO MAKE A CLAIM FOR BENEFITS It is very important that you carefully comply with these simple claim requirements to ensure full coverage for any Occupational Incident, Injury, Disease or Condition: AFTER YOU ARE INJURED: TELL YOUR SUPERVISOR Immediately and by no later then the end of your shift In which the Injury, Disease or Incident occurred or the need to report arose. If your supervisor Is not available, you should inunediately call the Benefits Administrator at (915) 886-3553, ext 131, or 1. call Security. 2. COMPLETE CLAIM FORM 200 to claim benefits for an Injury or illness or If you have any symptoms or pain that may be Mainly Caused by wort at W. Silver. Forms are available at any time from your supervisor, Security or främ Human Resources. Claim Form 200 must be promptly completed, signed, and given to the Benefits Adunbilstrstor as soon as benefits are needed end promptly after an Incident occurs. 3. COMPLETE ADDITIONAL FORMS as directed by the Benefits Administrator and your manager, either when you complete your Claim Form 200, or on or beibra noon of the next business day after your report of an Incident or symptoms, such as fbllows: Authorization to Release Infbrmatlon Employee Responsibilities Checklist & Agreement Form 203 Form 204 AFTER YOU REPORT YOUR CLAIM 4. AGREE TO THE POST-INCIDENT WAIVER, FORM 202 (lix. "A"). You will be asked to sign the Release ten business days after you report an Incident and sfter you have been examined by a non-emergency physician. S. REPORT any Change in Condition by Immediately calling the Benefits Administrator (or If unavailable, Security) and completing the Claim Change Form 201. ThIs must be filled out and given to Ike Benefits Administrator, your supervisor or Security by no later than noon of the next business day after you experience r'ny change in your condition or If you later request benefits not used or needed when you made your Initial claim. Rerei t1oraLyeubeneflts, If you do act tImely report as Benefits may be delayed,oryorn y!OS examples of when you could 1lowcthrü required by the Plan, lose pert or all of youWPlaa Benefits: I. You don't follow instnrcons. 2. Y._ufalltocompleteforms. S. You don't oba&P You don't sign the 6. C P pruvilm the Benefits AdInIniIIteIOr. qinniyerFOrm202 Dcerplim oc2Cou*m*y. Seats I tots. liP rtnn UIJULJI J ( Case 3:14-cv-00200-DCG Document 1 Filed 05/28/14 Page 30 of 110 ( CT' Quick OvW.w ef the SILYERa&a, Ptas by timely icporing the Incident. physical reittictIons and the Benefits that might delay your recoveiy or worsen your injury to. give lull Providers. Information to the Benefits Administrator utact with the Benefits Administrator, respond promptly to phone c ad within 5 days to any letter sent to you. Immediately update Administrator of changes in address, phone or other irspoi Ezebaslons and examples of what you should NOT do if you want to Covered are in §7.Ol-7.O3 and elsewhere in this Summary. C: BOW TO RQ1TEST REALTHCARE ALL BEALTUCAIE MUST BE PRE-APROVED by the Benefits Administrator and must be from Designated Providers, or it won't be covered. The Benefits Administrator makes nil Hesitheare arrangements for you, 24 bours(day. See § 3.Ols. During business hours, call (915) 886-3553 ext. 131. AFTER HOURS NEEDS. Call Security at (915) 886-3553 if your need for Occupational Healtbcare atises after regular business bows andlor the Benefits A4ministrator is unavailable. Don't acbdu1c, reschedule or skip appointments without the Benefits Administrator's Pro- ApprovaL Don't contact Designated Providers or schedule an appointment if the Benefits Adminisuator has not approved it, or the service may not be coveted. "EMERGENCIES" mean life-threatening situations only. In a true emergency, you should go to the nearest available healthcare facility and contact the Benefits Administrator at the earliest possible opporamity. Reduction or loss of Benefits may result if emergency room care is used when there is no true emergency and no Pro-Approval. If you need Emergency Medical Care. you should go to the nearest facility available, and contact the Benefits Administrator at the earliest possible opportunity (see §3.Ola(2)). C C C. SILVERapthz. Sunmy PI*nDcic1pttoi C pi4* 2012 Dmoku & Smith. LU' 179950.1 3 000:mG Case 3:14-cv-00200-DCG Document 1 Filed 05/28/14 Page 31 of 110 ARTICLE 1. THIS IS YOUR SUMMARY OF WORK INJURY BENEFITS Tha in your Thled Amended Snm Plan Description ("Summa of the Soptlons Work Injury Plan. It Is effective on May 15,2012 and replaces all prior .nm'v,rles of all prior occupational benefit plans. You are responsible for reading this Summary carefully. Your right to receive Plan Benefits depends on your following the simple obligations explained In this booklet The full details of the Plan ate contained in the current fomial Plan Document You may ask the Benefits Administrator to see or get copies of any of these documents. If there Is a conflict between this Summary and the fbrinal Plan Document, the formal Plan Document will control. Please note that definitions of certain terms that are capitalized are in Article 5 (a full list Is In the Plan Document). Whenever you have questions about the Plan, this Summary, your benefits or a possible Occupational Incident, Injury, Disease or Cumulative Trauma, please call the Benefits Administrator. ARTICLE 2.01 2. GENERAL PLAN INFORMATION Plan Designations. (a) Plan name. Whenever this Summary refers to "the Plan" or "SLVERoptions," the SILVkRoptions Work Injury P1an which Is the cunent, formal name of the Plan. it means (b) Plan type. The Plan is an employee welfare benefit plan regulated by the federal Employ.. Retirement Income Security Act of 1974 (ERISA"). After the Effective Dam, the Plan provides legally enfpracable "no-fault" benefits for covered Employees and/or Benefictanes when a Covered Occupational Incident Is determined to be the Main Cause of an Occupational Injury or Disease. Employees pay no premiums, co-payments or coinsurance, or preset waiting period or deductibles before Plan Benefits apply to a Covered Incident. (c) Additional InformatIon required to be disclosed to you is listed beIow Name and Address of the Plan Sponsor: W. Silver, Inc. ("Company") MaiI P.O. Box 12904, El Paso, TX 79913 9059 Donlphan, Vinton, TX 79821 Qffi Company Identification Number. 74-1646942 Plan Number. Type of Weifere Plan: 503 Occupational Injury Benefit Plan Type of Fuadleg and Adndniatzetlon: Plan Fiscal Year The Plan is seif-fizeded and administered. July I through June30 Plan M,utk$rator: W. Silver, Inc. Mark Fenanbock President M811: P.O. Box 12904, El Paso, DC 79913 Qçç: 9059 Domphan, Vinton, TX 79821 Agent fur Service of Legal Process: Cristlnaiarrell Mail: P.O. Box 12904, El Paso, DC 79913 Qffi: 9059 Donlphan, Vinton, TX 79821 (915) 886-3553 ext. 131 Benefits Admnintrntor 8!LVER0ptkJQS iminary Pun DescrIption LLP C Cop)t 2012 Conear. Bruots & snts. "cr55,.' ) 000307 Case 3:14-cv-00200-DCG Document 1 Filed 05/28/14 Page 32 of 110 2 2.02 Your Option to Select GOLD BENEFITS. (a) Gold Benefits. The Plezi cifere you (and your Beneficiaries) Gold Benefits In the fonn of various medical, wage, impamment dismemberment and death benefits for Covered Incidents that are the Main Cause of an Occupational Ii*jwy or Disease. The Plan's Gold Benefits are Intended to be the exclusive remedy fbi ill Occupational Injuries or Diseases and any telated Legal Actions by Employees (and their Beneficiaries) who agrel to the Post-Incident Waiver Form 202 (fix. "A") (the "Waiver). Gold Benefits are voluntarily oftbred to you by the Company fbi tha purpose of obtaining your agreement to the Waiver (fix. "A") (which Is your promise thal, In exchange for Gold Benefit eligibility, you will not take any Legal Action against the Company because of a specific Occupational Incident, Injury or Disease). (b) Sliver Benefits. All employees are eligible for at least Silver Benefits and are offered the opportunity to sign the Waiver Porm 202 (fix. "A") to become eligible far Gold Benefits. Silver Benefits ofthr coverage of Pie-Approved medical expenses at 100% of Designated Pee Guidelines, which will be paid directly to the PreApproved, Designated Provider, and Modified Duty Benefits (Initially at 100% of your hourly rate, but see §4,02 f& when 60% and $600fweck cap applies), If(1) you are Eligible by satisfying all requirements in Article 3 and §7.01; (2) an Occupational Incident during Active Service is aba Main Cause of your Occupational Injury or Disease, or Active SerVice Is the sole cause of Cimiulative Treuma, and (3) you arc not Excluded or Disqualified from Benefits fbi reasons stated In Article 3, §4.02, *7.02 and §7.03, or elsewhere. Silver Medical Benefits we limited to no more than $10,000.00 and apply to employees with covered medical expenses occuring within the first thirty (30) days a lcLdant Date. You do not have to agree to the Waiver (fix. "A") to receive Silver Benefits, but you must be eznjiloyed and cooperate with all cOrer Plan requirements. However Wage and Death & Dlsmemerment Beasfihs will not be available to you (except for the $5,000 Burial Benefit), nnr.will er Mudirel B fits g*ipüe ab3$I,0Oj.O0 or beyond thirty (30) days after the Incident Date, union md imtilii1iland mmmdc the Wmver., ( (c) Walver-lsopltoaataadvoluntary. Noonewillbeforcedtosignthe Waiver. Itispuicly optionaL The Waiver Is available for you to sign at any point on or after the tenth (10th) business day following the initial report of an Incident or Injury and after you have received a medical evaluation by a nonemergency doctor after an Occupational Incident, Injury or Disease. Once you sign the Waiver, you become eligible for all applicable Plan Benefits, both Silver and Gold Benefits relating to the reported Incident, starting on the date that you sign and return the Waiver to the Benefits Administrator, subject to the other terms of the Plan. You will become eligible for all applicable Plan Benefits retroactive to the dat. you first reported a Covered Incident If you sign and return lbs Waiver to the Benefits Administrator by no later than the thirtieth (30') day after the date that you first reported a Covered Incident, if the Benefits Adninistretor determines that you promptly corrected any prior noncompliance (lee, e.g., §7.03) relating to the reported Incident. Ify InIe to not alan the Waiver, thón you will (1)Jptimev1 Go Benefits, (2) becIlgjtde n. aowover, such rights can only be pursued in binding arbitration became all employees have the Company to arbitrate such matters (see fix. "B"). 'n., (6) Silver Benefits are very limited compared to Gold Benefits. Because the Plan is designed to encourage you to sign the Waiver in order to be eligible for Gold Benefits, the Silver Benefits offered to thos. who do not sign the Waiver ire much more limited In amount, coverage and duration than what Is offered by Gold Benefits. See Table 1, §2.02b and belowth1hnits to Sflvepuefitm as compared to Gold Benefits. SILVERopllcns Suimuiy Plan Drsciiptfoa C CopyeIaJs2Ol2 CntanOr. s & Smith. LU' ) ( 000J0t3 Case 3:14-cv-00200-DCG Document 1 Filed 05/28/14 Page 33 of 110 2.03 Eligibility and Coverage.. (a) Who can participate In the Plac. You are a participant in the Plan If you are an ai the Company (whether flail, part time or 'as needed") as defined by applicable law, or If you are a Beneficiary of an Employee who ii eligible for Plan Benefits as a result of a Covered Incident Any person to whom the Bonifits Administrator presents the Waiver becomes a participant in the Plan (according to its terms) upon signing the Waiver. Independent contractors, employees and subcontractors of mdependent contractors, leased or temporary employees of a third party who are assigned to work at the Company are not covered by the Plan afld are not participants In the Plan. You axe eligible for Plan coverage and its applicable Benefits lf after the effective date ofthe Plan, you were in Active' Service in the Course and 5copo of Employment as an Employee at the time of. Covered Incident and during the Ternt of the Plan, subject to all of the terms and conditions of the Plan. EmployCe (b) What Is Covered by the Plan. The Plan provides benefits for an Occupational Injury or Disease, the Main Cause of which is determined by the Benefits Administrator to be a Covered Incident under the Plan. 1. A TMCovered mcdiii" is an Occupational Injury (Including death or disability) or Occupational Diseate which you experience as an Employee, Including Cumulative Trauma, subject to certain liuzitatlons The 1ncideni Injury or Disease must be Mainly Caused by your work for the Company (he, your Active Service) that relates to, or originates In the business of the Company within the Coursc and Scope of Employment. ft must not be the natural progression of. Pm-oxisting Condition. 2. "Course and Scope of Your Employment" means that you must be involved in the normal activities of your work for the Company when the Incident occurs. The Plan does not provide any Benefits for injuries or disease which are Mainly Caused by, or axe the naturil progression of, the following (a) non-Occupational Disease or (b) Pre-exiating Condition (accordingly, the Plan will act cover claims for Cumulative Trauma during your first 12 months of employment with the Company), or (C) other injuries, conditions, diseases or illnesses that were not Mainly Caused by your Active Service for the Company. AddItional details of what Is covered and excluded from the Plan can be foimd 3. in §7.0l, 7.02 and 7.03, as well as throughout the descriptions of each Benefit (see ArtIcles 3 and 4). The Plan Administrator, In its sole and absolute discretion, by and through the Benefits Administrator or Appeals Panel (as applicable), will determine If an injury or illness is in the Course and Scope of Your Employment (based on all of the surrounding facts and ciiuumstsnces) such to be an Occupational Injury or Disease mainly caused by a Covered Incident SILVRRoptiom. Summuy Plot DcsciIp 0 COpTiI5 2012 Cootur. &o ilasas.I & Sndth. LI.? OOOJ9 ( Case 3:14-cv-00200-DCG Document 1 Filed 05/28/14 Page 34 of 110 ( ARTICLE 3. MEDICAL BENIEFITS 3.01 ConditIons for all Medical Benefits (Silver and Gold) Medical Benefits are only for Pro-Approved Healthcarc from Designated Prov1dn when such Is Medically Necessary for Employees because of a Covered incident The conditions In (a) through (t below apply to Sliver and Gold Medical Benefits. (a) You must get Pro-Approval for all Healthcare. ft is always w resoonslbflitv to rlestPTS-Aenroval fun the Benefl Administrator for cmii mid every lonobitsuent trelitmcnt. and Hàltháare iiLflr*hlchanv ive of MMIáII Bààflt Iisàusfit. Call the AdmioL*,.lur for P-Aprávil Ed dlróctlàn bed filling r ifiJling en'Crlion, purohasingBáàfli any medical supplies and Durable Medical Equlpfliànt You can lose Benefits and be personally obligatd for expenses If you do not request and receive Pro-Approval. 1. AItsr.houn needs: If the need for Occupational Beelthcare arises after regular business hours andlor the Benefits Administrator is unavailable, someone else will be on-call and available to Pro-Approve treatment Do not just leave a message after hours If you arc trying to get Pro-Approval. You can always contact the Benefits Adminisbator (or un-call designee) by calling the 24 hour hotline numbers (see quick overview and § 7.01). ExplaIn that you are requesting Work ln.3uxy Benefits, and deacrlbc any need Immediate assistance that you need. 2. Emergency Medical Care will he covered without the usual Pm-Approval process if the Benefits Administrator determines that, in addition to all other conditions that apply In all Healthcaie and Medics) Benefits, each of the following applies: (a) you had a genuine need for Emergency Medical Care (as defined in Article 5), (b) It wis Impossible for you to get Pro-Approval before or during the need for Emergency Medical Care, and (c) you or someone on your behalf informed thC Benefits Administrator of the need for Emergency Medical Cats at the earliest time posilbie after the emergency was over, or by noOn of the next business day after you arc provided Emergency Medical Care at a hospital or emergency tbcllity, whichever Is earlier. This exeeption of providing coverage without Pro-Approval applies only if an actual need for Emergency Medical Care makes Pro-Approval Impoisthie (net just inconvenient). Just because you seek treatment from an emergency room or call an ambulance does not mean that the Hsalthcar. Is Emergency Medical Care that will be covered by the Plea. Just because a claim qualifies as an "Urgent Care" claim for purposes of the claim response timeframes in §8.02 does net mean that the Healthcarc will be covered by the Plan as Emergency Medical Care. Repeated unneceasaly use of the emergency room cray result in loss of reduction ofBenefits. C 3. Un-Approved Ikaithease. You may see any Heahhcarc Provider of your choice at your own expense. However If this interferes with your recovery, extends Lost Time or interferes with the Pro-Approved treatment plan, then your Benefits may end or be reduced. if you go to an emergency room without Pre-Approval for something that is not "Emergency Medical Care" as defined by the Plan, then you may be held personally responsible by the emergency room (and other providers) for the charges. 4. Un-Approved opinions offered by Hcalthcarc Providers who have not been PieApproved or who are not Designated Providers will not govern Benefit decisions wider the Plan. (b) You must authorize and cooperate with the mug, of medical and claim Information. As a condition of all Medical Benefits, and so that your claim can be covered by the Plan, you must consent so the Benefits Administrator (or designated representative) (I) being present with you at your Healthcarc S!LYERoptions Sunvnhiy Plan D.wiptton C Cpi1zte 2012 Cà. Brocta 7 &SiC UP 1799513i ( ( 'i 000'JiO Case 3:14-cv-00200-DCG Document 1 Filed 05/28/14 Page 35 of 110 ( appontorents. (2) contactIng your Designated Provider directly to discuss your condition, treatment and other matters relating to a Covered Incident, and (3) receIving copies of .11 medical records that relate to your Resithome covered by the Plan and any other records which might relate to the Benefits Adminimutor's investigation of your claim, to includs but not limited to records celevant to Pre-Fxistlng Conditions. (c) You must fully cooperate with the treatment plan. You must receive some form of covered Healtbcare within ninety (90) days of the Covered Incident or else It will be presumed the condition Is not Mainly Caused by a Covered Incident, In which case Medical Benefits will not apply. You must promptly cooperate with appointments and treatment, including direction by the Benefits Administrator to see a Designated Provider for an initial medical evaluation. Starting an appointment without the Benefits Administrator (If you arc informed of bin/her intent to attend), or skipping, scheduling or re-scheduling appointments without the Benefit Adnunlstrator's Pie-Approval is noncompliance (see §7.03). You can lose Benefits if you are noncompllaat with the Designated Provider's treatment plan, Plan titles or direction hum the Benefits Administrator or others involved with the Plan (see §7.03). (d) No cost contribution from you. Where Medical Benefits have been Pm-Approved fbi a Covered Incident and any specific &althcare, the Plan will pay all costs according to its arrangement with the Designated Provider (usually at Designated Fee GuideLine rates), and you will not be responsible for any co-pay, deductible or any share of the cost, and no direct reImbursement will be sought from you for Medical Benefits already provided. Exceptions Include if the Plan must enforce its rights to subrogation (g6.07), to recover overpayinents (6.03 and §6.08) or to coordinate benefits (g6.03), or if there has been Fraud (7.02(3)) or untruthfulness (7.03t). 3.02 MedIcal snausgenseat guidelines. c' All Healthcsre, whcther provided as Silver or Gold Benefits, Is subject to the following conditions and mitatioiis. (a) Case 'ngemeet. In connection with providing Medical Benefits under the Plan, the Benefits AdminIstrator has the authority to implement and employ any and all professional medical review and case management procedures It considers necessary so ensure the efficient sad effective provision of Medical Benefits in connection with a Covered incident These procedures may Include, but are not limited to (1) use of alternative health care facilities, (2) concurrent review of the course oftreatment prescribed by a Pro-approved Designated Provider and utilizaticin review of a course of treatment , (3) pro-admIssion evaluations and testing, (4) employment of case managers In order to assist you with your return to work or rcachlnl MMI, (5) usc or development of certain managed care protocols. limits or standards to decide Medical Necessity or other Issues, (6) occupatIonal assessment to evaluate vocational v.p*biitic, and (7) flmncticcal capacity evaluations. Standard therapy limitations. Physical therapy, rehabilitation programs and other (b) ongoing, prescribed remedial treatments or therapies are generally subject to a 6 week mna3dmusn. The Benefits Administrator may renew Pm-Approval for such Uealthcare upon receipt of a satisfactory certification from a Designated Provider when such is consistent with the purposes and terms of the Plan. Additional Opinions. The Benefits Administrator may require or allow, in the Benefits (c) Administrator's sole discretion, any number of second opinions ("Additional Opinions") at any time. You may request mm Additional Opinion in writing. You must show good cause (see §3.03c) for your request 3.03 SelectIng Designated Providers. treatment, Hesitheare, advice, evaluation and diagnosis of Employees with an Occupational Injury or Disease will be provided by Designated Providers only. Employees who want Healthcaro mast request it S(LVltopttms Summnam' Plan DescriptIon OCOP)T* 2012 Cammaigy. ooki kSwith, LLP Lt955*3.I 000311 Case 3:14-cv-00200-DCG Document 1 Filed 05/28/14 Page 36 of 110 from the Benefits Mininistratcr, who will retbi the Employee to * Designated Provider (e.g., lnidallya clinic or occupational phyeicin litci, referrals to specialists may ba made). (a) Designated Provld.is are the only liaithcsr Providers to which Madital llenelts may keep a list of Designated Providers, which n be changed front thai to time. A copy, if any, Is aailabIc at no cost upon written request. Your Designated Provider will be selected based on .vailabll1y, typo of Injury, y input or request, suggestions by the Initial Desigoited Provider, the Benefits Admiglatratci's protocols and discretion and other relevant fectora. apply. The Bsnsfr Mmlalstretor (b) Emergency Medical Lit, szempdoe. The only exception to obtaining the Bunafits Admlulshator's Pu-Approval is if Emergency Medical Cmii is required (as defined in 3.01.(2) and Axticle 5). Such Einergcacy Medical Care will be covered uvec if It is not provided by a Designated Provider, if no Designated Provider was avail&ble to timely provide the Emergency Medical Care that w needed, the Benefits Administrator was notiBed of the Emergency Medical Care within the thnsframss of f3.Ol1(2), and ill }lealthcare provided after the initial Emergency Medical Care is provided by or at the direction of a Designated Provider whose involvement has been Pre-Approvcd. (c) Lhwglng Designated Providers. The Benefits Adininjtritor may atshorlze or require a change itt your Designated Provider at any dine. If you are dissatisfied with w Designated Provldtr or 'cant an Mdldonal Opinion (see 13.02c), your request will be grertled If you show good canes writing in to the Benefits Administrator. A request need not be granted just because you disagree with truting yoni Designated Provider, or If your request Is pars of a pattern of cendect that can disquali a person from bceflot (e.g., noncompliance orreaiswtce so recovery or nuannest see 17.03), f ) (d) flesignasad Providses are independent ceatreetore. net cntoyeca or agents of die Plan, Plan Admialatretor. Benefits Administrator or the Company. Designated Providers cannot mike binding Benefit or Coverage decidonm. The Plair Adinlaherstar (Benefits Mmksl,tssto,) decidis whether to cover expanses or pay Benefits. All Helithuare Provides, ess solely liable for any dispute, loss or complaint regerding their practice of medicine. Neither the Plan, Plan Administrator, Benefits MmIn3atar ci the Coany can malts or quaD of)*sulme, or predict or ili r di. a anon, omissions, dcclsIons advice, negligence or malpractice by any He*lthcarø Provider. gnse 3.04 HealtIscore bacltded ps sse eM Ezetuded friu Coverage. Subject to the other cooditicosfor MedicS! Benefits slated In this Article 3,the following coeditioas appty (a) INCLUDED In Coverage. Medical Bcocfhs Cover 100% of the following, when Pr,Approved by the BCnefltu AdmInIstrator and ordered by a Designated Provider, If the Benefits Adin&.atoc finds such is Medically Necessary, Usual end Customary and does not exceed the Pee Guidelines, and such other Hsalthcar, specified hr the Plan Document or designated or datetmined flom time to thai by the Beaiflte AdminI*ator fteyesste, 0. PVoMr fE.i. 'A).ycu ws .i,t1!sd10 Go(dècarjkih, th.Jbr oJ,Jlq v.,M,dicSBivJtfrfsr apvfod ep so 136 watJp2rrdeMcIãn14Wt?PouJtM S1O-000UetaIcrU. width. abme.tL.ndaiwieiGidd&eeftTwmus& SlLvgfrrçrdonz Scaaiary Plan Dantpties ) 'INto' LLP 003JJ 2. Case 3:14-cv-00200-DCG Document 1 Filed 05/28/14 Page 37 of 110 ( C (b) EXCLUDED from Cwsrage. The fbllowktg Hesidicare or other expenses are Excluded from Silvir and Gold Benefit Covcrage 1. Expenses 0r something other than an OccupatIonal thjsiy orDuesse, e.g., preventive care, industrial hygiene. Expifimentil Thennenta, explorssoiy procedures, Cosnietic Surgeiy, routine eye Cite, Weight control, exercise programs or n memberships. 2. Expenses lbr non-Occupational causes, smoking cessation, chemical dependency, Personnel Actions, stmes P .exlsdogfSubseqiepnt Conditions Or hazardous activities. 3. Expenses Inconsistent with the Plan, s.g., not Medkelbr Necesavy, not toni a Desigoated Provldsç not Pta-Approved, exceeds Usual orCustoniwy Charge, or paid by Other Welfise Benefits. 4. CertaIn types of provider or service expanses, e.g., biofbedbad and other forms of self-care self-help training or any yelotad disgoostic testing. hypnosis, Custodial Care, or care that a lay person caa do, charges from a naturopath, chiropractor, acupuncturist, unlicensed doctois, providers who are related to or normally live with the patient or the patient's spouse or child, parent orsibihig of the patient or patient's Spouse, Or 5. Expenses which are your responsibility, such es (A) loss or damage to Durable Medical Equipment, end (B) the purchase, tenlil or repair of environmental control devices, Including bat not limited to sir conditioners, purifiers, cad buntIdlflere exercise equlpmem ilevators, stair 110s blood pressure eqitipment spar. or usppliee, goods or braces, spare or extra artificial limbs or appllanèes; kaine of personal comlbat or sntertsiismcnt (e.g., phones, videos, TV, guest trays), nonbodily appliances, items threonysnlence or luxury (e.g., whirlpools, mattresses). ea 6. Such other expenses excluded in the Plan Document or in this Summery. 3.05 When Mediced Benefits East Medical Benofita generally end upon the earliest occureence of the lbflowlng the conditions hi §2,02b If you are only eligible for Siher Bsneflta nod when you m released tons care by your Designated Provider, whsn you reach MMI, or 156 weeks aftdr an Incident Wyou qualii, for Gold Benefits. Other condhlona ean'lng the end ofMedlc.l Bensfib Include, bid are not limited to, the Mowiag (a) Benefit Mmdmwn under §6.04 is reached. (b) Commutation (scifiarnant and release) under §6.02. (c) Exclusion, disqualification or ineligibility, e.g., noncoaplisece with Dusenern (g7.03). (d) Treatment by an un-Approved Hea)thcare Provider when the Benefits Administrator determines It Inieriloes with Approved care. (e) Employment ends, unless you signed the Waiver (sac §6.01). (1) Other coveenge Is available. (g) A MedicalNecessity detauninatlon is made by the Benefits Administrator. (ii) Death otthe Employee. £ILVspdces Ses sary 10 Pbs Demipilon (J) ( OOJ 13 Case 3:14-cv-00200-DCG Document 1 Filed 05/28/14 Page 38 of 110 ( ARTICLE 4. GOLD BENEPrrs: WAGE BENEFiTS 4.01 App CondI gtodWagefleneflsa. (a) Eligibility. Wage Bencflt may apply If an Occupational Incident is the Main Casue of your b)wy or Disease. The Waiver (Ex. "A") must be signed to receive Wege Benefits an they are Gold Benefits (except for Initial Modified Duty provided under Silver Benatha as per *2.0Th). Modified Duty, Lost rene, end Supplemantel Wages are colleetwety referred to when the sitt "Wage Beoefi*s" is used. Wags Bmafits are not sick pay or your usual pay that you sent flun hours worked. flosvsr,thc Coina1g is only obligated to pay Wage Benefits beosuse It voluntarily established this Plan. Wage Benefits au always payable or needed In all claims, even If Medical Benefits are provided and the Wilvur Is sigued.. not (b) Thee. terms and conditions apply to all Wigs Bea.fltar Tb. dadisetlom end wlthholdliip usually made from your regular paycheck will 1. generally conthrue (Including legally enforceable garnishntents and .11 applicable texas). 2. Wage Benefits are generally c*.lrted as a percentage of your Average Weekly Wage C'AWW") not to exceed the weekly wage cap p600), as shown In Table 4-i; 1 3. ReceIving Wage Be.eflts. Wage Benefits do nd have to be paid by automatic deposit They will be paid on a Psc Period basis. Voices toLd otherwise, you roust penonlly pick up your Wage Benefit checks torn the Benefits MalnlstrataVs office on the Company's established paydays. This Is to insure continued communication between you end the Benefits Administrator. (a) Hardship. In extreme e c.ptiorn, such as surgery, incapacity, or other similar situ*ioo, the Benefits Adnibrlstrator may allow flexibility In delivering your Benefit check (d) Exclusions. Ike following me generally roe covered by Wage Benefits (but may or may not be treated as compensable time by the Employer as part ofits payroll practicas): I. Any Day of Rest or period when you are not scheduled for work where such is unrelated to a Covered Incident. 2. Time spent reporting en Incident, completing Benefits AdmWstralds directions. forms or cooperating 3. TIm. spent Receiving First Aid or Heakhcere. 4. Mileage and time spent travellsg to from md at any type of with the Reaithcaxe ii 000:J14 Case 3:14-cv-00200-DCG Document 1 Filed 05/28/14 Page 39 of 110 Ippolnmtant. Appointments must be scheduled during off duty hours so there Active Service or Modified Duty. I ( Ls no Interruption of 5. Wage Benefits are generally paid oily In whole day increments. There are no Wage Benefds for a partial day absence related to any of the activities in (1) through (4) above, or if otter sources of payment apply, inch as the Company's payroll practices. 6. Loises from Inablity to work Incident are excluded from Coverage by the Plan. for other employers as a result of a Covered Return to work after Oecapedoanl absent.. If you are returning to Active Service after (a) receiving Wage Beceths, you must promptly submit the Designated Provider's specific verification of your fitucas to return to duty to the Benefits Administrator so that Benefits can be adjusted accordingly. Thereafter, imless you are relented to Modified Duty, your return to work wilt be governed solely by the Company's pereormel policies and sppllcable law, not by the Plait. Wage Benefits End on the earliest occurrence of any applicable time limit (e.g., Modified (1) Duty (either 30 or 60 work shifts), Lost Time Wages (up to 104 weeks after the Incident Dat.), etc.) cc upon other occurreacea specified In the Plait, to Include but not be limbed to arty ofthe following: 1. Benefit Maithuns under §6.04 is necked. 2. Commstalloe (esttlement and release) under §6.02. 3. Zaclulon, D1.qusbflcsdo. or IneligIbility, e.g., nut accepting Modified Duty or positions offered (f7.03). 4. C Dealbofthe Employee. one en described in ft4.0.04 and §6.01. Spscc (g) Other Leave Rights. The ending of Wage Benefits does not necessarily affect your right to PMLA leave or other leav, of absence (see Human Resources f(lT details). 4.02 Modified Duty Beneflue. Purpose. The purpose of Modified Duty u to temporarily provide a way for you to work In Ifyou htve tmpoiary restrictions from an Occupational Incident Modified Duty is Intended to allow you to recondition, contribute, and develop stamina to safely return to Pull Duty. (a) seas demanding woik situations Scope. You may be offered temporary Modified Duty to meet all rsstrictioen and (b) limitations established by your Designated Provider, the Benefits Adrnlaistra*c and aai*1ate menAgemeiL The Benefits Administrator shell coordinate with mnagement to see If Modified Duty is available ax the foollity where you are ordinarily assIgned. It meat appear that you will be able to return to regular, Pull Duty within 30 work shifts. Modified Duty may hi exceptional cases be renewed for an you will, in all reasonable addItional 30 work shifts If the Benefits Administrator deleimiane ll probability, continu, to improve and teatime Full Duty on or before the arid of your Modiflud Duty Aulgument 12 SLLYeRuptoas Sanmuy plan Deeat5ion CCore,ia2Oi2C'-sear.acClts&SciIth. LI.? 99itaL ( 003J3 Case 3:14-cv-00200-DCG Document 1 Filed 05/28/14 Page 40 of 110 ( ) (c) You are reati4eted while on Modified Duty, as foliows 1. Yet ester 10110w all rutelcijoas set by Designated froviders, the Bestefita Administrator, and those supervising your work, and sign work restriction arrangement forms. 2. You meat meet ill perfermauce, attendance and other reqoheaests for the Modified Duly posidon end follow all other Plan rules and restsictions (e.g if you are on past time Modified Duty, you may lose Benefits If you use time off for purposes Inconsistent with your recovery, lilce for sports, miotberjob, Stc., see §7.03). 3. You meat perioanfly contact Itt. Benefits AdmInIstrator every week to giv, an update about your progress. Inunedistely report difficulties, new symptoms or ra-rnjiuy. Eligibility. Modified Duty Is not eppropsiase for everyone. This Is decided by the øcneflts (d) Administrator based on availability of positions, the progress and prognosis of your recovery, your cooperation, and the op1lon ofDesignated Providers and raraiagcuisut, asnong other things. era (c) Co*p.11r.1In Modified Duty is based on your current applicable pay rate (converted to hourly rate ifanceseery) rather than on your Average Weekly Wags. 1. Gold. If you etc on fidi-tirne Modified Dirty and you accepted the Gold Benefits Offer, you will be paid at 100% of your curreut hourly reta for the borne of actual work performed. No weekly cap will apply. Any applicabl, wage preiniuru will be added If not already included Ira your Mod Od Duty CompensatIon and If you era working IWL-time. ( 2. SUrer. If you do not sign the Waiver vhen it Is presented, your Modified Duty will be snlrjcct to the Silver Bmaflus limits of being paid 60% of your aiirt hourly rate (capped at $600/week) or minimum wigs, whichever is higher. Modified Duty under Silver Benefits Is only available within the thirty (30) day period following th Incident Dale. (1) Medlfled Thit' Ends as soon as any of the ácums*aueee described below occurs. Lost Thu. Wages will not re-start if Moddled Duty ends because you did not 000pcs*te with the Plan or because of your noncomplIance (see §7.03) I. Assignment ma coesplste unavailable, or unsuitable. 2. Recommendedon of Modified Duty ends or is withdrawn. .. You fail to perform as designated in lbs Msigiunermt. 4. Expiration of the Modified Duty period (see fi2.02b. 4.02(2)). S. Emptoyment ends (see §6.01). F1tflA ante of abauce rights might allow you to choose to not resume work rat your ( unpaid leave expires. If you are offered Modified Duty and choose FMLA leave instead, or decline en offered position, you will not be eligible for Wage Benefits and you may be disqualified from all flesefits. SlLVIRopden Summary POn Dranlpt$on 0Cg2OI2&i 13 BIwta*SIthth.LLP UnOJIC Case 3:14-cv-00200-DCG Document 1 Filed 05/28/14 Page 41 of 110 (I Lest Time Wages (a Gold Denofle). 4.03 (a) When payable. Lost Time Wages can begin on your first faR day of schethiled work that you are unable to work, If you timely return a signed Waiver (Ex. "A") and are eligible far Gold Benefit. 2D2). To be eliglbk, the MiIn Cause of your Inability so work must be confirmed by a Designated (a.' as Occepadonal aUd your liability to work Full or Modified Due' must first begin within ninety (90) days after the Iucldsflt Dice, or ens )msdred eigh (180) days after that data If you received Healthcare within thirty (30) dtys *cm the Incident Date and you remain render Continuous Treatment. Your first which will be after you have been payment of Lost Tim. Wages will be after you aign the Wawer (1flh) business day alter the Incident is evaluated by a non.smmpooy doctor and not beibre the tenth tcpmted(a.e *2.02). Lost Time Wiges me payable at the rates in Table 4-1 In §4.Olb, not to exceed a cap of $600 pàrwàk. Lost TIns Wages End as soon as any of the circumstances dsciibed either in § 4.Olf or (b) below ocuw,: I. Maximum Medical breprovemeut C'MMI") Is reached or upon the expiration of 104 rifler the incident Date without regard to how many weeks of Wage Renefils have been paid. 2. Work Release by & Designated Providcr nettiring that you mu capable of resuming die work lbr which you ate qualified to pa.fc.w. work for which you were employed or er Lost Time Wages coathiue for Covrcd Incidents until yost are rislessed loony work §4 .03b) and up to 104 weeks alto the Incident Date. 3. (but see 4. Your eligiblilty fOr Other Welfare Binefits. 3. emest your thcidcntimed work ends far reancea other Your a Pro-Approved madical evaluation by a Designated Provided (see 16.01). recona conFirmed by 4.04 Supplemental Wags. (a Gold Beads). When payable. Supplemental Wages zt on the first Mt Pay Period alley Lost Tim. been released by a Wage, end and you see not released to Full or Modified Duty or after you have lbr which you ar work any to or employed were which you Designated Provider to resume the work for Waiver (Ex. "A"). qualified to psrfbtin. No Suppisniesdal Wages me payable until you scunu a signed to the 1560 week up of $600Iweek a cap exceed to AWW riot of 60% at are payable Supplemental Wages (a) alter the Incident Date. You must make timely and complete periodic written reports report. Reports must Include all every 90 days front when Sup4cznental Wages begin or from your 'rut decides if Supplemental Wages AdministrStor Benefit. The end. may Benefits or requested, information met: are apply, and ifthe following mitsinumi requlemeets Deterselniag Eligibility. (b) I. You have irot been released to any type of work that is available. 2. You have, in good faith, atlomptod without success to obtain work of 3. offered or requested You have (Idly cooperated with retraining and in-employment eth,rts by the Benefits Admin(Mratcc, LI any. U cc Sy pe. 14 Plaabceoe tori "ene,.aroob LSate.LLP $ilYEaesiara any l7isSis.1 0 flOi 17 Case 3:14-cv-00200-DCG Document 1 Filed 05/28/14 Page 42 of 110 ( 0 Supplameelel Wages End If any circumstances In either §4,OLf or below occuzs: 7 Work release certtfles you can do renento work, or you do reften to any type of work. 2. Yot death. 3. Your periodic report Is 4. The end of the jek tisfac1oi' or is not timely received. after your Incident Dale is reached. Your employment ends due to misconduct 405 Ati ddental D*ath aid Dlesnemb.reeeat (AD&D) Benefit (a Gold Benefit). (a) Whim payable. AD&D Benefits are only avellable to you (or your Boneficlaiy ut the case of death) If you elect Gold Beneflie whIle you are employed by the Company, by timely signIng the Waivet (Ex. "A") (or, In case of death, your Beneficiary signs s comparable release), and If days efter a Coveted Incident, you suffer a lois (as described in the Schedule Losses wIthin 365 at' below) us the direct and sole result at's Covered Incident Ifyou quality, the Plan will pay you (or yow Beneficasty) the Benefit Amount described In the Schedul, of Louses, which rsprósents a peracutsge of the AD&D Autonet. AD&D Benefits are only psyible after the Benefits Mmlnlatrator receives shady claim and all p nditicne to AD&D Benefit eligibility are istisfied. Tb. BtoIf Its Aduihrieutor must receive timely urtitCa cemhificadon of a quelil,lng loss oftue (see 44.OSe) or of death (see 14.051). The A.D&D BCneflt will be redrmed by other Bencfltu psi4 or payable, arid by amounts paid as Brinl Benefits (see ff2.03b(4) and 4.OSg) to the ztem mcmey to avoid exceeding the Plan's Benefit M.ximuin (46.04) and the AD&D Benefit Maximum (see §4.OSb). Tb. ) is ton (10) times yor Bess Pay. Your Base Psy Is your armnuulizud but not to exceed $60,000 per year. The AD&D Benefit Maximum Is $600,000. The minimum AD&D Benefit Amotmt 1* $250,000, unless the Plan's Benefit Maximum requires a lower amount (see §4.054 arid §6.04). cu earnings as defined In Article 5 (c) Schedule Of Losses. T.M1 ard?.nesouu Lass e/tW oft Detob BothHria aotb Feet Sight ofBoth Eyes One Huid andOec Foot One Ilarid and Slghtof One Eye One Foot and Sight of One Eye Sisedm and Hearing in Both Earl Use ofiathAruis end Both Legs Use of Both Arms or of Both Legs Use otOne Aim and One Leg OoiUáid lasØ.4i0 100% OfADD Ausostil 100% ofAD&D Amount I00%ofAD*DAaotmt 100% of AD&D Amount 100% ofAD*DAmouimt 100% of AD&D Anrowit l0O%ofAD*DAmumt 100% ofAD&U Amumt 100% of ADLD Amount 75% ofAD&D Arnow 75%ofAD&DAmour4 One Foot 50%ofAD&DAmoutt 50% ofADftD Amesu Spe.ds 50%ofAMDAnown 50% ofAD&.D Amount Sit of One Eye Hhig in Both Ems Use of One Arm or One Leg On. Thumb 50%oFAD&DAinowtt 50%ofAD*D Amomlit 25% of ADtiD Amount S1LVRocdnneSummuy P1inDuct4pthe 0 ( OCepyrik2Q2Ceaf. 15 *$ntth.LI.P 000013 Case 3:14-cv-00200-DCG Document 1 Filed 05/28/14 Page 43 of 110 (d) Moru than one lou. If your Covered ktjury resuks In more than one of the Ices.. listed in the Schedule of Losses, only one Benefit Amount equal to the !arest uppilcable Benefit Areonel flalad In the Scbadulc oflmse. will be payable with respect to the Covered Incideir. The payment of in the event of death that results In thu payment of Dianen*suntent Benefits will caere (or be Death Benefits fbr the same Coveted Incident Your totel M.dlouI Benefits, Dismemberment Benefits, Wage Benefits and Death Benefits, when combined, shall not exceed die Benefit Maximum In §6.04,1* is th,.sf in the Benefit Midcistutor's discretion to pay the AD&D Benefit in hemp sum or m perk,dic payments ovate period not to *ceed atotal of five (5) years. - - oet) TotaZ aid permanent Ieee of maw ofa member ofthe body Is the same as loan of such (.) member, an described below. Before payment of the Dimeunbenn.nt Bpaeflt Amount, toss of us. must be certified in willing bused on the Pee-Approred care of a Designated Provider for 12 straight months fluin the time the losi of use began. At the end otthat den., It must be medically desemtfned by twl*ten repoit from a Pro-Approved Designated Provider that the loss of urn is total, permanent and Irrecoverable, and that you fully cooperated with all aspects of the lmalmsnt and any tebebilitadon measures. The details of what Is meant by Ices of me" with respect to specific types of losses mu explained below: I. 2. 3. 4. 5. 6. (I) dr/s } Loss of Arm or Leg niesus the coniplete scvusar.e thmgghorabove the .hould or blpjcint. Loss of Hesdur Focungens complete, p. .evonno,deo,* or abevewiler or ankle joint. Lose OfS*LIIesse*O1.I sod iTsuOc.bie less of the attire slgin in dntsye LoU ofSilineb means the total and krsvocable loss of the enthe sbiliio speak. Lois otflusdegmains the tout and hr.voc,b4. Ices ofthe cadre &uilliytobeer ii both ems. The loss of one thumb means complete scvcmaceduoughoribove the meteeerpophilangetl Joint. Datk Benefits. If you die as a direct and sot. result of a Covered Incident wIthin 365 ntid,d loss allocation of the Death Benefit as f the Incident Dpin, your eligible Beneficiaries are psos4d.d It 44.05b To be eligible, each Beneficiary mint (1) submit a written .Win to the Benefits Adalnistrator within twenty-thur (24) months after the das of the Incident caning death, (2) sign a j satisfactory Benefits A4ntint'', retesee comparable to the Waiver (En. 'A") In such form sad (3) must cooperate with the Benefits AdssinWciIufa leveetigatlon, to include, but not limited to cementIng to an autopsy and other pre.00idittans as detailed In the Plon Docesneni, md (4) not take notion biconstetetit with the terms ottbe Waiver (En. "A"), Its corresponding Beneficiary Peleusa, and the Aibitretion Agreement (En. 'fl"). Buiint Benefit. Up to $5,000 for burial, fUneral, trunsportatlout of the desm& or other (g) similar memorial isrylces oily be paid as an etivance on applicable Death Benefits Ifs Covered Incident Is claimed so be the Main Cause of death of a Covered Employ.., whsthat or not you or yoir the Beneficiaries have signed the Waiv& or release. Such payments shall be direct from the Plan to other supplier of the servIces. lb. payment wtdir this provision does not obligate the Plan to any even If payment or coverage of a claim. Burial Benefits may be paid (arid mu not sutject to repayment) the Investigationof the claim 1. not complete or later results hian adverse benefit determination. There are three classes of Beneficiaries in whom the Benefits Beneficiary. (Is) any), (2) yoUr Administrator may allocate a payable Death Benefit (I) your surviving spcone (IfMmlnIstraItw Is Benefits Tb. any). (if parents (3) surviving your and surviving chil&an (if any). be rsaioeabls and authorized to make such allorif4ons emo' the classes of Bsneflclarles as may Beneficiary who has a legal .uMvbig each such from relisse binding a obtain to ii order appropriate right of antlon agabnt the Employer us a result of aCovered Incident 16 $JLVERoydcsfSAlWiree'Y Plea Deecripiten 1795S31 01)0:31 Case 3:14-cv-00200-DCG Document 1 Filed 05/28/14 Page 44 of 110 0 ARTICLE 5. DEFINITIONS AND ABBREVIATIONS Certain worth and phrases with she that letter capitalized In this Suiniy have specie1 rur.,àg, as La more filly defined hi the Plan Document A thw of thee. terms are briefly summerfzed below. A complete list of definidoos Is available upon request. "Aeddest" means an evelit that wa imlotended and unexpected which owmd it a ipecifically identifiable place sad time and Was the Main Cause of en bUujy (Independent of sickness disease, mental incepeohy, or say thei came). "Aive $enjc&' means the perfrmence by an Employee of assigned duties In the Comae and Scope of Employment with the Company. "Appeals Paid" means the person(s)thslgneted by the Plan Administrator to eevisw appealed clehns. "Atbltrstlo. Ameaeut" means the current Arbitration and Jury Waiver Cornpaz and eli of Its employees, and any enisadments (see Notice, Ex. "B"). Agreement between the "AWW" or 'Average Weekly Wag&' means your Base Pay divided by52 If you entir. yea:, otherwise divided by the number of weeks you hsvs been employed by thewere employed the Company. "his Pay" meme your annual gross comings (including overtime, bonuses sad commla.Icoa, any) as If last reported by the Company prior to the Incident Date on IRS Form W-2. If there is no prior W-2, your u iarnlngs wilt be totaled, and divided by the nember of weeks you worked, then nrukiplled by 52 to aunuallz* your pay. "heusflts Administrator" means the pesson(s) designated by the Plan AdminIstrator to manage claims, and those appointed to assist the Benefits Administrator. C "Compass?' means the employer. W. Silver, Inc. "Centinnoan Treatment" means ongoing, regular observation, monitoring, treatment or evaluation of a Covered Injury or Disease by aDesignitod Provider where the patient has not been released from case aid Scop. of Employment" means any Active Service in furtherance of the Company's business, excluding your regular commute tolfron work, an personal deviathus, end as per §2.03b(2). "Course "Covered Incident" means an Accident (or series of Accidents) resulting In an Occupational Injury to an Employee that arises out of the Course and Scope of Employment after the Effective Date and during the Term ofthe Plan. "Cumulative Tranma" means damage or bane to lbs physical structure of the body (including death) mainly eamed by the combined effect of repetitious physical activities ixtandlog over a period of tints that occur solely while pezilamiug Active Service, where socir is ce".sd directly sod independently other causes by Active Service. of all. "Designated Fee Gald.Uaes' means the Medical Pee Guidelines or rates designated or agreed upon by the Plan Admithtrator and adopted in writing. "Designated Pmelder" means a heaitbca,e provider Pm-Approved by the Benefits Administrator. 0 S1LYEopdaasSwweery Phe Duwlpdoe Brcob& LL OC,2OI2''. ires 17 S, 000320 Case 3:14-cv-00200-DCG Document 1 Filed 05/28/14 Page 45 of 110 ( y.icsj,, itet." of We plan when four adopted Is lime tO, 2002. The Plan was stthssquently amended over the yams. The sraendnents reflected In this Third Amended Siuzimaty era eff,ctive for (a) all Covered incidents occurring on sad after May 15, 2(112, and (b) all Ben,tits provided by the Plan on and after May 15,2012, throughout the Tone of the Plan. 'Emrgency Medical Care" means (n)llist Immediate, initial, Medically Necessary 11e1*car., (b) that must be rendered fbi an Occupational condition (c) that results uz symptoms (including severe pain) of sufficient severity (e.&, severe bleeding, Ices of consolcusuess, conviilslozre) that a prudsus Ilyperson could reasonably expect dm1 In the alisence ofne'ii medical attention, the s)m*us would result In subntinI, prolonged physical Impabmeot or loss of lift AND (I) serious jeopardy to the person's health, (2) serIous hirpalaflent to bodily fUnctions, or (3) serious dyafirection of any bodily ospn or pelt Aches, pain, nausea and other symptoms that .rc not severe usually do NOT satisfy this definition. Easp1oy.e" means a person dlrectiy hired by the Company who icon the Company's payroll, for whom the Company issues an IRS Form W-2 sad as otherwise described In §2.03,. "PMLA" means the PamIIy end Medical Leave Act 'QeW Benefits" means all Silver Benefits (wIthout the limitations that are applicable to those who have not algeed the Walwr) plu, those sddlt'omal benefits that are conditioned on your ieament to the Waiver (lix. "A") (see §2.02s), tsckuling MedIcal Benefits beyond the 30 dayISIOtIQO Silver Benefit litnits, Lost Time Wage Sonellts, 100% Modified Duty Benefits, Supplemental Wag. Benefits, AD&D Benefits and such other Benefits which are not otherwise payable unless the Waiver Ii signed. "Incident" means en Accident or occurrence (or sedan of Ascidenle or occurrences) daring Active Service after Ihi Effective Date and diiIng the Teen of the Plan which directly causes am Occupational Injury or Disease. A "Cawtsd Incident" is use which the Benefits Adiabisliator baa dslirmlned to meet of the Plan such dii the Plant. authorized to provide Benefits based on the existence of an all .mt4 ) Occupational Injury or Disease so which Benefits apply. as follows, whether a timely report was given or not (a) 'when bwotving an Injury, the deE. on which the Incident that caused the injury actually occurred, and (b) when involving a Disease or Cumulative Trauma, the first dale on which a condition, symptom or other occurrence mialficted itself; "Incident Daba" means "Legal Action" means say tape of lawsuit or proceeding for any type of remedy relating to an Occijistlonel Incidalt, such as for negligence (caa and cedinery), personal injiny or the type of matters released hi the Waiver (Eu. TMA") or a Beneficiary's comparable release. As used hi this Sununsey, exohidad flora this term in any right or action taken under ERISA. "Main Cause" or uf1fly Ceased" mains the primary direct and predominant caine of an 1cident, lqjury or Disease or Cumulative Trauma as determined by the Benefits Mrnbtkttator. 'Mmlana Madleed lasprosreensat" or "Miii" means the earlier of(s) the point at width a Designated Provider detusmiecs that, ala matter of ramonable medical probability, heWer or other Hnelthcai, Is not likely to significantly improve the condition caused by Covered Occupational Injury or Disease, or (b) 104 weeks afterthelacidnat Date. 18 5ILVcp6omSy Plan Osscdç*lai o OC*2.I. meQts*Ita,U.P 000021 (. Case 3:14-cv-00200-DCG Document 1 Filed 05/28/14 Page 46 of 110 ( eeeuaxy' means Heclthcsrs pcovlded by a heatthcars cptoa) act wi scope of hi.r larme accotd.nc. with evidence-hued medical TMMsdkaUy (cauluding prac*it!tonar of the healing id in the Uniatd ar S& in treatment guidelines or principles that are generally recognized by the medical community or gpnerally accepted standards of medical practice that me hued en credible scientific evidence published In pe .vtawed medical literature generally resogrdmd in the reinvent medical community, end dial Is Clinically appropriate and considered effective for the condition being traaied. Hnslthcars that maute the foregoing definition is still subject to 11 other precotiditicue to coverage that apply under the Plan, such as Pro-Approval and the Desigamed Providerrequbament. "Ovenpa*leaal Disease" means a pronounced deviation from the normal healthy stile oC body that(s) is gcneaafly accepted as a condition that is contracted or austilom) by exposure to envitonmantal or physical hazarth encountered In the moth place, (b) Is In foot Mainly Cauacd by your Active Service after the Effective Dale arid during the Tiara of the Plan, and (C) which directly maclie In Medically Necessary fleelthcare, Lcd Thus and/or death. An Occupational Disease Is not en.ed by an AocIdent end does not include ordinary diseases to which the general public Is sxposed outside your regular jth duties, nor does 1* include non-work related Injuries, Illnesses or sickness Cumulative Trauma or any ordinary '1"asce of life (e.g., arthritis, wear and tear from aging, etc.) or any condition coveted by workers' compensatlim. Occup.tloiial lujiry means at' ldanlifi.hh damage or harm to the pbyslcal utrectias of the body (inchdIng death) diM Is Mainly Ceased by a Coveted Incident occwrtng daring your Active Service. including Cumulative T,mana, but excluding any mental, narvoun, emotional and/er pychological condition or disodr Which is act adhact remit of a Covered incident"Pre-Appreval" and 'Pre-Appsswsd" means approve) In advance by ib. Benefite Mminlatretor's specific, knowing corsent to some action, usually to accept financial responsibility for }Iealdtcare before treatment is given, such as for charges for hospital èoision, pity Iclantreatment or other Healthcire. ( "Pie-Eslitiag CoadHien" means an Injury, Disease or medical condition for which you sought or receIved examination, diagnostics or tisatmeat by any healdicata provider at any time from nInety (90) days prior to being employed by the Company up to the IncidentDate or which existed prior to your date of hire by the Company. Waiver" means the moat recent version ofthe Pcst.Incident Waiver Form 202 (Ex. 'A") "Setr Benaftie" are thee. Ihuhud Medical, Modified Duty and Burial Benefits which apply to mp1oyoes who have not slpedthe Waiver (En. 'A") as explained In li2.02b 2.024 and 405g. "Sem.y" means this Swuniaxy Plan Description (this booklet) and any written amcndmcnts "Term of the Plan" means that period when the Plan (as amendsd) in eftbctive, on and rfter the Efibcdw Date end up until the date upon which the Plan Ii terminated as provided In §10.04. 4'Yoa' means a covered person, La., anEaploycs. SAL VZ.aopdom Smmnury 19 Pun Desetpbla 2011 Ccuumer Ssoot,*Il* LI) I A (OO122 Case 3:14-cv-00200-DCG Document 1 Filed 05/28/14 Page 47 of 110 ARTiCLE 6. 6.01 Benefits BENZflF UMTAT1ONS End If Eotploymaut or Plan Ends. Benefits end an of the date you mu no longer employed or if the Plan tenuinates (see Article 10) unless you timely sign the Waiver (EL 'W') and ready. (laid Bonefita during the Term ofthe Plan and before your employnteutends, in which case your Benefits will continue subject to the Plan's terms and conditions. 6.02 Commutation or Settlaasnt. In epoch chewuatances, any or all Benefits may be "commuted," that is, paid In a sum-certain aeulemeat when such Is approved by the Plan Admnmistruor, is consistent 'with the terms of the Plait and is agreed upon by you. hi the event of commutation, your claim's discowtted net value will be determined by aCcepted claim appralmi methods, accounting for present value and other applicable consideratloma. No flather Benefits will be ptytble after you accept the commutation amount. You (and anyone who could claim by or through you) must sign a release of all claims in order to receive the commutation amount. 6.03 CoordInation .1 Benefits. The Plan Is not hitended to provide any duplicate or substantIally similar payments. You must tell the Benefits Mmlnlslrstor If you isv. any other source of benefits or coverage, Inctudiag but not limited to coverage from Modicam, Medicaid, SocW Security Disability Income, other health insurance, disability nvoore Insurance or other insurance or benefits. To prevent payments which exceed 1410% of Covered or other allowable Banefite, Benefits payable mmd.r the Plan will be reduced by the total of all payments you receiv. from other soorces to the eam allowed by applicable law. seucs 6.04 Bendla Maximum. "Benefit Is the greatest amount of dellars payable through the Pltn, whether (a) directly to Employees or Beneficiaries or Indirectly on their behalf and because ofother leases associated with a covered incident. The following Uhetrates the types of limits that amy apply to an Employ.. who signs the Waiver and qialifles for Gold Benefils Por L..nlai.ae limit for all Bessfhe (excluding Modified Duty) relating to 1. Occupational Iiusy, Disease or death Is $1 million, unless one Accident causes more dma one Employee to be bured. In that cue, the combined maximwn for each injured Employee may be less than $1 million each, see §6.4Mb. Th$ substitutioti of beneficlerisi for an Employee does not increase the Benefit Maidmun 2. Incident lunit. The limit for all Plan Benefits (including Deuth Bcooflts but excluding Modified Duty Wages) to all Employees Injured by a single covered Incident when combined Is $5 million. Cumulative Trauma or Occupatloital Disease caused by a saiiis of occurrences is considered one Incident and is subject to one maximum benefit limit. net multiples. 3. er lbnts be enaclficimueflt tvme. The Benefit Maximum for Silver Benefits s applied to an Employee who his not signed the Waiver (EL "A") is $10,000 or thirty (30) days alter the Incident Dáte wblcheir comCs first (see §2.02b) excluding the $5,000 Bath Benefit There era specific limits that apply to AD&D Benefits (see §4.OSb). (b) Modilchdon cf Benefits. In unusual circumstances (es, if there are multipLe i4imnte from a singJe lncidant) the Benefits Ackninimator may reserve reasonable amounts for fbtuze antIcIpated Benefits to comply with *6.04.. The Benefits Administrator may reduce, suspend, limit or deny Beneflie to certain beneficiary classes or similarly sheeted claimants in a manner consistent with the Plan's purposes. Sltvzaepdmsnaimny PimPsstrdeu 0 uQj,roie,.sveia &su 20 U.? Ol)QJ2 Case 3:14-cv-00200-DCG Document 1 Filed 05/28/14 Page 48 of 110 ( TT 605 Usoeflin DecWon AUthOd The Benefits Adwhgsstor wilt dctemdne in his/her discretion what amounts vs Other Wilfers Bnetlts, what is a subutantially similar purpose, in what order to coordinate beusfits, whether en overpayment n.h made and what is a aubroptica claim, as well as all other may be paid or deitlad in whole orla part pending the detennbmliosts required by the Plus. Benefits receipt of information deemed necessary by the Benefits Administrator to determine eligibility fur covere and investigation of the Incident, the claire end all applicable ellglblilty psndlng the Benefits Administrators heats, among other thmgs. Benefits vs always subject to eligibility requirements, dlequclihloatton, review, reinstatement (either prospectively or retroectively) and subsequent modification by the Benefits Adminlsfr*$or. This cern occur If, e.g., there Is new fomatlon OPinions or events at upon the conclusion oft claim hwesttgafton. The Benefits Administrator may modify a prior decision or reopen an Inveetlption repidleis of a prior dacision. 6.06 Plan Payrneuts Benefits may be paid directly to the supplier, Designated Provider or other person, or relizthvssd to the claimant when Pu-Approved. My payment made in good faith will fully relay the Plan of hi liability to the supplier, Employee. Participant, Benedclaiy and legal bCSIOCIIIIIS to the extent of the payment. The Plan adjusts invoices from Providers consistent with DCslgnated Fee Guidelines and other arrangements In effect. Payments accepted or cashed by Providers constitute full and final satlsfedlou of the Plait's obligation as to th. service or chargo In question. 6.07 f ) You Meat Cooperat. with Subropdon. (a) What Is menu by "aubroptien"? hue Plan is entitled to an automatic lien end subrogation tight that attaches to say claim that you or your Beceficimy may have against say Third Pvty. The subrogatica lien and right means that Ifs Thini Party (that Is, another person or ntlty, inchndiaag the is liable Compm') tbr your Injurie, cc losses, then you must reimburse the Plait *oas the first prowde you Party tbt 5Y Occpatimsl 1imwy, Diseas. or loss for which any Plan Benefit Y 5e5tYC front any ' baa been (or will be) paid. You consent so the liasnand subrogation right, and such amounts which mast be reimbursed to the Plan when you accept Benefits paid so you or on uslgn your behalf You may be required so sign a vMttas assignment (7.Ole(4)), to penalt the Plan to me Third Pasties on your behalf end in your e, md to cooperate with any legal action taken to enforc and protect the Plan's rights. Thl subrogitlo* lea and right applies eats If ycUr recovery does not reimburse yen to the lull extent of your lose ci injury (that Is, It applies even If your recovery does not 'make you who1e'. You cot allowed to ofet your subrogation reimbursemem to the Plan by any ofyour attorney's fees or flat anyvsother reason. (b) You must Inks an action urcomasy to help the Pina recover Ito payineub. You must immediately Inibun the Benefits Administrator If there Ii (or may be) a Third Petty liabl, fur due Incident, your Occsçational Injury or Dieaae or tosses, or if you ye claiming or receiving payment or credits of any type from aThird Party, or If you become aware of any payment which is so be made and to which the Plan's subrogation hen and rights eppiy. You must not take any action (such as signing a reluse or etticment with a Third Party. spending any peysusnis you receive front a Third Party before paying the Plan full reimbursement) that might limit or hanu the Plan's right to zaco reimbursement for Benefits paid or to be paid by the Plait. The Plan's right to recover shell not be reduced or otherwise adversely affected by your failure to recover .0 of your damagssfrom the Third Paity. (c) Your DeadIn may sad orb. reduced, or you may becoms personally responsible fur the subrogation amounts due th Plan, if you full to folly and timely comply and cooperats with your duties unda §6O7, which Include (but are not limited to) providing Information and signed documsats seeded by the Plan to enforce and protect Its subroption ights. Suenwy Thai Oceuuilila toll Csrgus,. Sioea Sum SILPaRoednes C 21 U.? O1)Oo2 Case 3:14-cv-00200-DCG Document 1 Filed 05/28/14 Page 49 of 110 (I Recovery of Eicw Payaeata. 6.08 Whenever payments have been made in excess of the amount allowed fo Binefits, the Benefits Admiois'ator has the right to recover these excess payments from you or any Individual, Healthcsre insurance company or other entity to whom the excess payments were wade, whither by direct legal action, offtet, deduction orwlttthokling from Benefits or other sources to the extel* allowed by law. Provider1 6.09 RIght to Receive sad Release Information. may, wIthout the consent of or notice to any person, IncLuding thi Employee, Pertlelpent or BeeflcIazp, release to, or obtain flour, any orpolsalioc or p01500, Information needed to implement Plan provislofle, to thu extent slowed by applicable law. Anyone who requasta Benefits meat promptly furnish lt the lnfbrmation requited or eequstsadby the Benefits Athnlnistr.tor. See 13.OIb. The Benefits Ad121011*11*OT 6.10 MedIcare Secondary Payer OblIgations. 'iou must cooperate with the Plan In fulfilling soy obligations related to reporting and rebnbnraig Medicare under the Secoody Payer regulations. The Plan rosy pay Medicare or rcduce Benefits when each l consistent with Medkere Secondary Psyor obligations. ARTICLE 7. 7.01 COVERAGE Who Is Eligible for Coverage. You can be EligIble fur Benefits without regard to rb or negligence If .11 requkemeass and conditions of the Plan are satisfied. You must not be Excluded or Disqualified from Coverage voder ff7.02 - 7.0$ or other previsions herein. ElIgIbility reqidrements that generally apply to both Silver and Gold Benefits ate iblad below. Ti be Elgibis, yan weal'. (a) Be an Eapley.e oith. Company regularly engaged it Its Texas thollides hr Active Service (or qualified en a Beneficiary) alterthe Efftctive Date ofthe Plan and during the Term of the Plan. C ) (I,) Agree to the Aibltraitea Agreemsat. Agreement to atbltration by yon and the Company occurs when you axe hired on arid after June 1, 2001 end/or cond*us your employment relaikatihip (or couthine to be covered by or receive the benefits thereof) at any timi on end alter that date. S.. the notice of arbitration In Es. "B." Rav, an OccupatIonal I4ary or Dimue that Is Mainly Caused by an Incident from your (c) Active Service for the Company alter the Ecdv. Date and the Term of the Plan. The Benefits Administrator be. the sole discretion to determine whether an Occupational Incident is the Main Cause of an Ir)wy or Disease end compensable ander the Plan. Natural diseases of tub, symptoms which conid just as likely occur atoiltede of work, or conditions or activities which we not Ocenpatlorial, we not covered. GIve timely u4 adequate notice of an Ixcident or change In condition as explained hr (ti) the Quick Overview. You should do this If an Incident causes physical contaai or afrain (whether pIo is launedistuly experienced or not) or If you hive symptoms that a prudent laypsescor, with an average knowledge of health and medico,, would reasonably recogirirn as potentially beIng Mainly Caused by en Incident or by Active Service for the Company. 1. You mast submit a written claim, (e.g., Form 200 or 201, an epplicoble) nolesa Good C.usc'Opptles (*2 below). 2. "Good Cause" mewa you prove by verifiable evidence that the Incident and your cc Disease Is Occupational. You meat show reasonable justIficatIon for untimeliness or Injury 0 S1LVZim$ Srmuwy PbaDesulçdse OC2OI2Cav$ar. Siuob & th.U.P rn,Sn.I 000325 C Case 3:14-cv-00200-DCG Document 1 Filed 05/28/14 Page 50 of 110 inadequacy of your notice of tbs Incident or Condition. You must also submit Form 200 or 201 by no later than thirty (30) Days from when it was due, or fa. Good Cause excaptios will nor apply. Determinations of Good Cans, are In the Benefits Mmininr.i sole discretion. Ius 3. of B'nrb can occur If you do not give a timely or adequate Incident Report This Is to encourage sound safety habits and to exclude non-Occupational Incidents. Untlaveh (it) Complete other docuthenla. At the earliest opponurriry after us Incident or Condition is rqodud, you mint report to the Benefits Mmlnlrtrntor to ilgu andor fill out all other documents requested by the Binefits Administrator, to include but not limited to the following: I. Poat4nddent Waiver Form 202 (EL (optional, to quillil' for Gold Benefits). 2. CossuttoBeleess of Medical Infbunation (Form 203). 3. Checkliat of Employee Responsibilities(Form 204). 4. Assiguanent of Benefits & Acknwledgment of Axtiltretlon Agreement (Form 205). 5. Consentto dreg, alcohol and other testing, if any. You ist lWly cooperate with claim laveattgsdo.. The Benefits A4IDIIIhSrIIOT may Pr.(U Approve an initial examination and initial treatment or diagixItics pending the Investigation of your claim. ApprOval of healthcare does not mean your claim Is accepted. lire Benefits Administrator may end Benefits 1f when the investigation in complete or upon receipt of other information, the Benefits Administrator determines that you are not eligible for Benefits or that you are disqualified or excludd from Plan Coverage. The fact that the Benefits Administrator Pta-Approved Benefits while the Investigation w pending, does riot prevent sconcluslos that Benefits do not apply, nith that Benefits must be ended.. Who and What Ar. Excluded from Ctwerage. You will not be entitled to Coverage for Silver midlor Gold Benefits Ifyou or your Claim fells within any of the following exclusions: 7.02 ( ) 1. Nes.Oceupatisnal Injuries or Diseases. Conditions which are not Mainly Caused by your Active Service for The Company are excluded from Coverage and are considered to be nonOccupational. Your claim Ii presumed son-Occupational If you allow a claim for beuefha so be made with a Group Health Plan, endlor you receive benefits from merther anuses that excludm Occupational Conditions. Infections of arty kind at, excluded regardims bow contracted, except viral end bacterial hnlbotioss are covered If thoy are mainly caused by a Covered Incident and are of a type to which the ordinary public Is not exposed. 2. If yes are got Empteynd by die Company at the thus of the Incident, or if your Active Service with the Ccenpany is notthe Main Caine, your claim will be excluded. 3. Fraudulent Claims are excluded, including but not limited to Clainra, Injuries and Diseases which at, false, exaggerated or made In bed faith. ar well as any and all manner of deception. It is act neoeeany that legal or criminally actionable flsUd be proved. 4. PrIor to tIhctive Data. Any Incident, Injury, Disease, Cumulative Traimus or Condition that .rlses belbes the Plan's Effective Date or aller the Term ofthe Plan is excluded. 5. Exposure to hazardous substances that may caine an Injury, disease, harm or medical condition axe not covered by the Pl*n. Harardous substances Include, bat are not limited to asbestos, lead, radioactive or explosive substances such as nuclear material. 23 ma .1 000J26 Case 3:14-cv-00200-DCG Document 1 Filed 05/28/14 Page 51 of 110 6. SukIds aratteinptsd saidde ta excluded from Coverage. 7. ODuly Injuries are excluded, e.g., those arising from voluntary paiticipatlon In off duty recreational, social, athletic, second jobs, domedin or other activity that is not Active Service. in usdud.d such as onset of symptoms at 8. Hurl Attack or similar events e.g., stroke, myocardial influrotlon, carebrovascular cvsnt aneurysm, throatbosis, or other similar by Active Service and occurred suddenly event or couditlon Is excluded, unless it Is Mainly and Imrn.dlatdy following an Incident at a definite thne and place during Active Servlca Ced 9. Islauttonsl lujartas are ezilud.d. e.g., injuries which are self-Inflicted or result from your criminal acts rather dun accidental and unintended Incidents, whether you as. sane or insane, to include but not limited to your participation in a rIot civil disturbance, auauk felony or was. 10. Substance Abuse Policy 4oladouo will exclude you born Coverage, an will the followiar the Incident occurred while you pure Intoxicated or under the Influence of alcohol or drugs (unless such np were taken wider disecticu of, and as lawligly prescribed by, physician). 11. Injury ceased by a Third Party is excluded Wit Is usectated to your Active Service. 12. P snisl$nØabasquenl Conditions that muth. Main Cause of your hijwy or Disease. or the need for HsalthCar. and which ass not Mainly Caused by en Inoldsnt are excluded: such as aet.oarthdtls, arthritis sadler arty consequenc. of the aging procesa or other degenerative process. 13. Acts orGed as. excluded: such a weather or natural disasters. 14. Persimnel Actions, e.g., claims for any type of loss resulting from employee discipline, suspensIon, discharge, leave or lay-off are excluded. 7.03 How You May Los* Benefits. You will be disqualified from Coverage for Silvs sail/or Gold Benefits if any of(s) through (k) apply: You engage I. nettelilsi lacorisletsatWith yeor states, restrictions, inability to work, Or (a) engage hi activities that may worsen yosw condition or delay recovery and return to woik, such an follows Bmployineot, elsewhert of any type, when not Pro-Approved. 2. UnApproved volunteer activities. 3. UnApproved attendance at say type of schooL 4. ApplIcation for, cc receipt of unsmpk,ymas* beucflts or other claim Inconsistent with Inability to wodi5. ReceIpt of woticers' compensation benefits fOr the same condition covered by the Plan. athletic activities, hobbies, hazard6. Vacation, trips, or other pleasure, ous recreational activities, insppsoprlats household or other stanuous activities. 1. rreatfol, Noepflancs. You can be dlaquarstled If you fall to follow the reasonable directions of (It) the 8eneflls AdmInistrator or Designated Providers, or refuse to cooperate with the Incident investigation. You must not be abusive towards persons involved with due Plan. Other examples: 1. ShippIng, scheduling or reachedaUng appointments of any kind without the Benefits Administrator's Pro-Approval. 24 .LVERopdouuSuntros7 Phe Dcscripuioe tecol. & seen. IA.? 000 J27 Case 3:14-cv-00200-DCG Document 1 Filed 05/28/14 Page 52 of 110 I CO6" 2 the Designated Provider without noti1riog the Benefits Administrator or other sotsots causuig the Benefits Administrator's absence ftom aPrmder meeting. 3. Not following 1k, treatment, rebab or recovery plan. refusing treauneuit a seasonable person would tmdertakC to attempt to correct or Improv, a condition or prevent its worsen. 4. PallIng to lmmadInt.ly no11fi the Benefits Administrator when certified by any Provider as capable of resuming full or additional work duties, cc when work restrictions change. 5. EshIbising resistance to,, or not coopasuting with, the trcatuient plaza. Modified Duty or other direction. Assignment, return to (c) bit Out of Contact with Plan Personnel. You must stay b* frequent contact with the Benefits AdmIIII*&ZOT while receiving Benefits by personafly contacting (or telephoning) as follows: liMe any Healthcare to obtain Pns.Appsoval (43.01). 2. Within 24 hours or by noon of the next regular business day following every Health case appoiraimsat, unless the BenefitsAdministrator was at the appoinirnesit with you. 3. Atleastevery Pay Pedodtoplckup yoiwchecb. 4. lmnsadiately to no6 the Benefits Admlnlstmlor of change ofaddreen, telephone number or other important information. 5. Within 5 Days after receiving notice from the Benefits Adnthilslrator requesting your rasponJ Notice is considered received 3 days after mafilag. I. (d) UxApproved Hesitheare ftoui any Healthcsre Provider. (c) You save th. eras, Isusporanly or permanently, where you sin employed. (1) Untrulbilsimes. if you us witnithild or dbtaoaost in any aspect of your Claim (e.g., obtaining or attempting to obtain benefits of usy type by false cc IIII&IO*thng pmcao.ss, deceit, concealment, misrepresentatIon, sot or omission regarding any matter p,rtaiithrg to the Plan), you may be dusqimuiflad. (g) Refuse Imedlde Mouilfied Duty or other AaslgnmauL (b) Uadaisiyflnadeqiaat. notice of Incident/change in condition usda to a pessumprion that your ccndltion is not Occupational, noises good cause is shown under 47.01d(2). (I) SeparatIon from omplijanat with the Company generally ends all SeeslIm unless you have Gold Benefit coverage by signing the Waiver (Ex. "A') psiorlo termination. See 4t01. You tak* certain Legal Actions that you agreed cot to pursue, as., you tat, action that Is (I) inconsistent with either the Arbitration Agreement or die Waiver, if you signed she Waiver. Benefits wilt be aithjoct to suspension and reduction If you, a Beneficiary or anyone acting or claiming by eal through them or you, caine a Legal Action to be maintained aphut the Company (or anyone In privily with the Company) which ecks dsraagós or other relief related so the Incident lbs which your Claim Is made where such Is Inconsistent wish your signed Waiver (Ex. "A"), a release sigoad by your Beneficiary, or the A1bitralion Agreement (Es. "B'). Benefits may be reinstated if concomplianc. Is promptly corrected to the Benefits Administrator's utlsfacticsi upon requsal. (k) Other rusces aiqalalned in the Plan. LPE1ces Sunmiry Pho 25 0CJt2C12CoiP.Bicats&SSta.0 0 (JO 3 28 Case 3:14-cv-00200-DCG Document 1 Filed 05/28/14 Page 53 of 110 CLAIM AND APPEAL PROCEDuRES ARTICLE 8. The procedures In this Ardcic S ma to comply with currently sppllceble ERISA claim and appeal response TaquirsIneust. Nothing in Art. 8 exteorla or modifies your responeibllfty to timely report Occupational Incidents as explained in *7.01 and the claim reporting procedures explained In the (uick Overview. 8.01 Row to Mike CWms and Appeals. How to claim hi 67.01 and ilii Oulók Oerv1,w O(ihII SirU. In most ceáá, your BáifiIá IB malt w*,madcalb' pendmg the Investigation of lb. Incident and your claim You can claim Benefits by Indicating what you Want on a coiflpletsd and signed initial Claim Form 200. if you wish to make a claim or recent Beirefita that you think you kaw been denied or not provided her you first repoitod an Incident. sebãed you must use the Chairgo In Condhioa Form 201. (b) Representatives can make a dulsu. if death, your incapacity or Faergency Medical Cue entative (e.g., fondly menbers or i*bere) prevents you fives making a claim an required, than your re may complete a ernporazy Claim Form for you. This must be done at the earliest, reasonable opposiwilty end within other Ikahi estebllthsd by lbs Plan. The Benefits AdminIstrat,r may require confbmatloo, additiOnal h eniatiOn and compliance with §7.01 cc other Pun sections. whenever a representative makes a claim or appeaL Rs.poà. to your The Bancflun Administrator shall promptly and reasonably starting from when your stated in Form 200 or 201 (or other written request) Is andy received The response will be Ii lbs mes (c) claim ølg$k and analyze cash claim and respond within the time periods In §8.02, (ii How you an AppeaL The Plan has procedures designed to provide you with an oppoctiesty for a full and fuir review of your dales. Upually you will rseclve a wvitte. nice explaining the Benefits Admliristratoes decision. Whether you receive such a notice or not. If you dls.groe with part or all of any decision or 4qqIaI of Bsniflls that you bsli.c has occwred you may ask for revcw by the or the tvouroaiL you m sixnli in the Ba' Appeals PaneL To dochimi van &saqIee w &w suiortinu (If any) diii s3qdeiá why you disagree. ía óxplainod in §8.02 for Cach tpe of Báñatlt Thai ao dufibrent tine llama that you must ccE$y with depending what type of benefits are involved Ia your appeal, which are explained hi §1.02 below. YouwilLtà oesidcredes wpeinn with the âib1á. ADIIeaIí are solely i*oeided In 6L02 and $1 1.04h. decision if voado othtimCtv law. governed by kcesMw. iIir deakmiiha AIdt ln si1 (e) Bespoase to your appiel. The Benefits Administrator may reconsider sad reverse any dcllon after an appeal Is reCeived, a may submit a position statement arid supporting materials to the Appeals Panel. Certain aistleri cannot be reviewed by the Appcala Panel (e.g., 'inustomer soMe." cowpWi about the Benefits Adminakato ma bfldhed under Articic 9). If your appehl is compute and within the jurisdiction of the Appeals Panel us provided by the Appeals Policy, then the Appeals Panel will decide ycair appeal within the ties. frames described In §8.02 by reviewing written submissions only. floodHa. for Jigs) 1.,eus.dkp under g1USA. The decision of die Appeals Panel Is final ( and binding . If you disagree with an appeal decision, you may challenge itas sand in Article 11. SJLYZRopVcaaSvirwiuY Plan Dcdpt1oc octe2cs2corur.esoola & Smtb,I.LP I) 000.323 Case 3:14-cv-00200-DCG Document 1 Filed 05/28/14 Page 54 of 110 8.02 Response Time. It Is the Intent of the Benefits Administrator to respond to all claims in promptly as c imatances allow. The datory time frame In whiub the Benefits Administrator js allowed to a whether your claim Is panted or denied depends on the nanire oliks benefit being claimed (e.g., Medical or Wage Benefit) and the nature of the claim (e.g., Urgent Care Pre-Servics or Past-Service CIaim) as explained below. Whenever cominunicath*s between you and the Benefits Adminhercliw me mentioned in Mticle 8, the term 'you includes you as the Emp1oyee as well as your authorized epresantative acting on your beha1f Itany. jrj (a) M.dical Bmeflts Response Tlmes Your Medical Benefits generally are paid automatically and directly to the Designated Provider who is Pie-Approved by the Benefit. Administrator. Therefore, In those sititles you do not have to request payment for Pie-ApprOVed Heahbcare to be coveted and paid. However, If you believe you am entitled to any type of Hashhcar. that you am ace receiving or If the Benefit. Administrator has notified you that some or ill of your Medical Benefits will not be paid or will no longer be paid (or some similar c*rni"wce), then you should follow tin claims procedure that applies to your particular Medical Benefits Claim, which will be one of the ibrec types explained below: Urgent Care, a PTe-Servke Chain, or a Poet-Service Medical Claim: 1. Rasp.,... TIara for 9lrgont Care" Claims: 1.1 DefinitIons. A claim involving Urgent Care is soy claim for Healthiest. or treatment if delays (I) could issiously jeopardize your Ilfo or health or your ability to rapin mauimwn fUnvdo, or (ii) would, in the opinion of your physician, subject you to severe pain that can only be effectively managed through the requested course of treatment. , ) InItial essilcase. If your claim is for Urgent Care, the Beneflts Administrator will not1 you ofthe clan decision as soon as possible, bid not later than 72 hours after a complete claim is recehod ar you If you l to ide sic1 far the Bomfit. Adnder to oton detenmne whether, or to what extent Benefits are covered by the Plan (I.e., an incomplete claim), or If your completed clsbn in incorrectly 61.4, then the B.nefils Administrator will ub*1 you as soot as possible (but not later than 24 hours after receipt ofyour claim) of the specific Information needed in complete your claim. You will be afforded a raioeabl. amount of thee, taking into account the chawestances, (bat net less thai 48 hours) to provide the specified intbnnath,n. The Benefits Administrator will notl you of the claim dcIslcn as won as possible (but In no case later than 4$ howe after receipt of .11 the needed information). 1.3 Anoesl. If you disagree with the claim decision, you may appeal to the Appeals Panel. Your appeal must be submitted (and will be handled) in the manner specified in Subsection 2.4, except that the Plan will follow Expedited Appeal Procedures as to the thnhig and form of conenimicatlons if circumstances make it necessary to be flexible aid inibimal In order to make atirinly decIsion. lb. Appeali Pinel will artify you of the determination on review as soon en possible (but not imr than 72 hours after receipt of your request review). 2. Renpenie Tine. for "Pre.$.Mce" Claims: If your claim flit Medical Benefits Is a Pie-Service Claim (messing a claim for service not yet performed and which Is not for Urgent Cars), the Benefits Administrator will have 15 days after röoeiving your claim so lists a decision on whether the claim Ii denlsd or granted. tsless an axteasion is aeceewy for reasons beyond the control ofthe Plan. 2.1 Sff.VZRaçdan Sunargy Plum D.wl,4,. 2012 Dueb * 5te, Li) 27 (9 000330 Case 3:14-cv-00200-DCG Document 1 Filed 05/28/14 Page 55 of 110 popep. If an extemica Is needed, the Bcae&s Adminlstn.tors deduce wIU be blued in nut later than 30 days. Wriden aødcs of the side 00 sad any edditicual to1oratica that is Oecdcd to process your clubs will be gIven to you puce to lbs expiration of the initial 13-day purled, will Indicate the spsds froumitseices requbtog pa extension, and will e the date when the claim decision Is expected tobe Iasus& 2.2 Jm_paJojt 2.3 MOeaIOfoiThatiODn.Cd& If an extension is needed becanes you thiled to anbmlt all of the lufoimatlon neoemauy to make the Wilal claim talcatica, the Benefits Admhiimator will give you cmi or written notice (Ifrequested) o(ai t,cluical deficiency in the claim filed and the rutceusmy to cure such deficiency wIthin 5 days following the Benefits discovery Of the defect. II ii order to make a bnef!t decision, the Benefits #4rathldeator mqucs*a additiceal information from you, you wilL be given at (cant 45 days to provIde the naluhig inSemaflon if the reason for the extension layout thilure to provid, needed biforrmatke, arid you eec timely notified of this lies, th. time puilod In which the Benefits Mmhtimatar baa to niake the decision Is ainpended tIol sd)*om the date of the notice to the wile, of -. Mmin's (I) the date on which your reeponee is received by tim Benefits Adndidtrator or (Ii) lie date eslabiidied by the Plan the giving the requested Snfonnatton (La., at least 45 days). The extension perIod (1..., 15 dry,) within which the Benefits Aderialsu*tor's decision must be made will begin to run front the date ott which your reapoma Is received by the Beanlits Metbiistrator (whoirt regard to whether .11 of the requested kiformedon Is provided) m If surlier, the due date setabtidisti by di. Benefits Mrnlnleuitor for flrtrthhing di. qusatcd Infotiniticu (L.a., at least 45 days). If your claim I, denied hr whole or hi part, the Benefits Mrnkdadstot will provide you with di. dicislOri In wilting In the form dsscalbsd below in §103*. a denial ci your claim, in pest or lii whole, and request * 2.4 AmpeL You may appeal to ' review by die Appeals PaneL Any appeal of $ Pm.Servlce Claim must be subtnittsd wIlbin 1*0 receive di. denial notice. Late appeals will be denied an entlateb. You may days aur request (in writing) to icyleW copiet of relevant plan docmsi, records, or othir Information relied upon by lbs Benefie M Matretor to comnedlon with your appeal, subject te curtain curift4eudaJi end other usenkejoas unidor applicable law. As part of your appeal, you way usbutit sy written coirmerits, docutnents, records or other luSetsatlon you believe will benefit the ,t±nuissloe of your appeal for rvvlew The Appeals Panel will review ycen appeal earl all written comments, documents, records and other lnbxmaticit that you timely subunit as part of your appeal and nodfr you of the find decision wIthin 30 days after receiving your written appeal of a Pre-Sssvlos Claim. Von will be notified ci the Appeals Patters decision regarding your appust to writing hi the m described below in §$.03b. 3. Banpouse Tim. for "Paet-Servtc&' MedlealCiafesec Any claim air Medical Benefits snider the Plan that is not a claim Involving Urgent Cam or a Pre.SeMce Claim, Is considered a Post-Service Claim govers4 by the following claim proceduru 3.1 fleflaitlon. 3.2 InkialRmmcmae if your claim for Medical Benefits undcr the Plan Is a Poet-Service Claim, the Banefiti Adednimator will have 30 days after ,eoeiving your claim to Issue a decision on whether the claim Is danlsd or grinted. 2* $øVERoV4eraSuany Plin DwutpOor Smat, U.? 01)0.331. ( Case 3:14-cv-00200-DCG Document 1 Filed 05/28/14 Page 56 of 110 ( [Th 3.3 Extensio rreanonse. If an extension Is needed tbr reasons beyond the coottol of the Plan, a decision wilt be isonod not later then 45 days. Written notice of the extension and say additional lafoswaticn needed to process your claim will hi given to you prior to th. expiration of the initipi 30-day period, will indicate the special circumstances requinng on extension, and wilt state the date when the claim decision Is expected to be &ssnad 3.4 Mo qj'eg4. if the Benefits Adminlitrator requires additional rms*Ioi. the noticc of satseslon will ipeerficafly describe what in*xmstion is needed. ii; In ords to teak, a decision, the Benefits Mmlnistz*or requests additional information fives you, you will be given at least 45 days to provide the needed information. if th. reason for taking the óxleesion Is your failure to provide inflxmadon needed to decide the claim, and you are titnaly notified of this fact, he thee period in which the Benstits Adminimalor has to wake the decision Is th. same as explained is Section 2.3, above. If your claim is denied in whole or in pert, the Benefits Adreinhsbator will provide you with the decision itt wilting in the lines described below in §I.03a. 3.5 Anneal. You may appeal in writing a denial of your claim, in part or In whole1 sod reqtse& a review by the Appcsb Panel. Any appeal ofa Pm-Service Claim must be within ISO days after you receive the denial nothó. Late appeals will be denied as untimely. You may request (in writing) to review copica of relevant plan documents, records, or other ifurinatlon relied upon by the Benefits A4tniuisttutar In connection with your appeal, nabject to certain conMentiality and other reselotious rmder applicabl, law. As pert of your appeal, you may submit any written conimesb, documents, records or other fthnrratisa you believe will benefit tha submission of your appeal for vview. The Appeals Panel will rvlsw tbe ippeal and all written comments, docuntints, records and ether laforuwlion that you timely submit as pert of your mppal and notify you of the fisal decision withm 60 days after receiving your written appeal of a Port-S.n6ca Claim. You will be notified of the Appsmls P*n.la decision hi writing info. form dCscribed below ln8.O3b. sued ( 0 (b) Response thee for Claims for Wag. Benefits: 1. n1tia1 iesponan Your Lost Time Wage Benefits normally will be paid and started automatically after you timely report a Covered Incident sad meat all qualifications for such benefits Similarly, if Suppiemertlal Wage Benefits apply, they will be started for you. if you believe you are Cirtitled to any type of Wage Benefits and you are not receiving them, or if the Benifits Admielstsaloi notiflel you that your clai& for Lost tune Wages or Suppleciental Wages is dented or such benefits ate ended (or some similar circumstances), then you should send the Benefits Athuiniseator a w,ittatr atmsot aening out the reasons 'why you believe you should receive the benefits. The Benefits Administrator will have 45 days afwr receiving your written request to Issue a decision on whether your stalin Is denied or granted. xtenslon for ramonse. If an extension is necessary for reasons beyond the conitol of the Plan, the Benefits AdmlnI*atcc'a decision will be issued not later than IS days, 'which may be further sxtendsd to lOS days after receipt of your written request fOr Wage Benefits If the additional extension is necessary due to umsom beyond the Plan's control Written notice ofthe extension and any additiceal Information needed to decid, your claim will be given to you prior to the expiration of foe Initial 45-day claim review period (or prior to the expiation of th. arty 30-day extension). The notice wilL Indicate the special circumetmrcis requiring an extension of time sod will bidiceto the dam the Benefits Mmlnlsttator expects to lien. * decision. If your claire for Wage Benefll* Is denied itt whole In part, the Beniflis MmkuIanntor will Issue a dcdion in writing in the form described hr §*.03a below. 2. a szlrnemiou my im DIUCdPIiOe 29 u-p I flfln,ld1r V I) tj Case 3:14-cv-00200-DCG Document 1 Filed 05/28/14 Page 57 of 110 ( AnpeaL 3. Youmayappeftingadcnialofycwclaim,bipartorinwhole,and request a review by the Appeals Panel. Any appeal of a Wage Benefit claim must be submitted within 180 days after you receive the denial notice. Late appeals wlU be denied as untimely. You may request (in writing) to review copies of relevant plan documents, records, or other formation relied upon by the Benefit Administrator in connection with the appeal, subject to certain confidentiality and other restrictions wider applicable law. As part of your appeal, you may submit any written comments, documents, records or other Information you believe will benefit the submission of your appeal for review. The Appeals Panel will review your appeal and all written comments, documents, records and other Information that you timely submit as part of your appeal and notify you of the final decision within 45 days after receiving your written appeal of a Wage Benefit claim, unless the Appeals Panel requires an extension due to special circumstances specified in writing. Such notice will inform you of the extension prior to the expiration of the initial 45-day period such that the final decision will be made within 90 days. You will be notified of the Appeals Panel's decision in writing in the form described below in §L03b. ) (c) Response Time for Combined Claims for Medical and Wage Benefits. If your claim is for both Medical Benefits and any form of Wage Benefits, the Plan the rules described under Medical Benefits In § 8.02(a) above. (d) will follow Response Time for Claims for Death & Dismemberment Benefits I. Initial Resoonse. if you die as a result of a Coveted Incident and your Beneficiary does not autotnitically receive Death Benefits after your death, your fletieficiary should write to the Benefits Administrator, send a copy of your death certificate, and state the reasons why your Beneficiary believes your death was due toe Covered Incident The Benefits Administrator will have90daystrecchtgtheclaimwjssueadecisiononwbetherthcciaimisdenjedor granted. / Extension for response. If an extension of time for processing the claim Li necessary 2. because more information is needed, a decision will be rendered not later than 180 days altar receipt of the claim. Written notice of the extension and the additional information that is needed toprecess the claim will be furnished to your Beneficiary prior to the expiration of the initial 90day period. The notice will stale the special circumstances requiring an extension of time arid will state the date the Benefits Administrator expects to Issue a decision. If your Beneficiary's claim is denied in wbie or in part, the Benefits Administrator will provide your Beneficiary with the decision In writing in the form described below in §*.03a. Acoesl. Your Beneficiary may appeal In writing a denial of the claim, in part or in whole, and request a review by the Appeals Panel. Any appeal of Death Benefits must be submitted within 60 days after your Beneficiary receives the denial notice. Late appeals will be denied as untimely. Your Beneficiary may request (in writing) to review copies of relevant plan documents, records, or other information relied upon by the Benefits Administrator In connuction with the appeal, subject to certain confidentiality and other restrictions under applicable law. As part ofyour Beneficiary's appeal, the Benefisiary may submit any written comments, documents, records or other information which the Beneficiary believes will benefit the submission of the appeal. The Appeals Panel will review the appeal and all written comments, documents, records and other infonnfion that Is timely submitted as part of the appeal and will notiI your Beneficiary of the final appeal decision within 60 days after receiving the appeal. 3. 30 SILVERap6ons Summary Plan Description CCep,i1a 2012 Coeneur. Bmolis & Smith, LLP i,es53.l 000:3 Case 3:14-cv-00200-DCG Document 1 Filed 05/28/14 Page 58 of 110 ( \ ExtensIon for anneal. If the Appeals Panel requires an extension due to special crcumstances and notifies your Beneficiary of that extension prior to the expiration of the Initial 60-day period, the final appeal decision will be made withIn 120 days. Your beneficiary will be notified of the Appeals Panel's appeal decision In writing in the form described below In §L03b. 4. L03 Form of Written Denial (a) In *1*1 Denial of a Clam. If any claim is denied in whole or In pert, the decision by the Benefits Administrator must be in writing and Include the specific reasons for the denial with reference to the specific Plan provisions on which the denial Is based. Whed applicibic, the decision must siso Include a description of any Information which must be submitted In order to correct and re-file a deficient or Incomplete claim, along with an explanation of why such additional information is needed and Information reitmrdmg the Plan's appeal procedures (Including thus limits appflcable for such appeals, and information nigardinj the right to file suit If a claim is dánfed on appeal). In addition, the If claim Is a claim fur Medical Benefits or Wage Benefits, you will be notified if an Internal rule, guideline, protocol or other similar criterion was relied on by the Benefits Administrator in deciding the claim. You will be provided with a copy of such rule, guideline, protocol, or other criterion free of charge (after your written request for such information is received). If your claim is for Medical Benefits and the denial is based on a Medical Necessity or otbar similar exclusion or limit, you will be provided, free of charge (after your writtefi request for such information is receive4 an explanation of bow that exclusion or limit and any clinloèl judgments appiy to your medical cirvüniatanccs. If the notice of denial is not furnished in accordance With the above procedure, you will be deemed to have exhausted all administrative remedies and may file suit in federal or stste court, as appropriate, to dispute the benefit decision in question, only as allowed by E1USA. ( ) (b) Death of a Clam on Appeal. If on appeal a claim is denied In whole or In pert, the notice of the final appeal decision must include the specific reasons for the decision and specific references to the relevant Plan provisions on which the Appeals Panel's decision Is based. You Beneficiary, if Death BcihfiIa are Involved) will also be entitled to receive free of charge (after (or your a written request for such Information is received), access to and copies of all documents, records, and other inforurhtion relevant to your claim, subject to certain confldCntl.lity and other restrictionS under applicable law In addition, if your dana Is fbrMedwal Benefits or Wage Benefits, you will be an IntCznal rule, guideline, protocol or other similar criterion was retied on by the Appeals notified If Panel In deciding the appeal, and you will be provided flee of charge with a copy of such nate, guideline, protocol, or other criterion after your written request for such infomiatlon is received. If your claim Is for Medical Benefits and the dehial is based on Medical Necessity or other sitnilar exclusion or limit, you will be provided free of charge, alter your written requást for such information is received, an explanation of how that exclusion or limit and any cli icel judgments apply to your medical circumstances. (c) Standard of Review. In the case of a claim for Medical Benefits or Wage Benefits, the review on appeal must be made by a different decision-maker from the Benefits Administrator and that decision-maker cannot give procedural deference to the original decision. If you are dissatisfied with the Appeals Panel's decision (or other Independent fiduciary's review decision), you have the right to file suit In a federal or state court over that Issue as allowed by ERISA. Your Beneficiary has these same rights as to DCSth Benefits only. SlLVRopdccs Simarei, Pun Darcptic OCatta2Oi2Ccis. Bmats& 5icId. liP 31 1759i13.I ( 000:34 Case 3:14-cv-00200-DCG Document 1 Filed 05/28/14 Page 59 of 110 ARTICLE 9.01 9. FAflNESS POUCIES unlawful Discriudnatlon Prohibited. AU Employees shall be treated consistently under the Plan on a nondiscriminatory basis without regard to legally protected classificationsas specified by the Company's policies and applicable law. 9.02 Uniform Benefit DeterminatIons. The Plan Administrator shall make all claim d ninatious, Plan Interpretations arid the application of Administrative Procedures, criteria, standards, definitions, cost containment features and other guidelines in a reasonable, uniform and consistent manner that does not favor or discriminate against protected classes, certain individuals or employment position or classification except to the extent permitted by ERISA or where necessary as a fimetion of plan design. The Plan Administrator may not administer Benefits In an a Lty or capricious manner, waive or impose conditions or limitations on an ad hoc basis, nor may it authorize others (e.g., the Benefits Administrator, delegees, third parties, etc.) to act in a manner prohibited to the Company or the Plan Administrator. _ 9.03 "Customer Service" Commitment. You are the "custome?' of the Plan. Just as you are expected to be courteous and cooperative with the Benefits Administrator and others, the Benefits Administrator and others involved with the Plan arc expected to treat you courteously end respccthilly. The Benefits Administrator will strive to promptly and timely respond to you as best is circimrstsnces allow. If a delay Is unavoidable, you wilt usually be infonnet If you feel you have been treated discourteously, or the Benefits Administrator or others handling the Plan have been unprofessional or failed to make a good faith effort to meet this customer service standard, then please write the President of W. Silver, Inc. at P.O. Box 12904, El Paso, Texas 79913 to explain your complaint. 9.04 Privacy of Personal Health Information. The Plan authorizes disclosure of claimant personal health infbrmation ("PHI") to the Benefits Administrator, hislher supervisor and assistants, and certain other persons employed or hired by the Plan Sponsor to carry out various plan arid claim administration functions for the Plan, es detailed In the separate "Notice of Privacy Practices" provided to all employees (a copy is available upon request), The Plan Sponsor wlU not use PHI far personnel matters or other unrelated purposes, unless there is written permission. PHI disclosures will be limited to the minimum amount of information necessary for each person to carry out his or her role in plan and claim administration only, and will otherwise be consistent with those types of disclosures which are allowed by rule without specific written consent ARTICLE 10. PLAN CRANGES 10.01 Authority to Amend or Terminate the Plait. Subject to this Article 10, the Plan Sponsor is authorized to change or amend the Plan or terminate the Plan, Including but not limited to increasing, reducing, adding or eliminating any or all of the Plan's Benefits, terms, conditions, for any reason, at anytime or from time to thus, In the Plan Sponsor's sole discretion. The Plan Sponsor may delegate this authority. The authority herein to amend or terminate the Plan does not extend to authority for the Company or the Plan to unilaterally amend or terminate the Arbitration Agreement, which Is not a part of the Plan end constitutes a separate, mutual agreement between the Company and Its Employees. 10.02 CIrcumstances for Amendment or Termination. The Plan Sponsor expects the Plan to be permanent and continue indefinitely. However, In the event that 32 SLI'ERoçdaas Summary Piari Drecdpsk* t022 Ceenso,. Bmci * Smfth LI.P ecpyrite 1se5131 1 ono;5 Case 3:14-cv-00200-DCG Document 1 Filed 05/28/14 Page 60 of 110 ( ( \ the Plan Sponsor determines in its sole discretion and based on its business judgment that there is good reason (e.g., the purposes of the Plan are no longer being adequately met by the Plan, or might be frustrated or adversely affected by any cimumetance or condition), then it Is authorized to amend or terminate the Plan as any tine In its sole discretion. (a) Examples of clricuaslances that might cause the Plan Sponsor to amend or terminate the Plan include, but are not linilted to, the foUowing (I) changes in the Law due to acts of Congress, the Legislature, agencies or decisions of the judicIary; (2) changes in economic cost and availability of indemnity and insurance polIcies; (4) avaIlability conditIons: (3) changes In the to address occupitional rika, such as workers' compensation insurance and fcasibility of other options or a different benefit plan: (5) any other reasons or circumstances that might cause the Plan Sponsor to reconsider or change the Plan. (b) No waiver of rights. The Plan Sponsor does not waive the right to amend or terminate the Plan merely because it does not change the Plan promptly after a circumstance justi1ing change occurs. The Plan Sponsor does not have to wait until It or the Plan experiences adverse affects before making changes or terminating the Plan. 10.03 Procedure for Amending the Plan. (a) All changes to the Plan must be In writing as an amendment from the Plan Sponsor to be binding and clThctive. Oral modifications shall not be binding or establish legally enforceable rights to anyone. Unintended or i.dveitent variances from the Plan's terms and conditions arc not amendments and do not change the Plan's terms and conditions. Amendment to the Plan or Its documents does not constitute a termination of the Plan. 1. A Summary of Material Madifleallon to the Plan will be given to you not later than 210 days after the close of the plan year In which a material change or modification was adopted, unless you are given a new Summary Plan Description that has been appropriately modified to include the changes. See the excCptlon to this rule In § l0.03a(2) below. 2. A Summary of Material Reduction of Medical Baneiha will be provided to you within ( sixty (60) days finm when a change has been adopted that Is an Important reduction In covered Medical Benefits or services under the Plan. 3. Adarlalstr*Uve Procedures and fonna are not sultiect to the procedure above, and may be changed in a manse consistent with the purposes of the Plan, the Release and applicable law, without notice at any time. Your rights and obligations when there Is an amendment. In addition to your right to (b) receive the notice described In § l0.03a end your obligations in § 10.05, your Tights and obligations are as fbflows 1. SlIver Benefits. Amendments aflbcdng Silver Benefits take affect immediately upon the amendments' effective date. 2. Gold Benefits. Amendments will not be retroactively applied to airy claimant of Gold Benefits who has a covered Incident afar the Effective Date and prior to the amendment date of the Plan, except as follows. You will retain whatever tights you had under the pie-amended Plan with respect to any Benefit you ware actually rend ving from the Plan just prior to the sflbctive date of the amendment Amendments therefore apply to all £lLYERopdar's Summary Plan Darctiptiou CC,u2OIZCo'utmse. flmob* Sma1. LI.? '""$3, ( 33 Case 3:14-cv-00200-DCG Document 1 Filed 05/28/14 Page 61 of 110 Employees and beneficiaries immediately upon the amendment's eftbctive data with respect to any Gold Benefit not previously being provided to the claimant, unless a dirent application Is specified in the amendment. A launination of the Plan is not considered an amendment ) 10.04 Procedure for Terminating the Plan. (a) Written notice of termination of the Plan shall be provided to you within a reasonable Iliac after the decision to terminate has been made. (b) Your rights and obligations when th. Plan Is terminated. in addition to your right to receive the notice described in tO.04a and your obligations in § 10.05, your rights and obligations are as fbllows: 1. Gold Benefits. If you era receiving Gold Benefits at the time of the effective termination date, your Gold Benefits will continue as though there was no termination, and will only end according to the terms of the Plan prior to its termination (e.g., the ending of your empLoyment or the occurrence of matters described hi § 6.02 and § 6.04 still apply to end Benefits, as may any other limitation that applies pursuant to ArtIcles 3,4,7 and other applicable provisions). 2. Sliver Benefits end on the eflbctive termination date, and no further such Benefits will be after the termination date. 3. ClaIms will not be covered by the Plan that relate to Occupational incidents (a) occurring after the effective termination date; (b) reported after the efibotive termination date; (c) reported prior to the effective termination date but for which no benefits were requested, peal or incurred during the preceding 90 days. - 10.OS Obligations Surviving Termination and Amendment. Regardless of termination or amendment, the foftowing obligations shall survive: (a) the mutual agreàment of all Employees and the Company to submit Legal Disputes to arbitration as provided In the Arbitration Agreement; (b) the release and waiver of certain rights of Employers end/or their Beneficiaries to take nay legal action as provided in the Waiver (Eu. "A") or any Beneficiary release. ARTICLE 11. YOUR ERISA RIGHTS You are entitled to certain rights and protections inder the EmpLoyee Retirement Income SeCUrItY Act of 1974 (ERJSA). ERJSA provides that persona who may receive Plan Benefits shall be entitled to: 11.01 RevlewlObtatn Information. The Benefits Administrator will respond to your written requests for infonnation. You may: Examine, without charge, at the Plan Administrator's office, all documents governing the (a) Plan, including Insurance policies (If any) and a copy of the latest annual report (Form 5500 SerIes) filed by the Plan with the U.S. Department of Labon (b) Obtain, upon written request to the Plan Administrator, copies of documents governing the operation of the Plan, including Insurance policies (if any) and copies of the latest annual report (Form S1LERcpttons Sunamy PIsn Dercilptien Bio,,¼s & Sint* IL? OCcpii,jt2O$2 34 C Case 3:14-cv-00200-DCG Document 1 Filed 05/28/14 Page 62 of 110 5500 SerIes) and updated luminary plan description. The Plan Administrator may make a reasonable charge tbr copies you request (c) Receive a summary of the Plan's annual financial report. if applicable. The Plan Administrator may be required by law to furnish you with a copy of a suminasy annual report, unless certain exclusions apply. 1102 Fiduciary Dattee end Non-Retaliation. In addition to creating rights for persons covered by the Plan, ERISA imposes duties upon the people who are responsible for the operation ofthe Plan. The people who operate your plan, called "fiduciaries" ofthe plan, have a duty to do so prudently and in the Interest of you and other plan participants and beneficiaries. No one, Including your employer or any other person, may fire you or otherwise discriminate against you in any way to prevent you from obtaining a welfare benefit or exercising your rights under ERISA. SeeArticle9. 11.03 RevIew of Denials. If your claim for benefits 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 review and reconsider your claim. The Plan complies with this requirement by offering an appeal process (Article 8). 11.04 Enforcement of Rights. (a) Requesting information. Under ERISA, there sic steps you can take to enfome the above rights. For instance, if you request materials from the Plan Administrator and do not receive them within 30 days, you may file suit In a Federal court or take other legal action allowed in your circumstances. In such a case, the court (or arbitrator, If an arbitration agreement applies) may require the Plan Administrator to provide the materials sad pay you up to SI to a day until you receive the materials, unless the materials were net sent because ofreasons beyond the control ofthe Plan Administrator. ( (b) Challenging appeal decisions. If after you followed the appeals procedure in Article 8, you have a claim for benefits which Is denied or Ignored, In whole or In part, you may file suit In a stats or Federal court, provided it is brought on a timely basis. (c) Other rIghts. In addition, If you disagree with the Plan Administrator's decision or lack thereof concerning the qualified status of a domestic relations order, you may file suit in Federal coutt or Initiate other legal proceedings that may be allowed. If ft should happen that Plan fiduciaries misuse the Plan'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 or Initiate other legal proceedings that may be allowed. The court will decide who should pay court costs and legal Ices. If you are successful, the person you have sued may be ordered to pay these costs and fees. If you lose, you may be ordered to pay tLese costs and fees, for example, If your claim is found to be flivolous. (d) If you have any questions about the Plan, you should contact the Plan Administrator or Benefits Mminlstrator. If you have any questions about this statement or about your rights under ERISA, you should contact the nearest Area Office of the United States Labor - Management Services Administration, Department of Labor, 525 S. Griffin, Dallas, Texas 75202 or the Division of Technical Assistance and Inquiries, Pension and Weflirt Benefits Administration, U.S. Department of Labor, 200 Constitution Avenue W.W., Washington, D.C. 20210. S!LVEROPIIODJ Swurnary Pun Description 35 C Cat*r 2012 Coesy. Scoots & Sngth. LLP 17595*3.1 I ( O003 Case 3:14-cv-00200-DCG Document 1 Filed 05/28/14 Page 63 of 110 ARTICLE 12.01 12. PLAN ADMINISTRATION Plait Administrator. (a) Named fiduciaries. W. Silver Inc. is the Plan Administrator of the Plan. The Plan Administrator Is the "named fiduciary" of the Plan for purposes of ERISA. The Plan Administrator may delegate all or part of its duties under the Plan and may employ such persons (e.g., the Benefits Administrator and Appeals Panel) as it deems necessary to carry out the purposes of the Plan. There is no health insurance issuer responsible for the financing or administration of the Plan. (b) Discretion and authority. The Plan Mmbiintrator (and those it designates, such as the Benefits Administrator) is authorized to take all such actions necessary to carry out the provisions and purposes of the Plan and to comply with applicable law. It has all discretion and authority to control and manage the operation and administration of the Plan In all respects to the maximum extant allowed by law (see § 12.02). For example, the Plan Administrator has the discretionary power and authority to construe, interpret and apply the Plan and its documents (e.g., this Summary, the Plan Docuznent Administrative Procedures, lists end fomis, etc.), to supply any omissions therein, to reconcile any inconsistencies within or between Plan documents, to correct errors, to c1aril, ambiguities, to make all fact findings, to draw conclusions and make all decisions and determinations required by the Plan (see § 6.05). (c) Worsen' cunspeusalion law Inapplicable. The Company does not subscribe to workers' compensation insurance (as pennftted by law). Inteq.il*Gons of the Plan are not subject to the Texas Workers' Compensation Act or any decision thereunder. (d) Benefits are the Exelusive Remedy against the Company for all damages and losses any type incurred when you agree to the Waiver (lix. "A"). The Exclusive Remedy cannot be waived. of (e) Resignation or removal A Plan Administrator may resign upon thirty (30) days prior written notice to the Company. Th. Company may remove any Plan Administrator by giving one (I) day advance written notice to the acting Plan Administrator. The Company shall act as Plan Administrator during any period In which selection of a Plan Administrator is pending. 12.02 RIghts and Duties of Plan Administrator. The Plan Administrator/Benefits Administrator may adopt and/or revise Administrative Procedures, criteria, protocols and guidelines, definitions, Interpretations. forms and communications relating to all Plan matters, to include but not limited to matters relating to Benefits, utilization review, cost con'i'nnent, releases, reasonable practices for the proper and efficient administration of the Plan, and perform all other acts necessary or appropriate for the proper management and administration dthe Plan (see § 12.Olb). In addition to obligations arising from the Plan and applicable law, the Plan Administrator must observe Your rights as provided in Mticies9. 10 and 11. 12.03 Indemnifleatlon of Plan Administrator. As permitted by law and applicable documents, persons designated as acting for the Plan Administrator shall be Indemnified by the Company against any and all liabilities arising by reason of any act or failure to act made in good faith and pursuant to the provisions of the Plan. 12.04 FundIng. Fund benefits. The Plan is unfunded, in that there is no insurance policy or trust fund to (a) pay Plan Benefits, and all Plan obligations will be paid from the general assets of the Company. The 36 SILVFJopdem Swnntuy Plan Drecripdcn OCoontea 2012 Cmmay,BmokS& Smith, LLP 17995stJ OOC33 Case 3:14-cv-00200-DCG Document 1 Filed 05/28/14 Page 64 of 110 Company has no obligation to, but may, obtain Insurance or other contracts in order to provide fluids to Pay erin benefits arising under the Plan. The Company has no obligation to establish any fund or frust to pay benefits under the Plan. (b) Not collateral source. Plan BenefIts serve to limit the Company's liability end are not ucollatersl source" payments. Receipt of Plan Benefits paid to or for an Employee constitutes that Employàe'a agreement to assign to the Plan and the Company any amounts the Employee might receive wider any Legal Aclionforen bicideut,uptothstotal ofPlanBeneflts paid ortobe paid. 12.05 Plan Records. The Plan is admninisteisd and Its records are kept on a fiscal year basis from July 1 to June 30 ibllowing year. except for the first year, which shall be from June 10.2002 to June 30.2003. of the 12.06 Miscellaneous. (a) Noanlienatlon of Benefits. You cannot pledge, encumber or assign any Plan Benefits except as provided by law and for (1) qualifIed domestic relations orders relating to marital or family support obhgations; and (2) deductions or withholdings authorized or Imposed on payroll earnings prior to the initiation of Plan Benefits. Qualified medical child support order detenninatlons do not apply. ( (b) The Plan Is not a contrsct of eiuployineni. All Employees remain employed at will. (c) Adoption procedure. This Plan has been adopted by the Company's governing body. (d) Governing law. This Plan shall be construed and enforced according to the laws State of Texan to the extent not preempted by Federal law, whIch shall otherwise control. of the , (e) No admission of BebWty or waiver of defense. Payments and Benefit determinations made under this Plan are not an atme1on of liability or responsibility by the Company or anyone else, oar are they to be considered a waiver of any defense or right of the Company in any proceeding or context For example, the decision to cover a claim Is not an admission that the Company was negligent, that negligence proidniazely caused an injury, disease or cumulative trauma, that pre-existing, subsequent or Intervening events did not break the chain of causation, that you were in the Course and Scope of Employment or Active Service when the Incident occurred, that you were not Intoxicated or negligent such to be solely the cause of the Incident, or that all medical expenses were reasonable and medically necessary. (1) Tax consequences. If you receive &lLVERopttons Benefits, it is up to you to consult a tax advisor of your choice to determin whether you rosy be obligated to pay taxes on some or all of the Benefits, Certain amounts may be withhdd as required by applicable law, but the Plan and persons acting for the Plan Administrator are not authorized to advise you on any tax liability you may or may not have. No lIMO, PPO cc other managed case entity, organization or network regulated by the (g) State ofTexas Is intended by the establishment of the Plait or the selection of Designated Providers. (b) No COBRA or other legally mandated continuation coverage applies. The Plan is not a "group health plan" as that term Is defined for purposes of coetbaring, or portability of coverage. The Plan is excluded front COBRA under the accident, disability, and workers' compensation plan exceptions. (I) Severability. If any provision of this Plan is unenforceable or invalid according to the law, the Plan will be construed and enforced as if those provisions had not been included. 37 1LVERopdcma Sunausry Plan Daiezlptio CCcovdgbi 2012 Cceaaiy, RenC & Sn&th. liP 179n$fl 000340 Case 3:14-cv-00200-DCG Document 1 Filed 05/28/14 Page 65 of 110 C 0 EXHIBIT "A" POST-INCIDENT WAIVER FORM 202 I) TillS FORM IS EXPLAINED iN § 202 OF YOUR SUMMARYPLAN DESCRIPTION Sit VERo3 Swnmay Nan Ociptio' C Ccp)' I795I3i 2012 38 Ccna. Btaoki & Smith. LU' O) 034 Case 3:14-cv-00200-DCG Document 1 Filed 05/28/14 Page 66 of 110 Foam 202 Page 1ot4 (Iivkb ee. J.Z Iikan3-4) '\ SILVERopt1on Gold Bail hi O and POST-INCIDENTWAIVER cnsvr Cu.W be glwn to amp1oe daiwb,gav 1.Jwy. a rctdisgrzt, ewvme oftera nsadiail evoiandoa Syc Inanargeiyee'e doøa'adaatsmj,erAai g tenth (IO' Swi,ru d y9tersbe MWoIMpoMofbifwy. Section 1. Acddagtllucldeetflnlewy Dasdou. Employee oune - Date Form 202 gIven to employee: Birth Date: Employee ID#:_____________________ Date Incident reported by Employee:_____________Dare Incidsat Occurred: Dnt a? nonemergancy niodical avaluedon:____________________ Describe Incident. location ofoccureetos, itd nature ofln)ury. dlseaie cc coudtthm._______________________________ SectIon 2. SILVERoroam Cold Beneftb Ofki. 4), than the Plan pcomlsan to provIde you with both Silver Benefits (an. 2.2 below) and Gold Benefits. The details ofthis oaw end pro and the i cd1flcne of Plat btIreflts are 5d1r stated In die SiLVERopdons elan docuiemt end eumminy plan deaniptiom. OaldBemfltag fly Include, when apPlicable. Initial wage replaccmcrdend modrfl.d duty bstàfttaet 100%ofyour 100% coverage for o'.appmved me erpenses, disanenbotmept benefits. and deeth bstCflte roateln applicable. Nsow atWaivarraletas only totheOcajilona) A cldinéói lmi6(thIacteenrthetwas reported an bgthe lit ray, a orcoedutlonmid all lea mid losses that in any way ads. foal the Incident (collectIvely, the clad tithed Ibed In Section land in di. Employee's Initial Claim Fore and any Change I. ) lfyoudo aotsdrlO? l"end/arlfyc 1yscknowtedgerncefptofddsorby below, you wlfl NOT be entitled to any wage rcpl.nnnenf benefits (be occupationil absenote, end you will only be dllMe1rSIlwaansflts4., covemgnofcat.In ailoV.ible medical es, 60% modIfied duty wages for upalliritod. 'ipwy pariod, and burial benefits occura) while employed, subject to the tame and conditions of the Plan. You teay ban received presented with this offer, but temporary Gold Balieflb will not continue wnican mid ralil you aen empoyOoldedorbbmag SceUse 3. E5PLOYEE WAIVER. By signing 'OPTION #1" below. I accept the Plan's Gold Benefits offer. To the teams mid condidasts of diii Offer, the Waiver below. and the Plan, as stated hi the arrant summary plan deewiption, dihetadditional copies oflhcae do mierite en allahieto era plandocutnard. enA Vbtcistlbe and jury vtalvaregeeeurcul. I undie upon request *0 the Benefits Administrator. 3.1 Inexobange for eligibility now (or rwhen needed, as applicable) for Gold Benefits according to the Plan's terms and conditions, I HEREBY IBREVOCABLY WAIVE ANY AND ALL RIGHTS AND LEGAL ACTIONS AGAINST MY EMPLOYER, W. SiLVER, INC., FOR ANY TYPE OF NEGLIGENCE, PERSONAL INJURY AND DAMAGES RELATING TO THE ACCIDENT, INCIDENT AN INJURY (as defined in Sections 1 and2 and the Plan) and release W. Silver, Inc. for arty liability relAted thbeeto, whether such legal action or liability is raised In court or an arbitration, whether the fUll extent of liability, injury or loss is now known or not, whether recovery is certain or tiscertain, as follows: I, end my betieficielies, estate, heirs and anyone claiming by or through me (collectively, "r'or "Employee"), release and waive any light to recover from W. Silver, Inc. and its lis±cs, parent and sub5idiay entities, assumed names, successors and assigns, and their officers, directors, shareholders, agents, insurers and employees (cøllectively, "WS1") for all liabIlities and losses of any kind, to include but not limited to any injuries, ifluess, occupational disease, cumulative traimia, móatal or physical cOndition, impainnentor disability or my death, when such is caused by, relates to or arises from the Accident, Incident, or Injury, incin ngbutnotliniited to WSFa negligence (ordInary or 3.2 - WeeFee o,ito*p,e.l U) cc trn2 CI,.ThsthI C 302 Simta 01)0042- Case 3:14-cv-00200-DCG Document 1 Filed 05/28/14 Page 67 of 110 ( Form2O2 Psgc2of4 14, 1' and all torts (including intentional) and any other acts errors or omissions related to orcontributhig to the Injuzy whether aclionable under any statute, cotnmon law or in equity, under any juriSdiction or theoty of recovery c liability, inci but not limited to vicarious liability. I andóritand that by gross), J AOM SectIon 4. !jntevee aed ma that (a) I am executing this docutned voluntarily mid without thuesa cc coercion of any kind frme airy pecloc cc (b) no unwritten rep. 4.LIoe by my presno acting no behalf of WSI has intleenced cc Induced me to (c)agrelngtoIlda document mvolves wel the legal rI above in exchsoge for eligibility for the Plan's Gold Benefits, which eligibility ut aL'grest value to ma evee If I do act dod up Iimeadlately or ever nag all or airy ofthe bmafl (d) the Plan may from dme to time be amended (after node, to mi arid without lois of benefits accrued prior as the ainoidmentar taminationofthePlai),ud the Waiver will still remain Sally aiféceablel (a) I signed andlor agreedasthisdocutriart as ryow free act, being Sally iota ud pIsent to do so ehd aflitarhigthat the istaru of the parties Is reflected In this doctmreat (l I ant not under the influence otsoy subetame that inipeire ray judgrnàit, ocr under any cranial brespsni or physical condition orcircunwtsoce that would adversely affect my ability to freely mid haowingly aceipi this offer or voluntarily agree to the Waiver at the tints ofagreelng (1)1 have the tightto seek proBeslonal legal advice about this armec. end as the masoithas I believe n'esemy. Ihave sought the advice olpereoir(.)ofniy owoab ngbelinealpingthlsdocumutr (it) lam iwere of the consequmicre mid benefits of agreeing to this docwnmit (I) Iwill rairarmnsilgibie for cc age the Silver Benefits whilst vu eniploysdas provided hi the Plan, even if 1 diclinc to agree to the Waivor (j) if any portion of this Waiver Is declared unenforceable by soy authority of couipetcit jurisdiction. itsitall be levered or csfncnwd to the remainder or entirety may b*g reed coiidstmd wtthth pwpoaesofthc Plan; (k) nr3 enipluyuwnt (If any) will continue lobe at will vvhithor I agrcd Ui the Waiver ornot O)the Information ha SeCtion I Is acaaiate sod complete, I reported the Incident acre than eei (10) busIness dsya before signing and agreeing to the WaI'er audi prviorarlyr,celverl a medical evaluation Oem anonemsrgency cars dociortiut was satisfantnty to me, (m)l previously received and we ste raid the Fisrf a cuifentmmenmy pima demiptiod. oonddjywulv.greenient,and all amdmwustraeCcit, if my; and(n) this egrannaig mid Waiver shall aurviveany diange cc ending ofiS ofthe thllowmgr the Plait, my coveragnaccordlng to the terms ofthe Plan, or my employment s. a'. ****a**flgye sign 0P770N#1 or OPTION #2 below, to bceyouchoke OPTION #1: 1nccq G.daeri4has iw ) ithemA'ssafloicveUjusenciiv. an epp&aNe. I mmdastsndthatalgningber, hivoLveswaMngvaluelegaltightasndielcasmsW.SIIvu,tnc.fromitubltkyaaspeclfl.dehovcend In S,ctio I. I have carefully read and raderstood this doeieent Slpaturei___________________ Dated;___________ Employee cc DeCignated Agent OPTION #2: IrvcsJverl a wpy efthis Geld3meJIte offer, betide not oempt the flew. uodsritand that by ethe from the Plan forthe inn OP'llObifl2, I will notbe entitled to any wags replacemmdbrereflta or Gold Incidad desaied ha SectIon 1, Saul If I have received amy such benefits to dale. I will be disqualified from such COla Injury Benefluusflbctive today and heeveftar, until I canon this form with OPTION ff1 signed. I iii Slpxtnrat__________________________________ Employee orcaigitMed Agent This The ebprhutedleEnglM on pagan 1-2, a dlsbnslatsdtoSpanish onpagor3.4. Pkasesipionpigc2 or on page 4. variance. The tern'. ofthi English vo'rlon are controlling. wiish translation lafor CdiarOII& Pee-beaten Ww Fon i02 - -. ) Dated:____________________ COVi1td5 l2 Cm-, teo & C Case 3:14-cv-00200-DCG Document 1 Filed 05/28/14 Page 68 of 110 ( 0 EXHIBIT "B" NOTICE OF ARBITRATION & MJRY WAIVER AGREEMENT SJLVERcpdons SW7m$y Pun Dcacription C Ccçt 2012 Cxy. Bmoi & sm 39 ILl' 17995*31 (. oOOi44 Case 3:14-cv-00200-DCG Document 1 Filed 05/28/14 Page 69 of 110 W. SILVER, INC. ("EMPLOYER") ( NOTICE TO ALL APPLICANTS & EMPLOYEES ) OF ARBITRATION & JURY WAIVER AGREEMENT On and after 12:01 a.m. on the Effective Date of May 15, 2012, all legal "Disputes" between you and the Employer (as defined in the Agreement) will be arbitrated and: - governed by the Federal Arbitration Act; -- supervised by the Texas Arbitration and Mediation Service ("TAMS"); - under the TAMS employment dispute resolution rules for arbitration controlled by the more detailed terms and conditions of the current Arbitration & Jury Waiver Agreement (3 Amended); - shall include (but is not limited to) any action relating to your employment or termination, any Injury or loss, any employment law violations, harassment, discrimination, retaliation or other legal "Disputes" (as defined In the Agreement); and ) - shall be subject to the same laws protecting your legal rights and those of the Employer that would otherwise apply, but all legal "Disputes" will be confidentially brought before a neutral arbitrator jointly chosen by you and the Employer under TAMS rules, instead of ajury, and if for any reason arbitration is not enforced, you and the Employer will try the melter in a court without a jury as provided in the Agreement. By signing below I acknowledge that I received a copy of this notice and the Arbitration & Jury Waiver Agreement (3 Amended) on the date below. I agree to immediately read and comply with the Agreement on and after the Effective Date. it In English on page 1, and it bansiated te .S),anith on page 2. Please sign on page 1 or page 2. The Spanish translation Isfor convenience. The terms of me English version are contra This notice W. Dated: Signed: Printed Name: for poatlng nd diatibulion to Mbivafiao & Waiver No eccpyvit 2012 Ccns*gy. Brook & &thth. U.? / all ouployeca(EngtIali & Spanish) 1fl9571.1 " _) OflC45 Page 1 of 2 ( Case 3:14-cv-00200-DCG Document 1 Filed 05/28/14 Page 70 of 110 W. SLLVR, INC. ("EMPLEADOR") AVISO A TODOS EMPLEADOS Y SOLICITANTES SOBRE ACUERDO DE ARBITRAJE Y RENUNCIA DE JUR.ADO VOLUNTAIUA ) En o después de 12:01 a.m. do Ia Fecha Eibcliva de 15 de Mayo dcl 2012, todas "Diputas" legates entre usted yel Empleador (como asia definido en ci Acuerdo) saran arbiirados y: gobernados bajo ci Ado de Arbitraje Fedeal; - vigilados sobre ci Servicio de Arbitraje y Mediaciôn de Tejas (rexas Arbitration and Mediation Serives "TAMS"); - ( ) bajo Las reglas do TAMS pars resoluclôn de disputas de enipleo; - controlado per los ténninos y condiciones mas de*1lAna en el mu reclente Acuerdo de Arbitraje y Renuncia de Jurado Votuntaria çiercer (3m) modificaciSn); - tendrá qua incluir (peru no esta limitado a) cusiquier acclón relativas a su empleo 0 ternunaclén do enspleo, cualquier herida o dafo, cuaiquler violacidn do lay de cntpleo, acoso, discrirninación, represalias o otras "Disputas" legates (como estãn defithdas en ci Acuerdo) y tcndz* quo ser sujeto a las miexuas leyes protegiendo sus derechos legates y los de el Ernpleador qua do otra manors so puede aplicar, pero todas "Diputas" legates cetera traldas en confin' antes us aibitro neutral escogido juntos por usted y el Empleador bajo las regales da TAMS, en yes do unjurado, y si per cusiquier razon el arbitraje no esta forzado, usied y ci Erupleador intentaran Ia causa en tma tribunal pero sin wi jurado como esta escrito en ci Acuerdo. Por firma abajo, yo rcconozco qua yo recibi una copla de este aviso y el Acuerdo de Arbitraje y Renuncla de Jurado Voluntarla (Tercer (3w) niodificación) en Ia fecha ahajo. Estoy de acuerdo de leer inmedlatamente y cumplir con este Acuerdo en y después deJa Fecha Efectiva. ate en Inter en pegüie 1,, ai en EipaAnlai lapaghea 2. Porfevoedeflrxwerse noabre enp.tejmalo pagksa 2. La a&ixM,, ii, apeS.! apara ne canvenleada. Las M'nlnos de Ia va'rMa en Ingla Esla aWsu ion tar qva conb'ølun. Firma: Dated: Nombre impreso: Axbtv*xtoo at WslvcNolice %r posIng and ataxbnion to all employees (Enghsh at Smith. Lii' øCOp)llgId 2012 Corgy. ømo & Spanisb) 1799571.1 000046 Page 1 of 2 Case 3:14-cv-00200-DCG Document 1 Filed 05/28/14 Page 71 of 110 (Eft&hip 1-2. *h Ia.pp. 3-4) ARBITRATION & JURY WAiVER AGRIZMENT (3e Amended) FOR ALL APPUCANTS & EMPLOYEES I. ff1tlas To benefit from the confidential end ecimd resolution of legal disputes, this Arbitration and Jury Waiver Aeonent (3 Amended) Agresznest') is between you (defined In Section 10) sod your employei, W. Silver, lie. ("Employas"), This two (2) pege Agreement is .mctke sad binding on you sad the Employer en and alter l201 n.m., May 25, 2012 ("Efibstive Dote") If you perform work for the Eteployer, any benefit is paid or payable to yen or on ysar bebaX by the Fi.pisur, or If you make an uppUestiso for emplOyment wish the Employer ailar be Eflictive Da*e subject to Sections Ii end 13. No signed agreement Is but yen will be asked to sign en acknowledgement ofreceipt of this Agrosniant. 2. exchanged for this Agreement lncludesi but is not limited to the mutual egreanesit of you and your Employer to mbltthtà ugh disputes (without a jury) end other valuable coesideretlon. it is understood that chges in your compensation, positiOn, benofit., covenge or offess and other terms and conditions of employment or benefits do not terminate or alter this Agreement. This AgTeement survives the teentinstion of your employment end applies to all fiitue employment as provided in Section II. 3. "Dheost&' that YOU AND THE EMPLOYER AGREE TO RESOLVE BY BINDING ARBITRATION INSTEAD OF BY A LAWSUIT OR JURY TRIAL (WHICH IS WAIVED as per SectIon 12), INCLUDE ANY AND ALL LEGAL OR EQUITABLE CLAIMS, ACTIONS AND DISPUTES ("Disputes") that now exist or way arise between you and Employer, and which are actionable at law orb equity and could be brought as a lawsuit in court ("ACtiOnable") Included without limitation are the specific disputes in SectIon 4 or any legal disputes related to the application or hiring process, pen/post eraploynuart processes, esfesemmee background chOcks, tests, evaluations, past and future employment, all terms mid conditions of employment, Employer policies arid prOcedures, the ending or eb-'&ng of your employment for any reason, the I q1atlon or breath of this Agreement, disputes relating to the scope or applicability of this Agreement and/cr any other dispute., when such is Actionable Exckiilona ira in Section 5 below. 4. SemitIc Dkiatas em'ersd by this Agreement include, but em not limited to all claimed violations of any chat tights law or any employment dascrrminsdtm, ratahatiosi, hirsamnent or wzvcgfbl discharge claimed as violating any applicable Ibdeml. state and/or local statute, ordinance or aovCcnrnentsl rágulAtion or common law any comriuusatfon. bile&or other esnoloymunt Dlsoutes Fórthdiit k11 fldiilui all li1thdviOlidomn of lb. Age Discrimination in Empteynterd Act, Ameriotns with Dimbilhtias Act, Civil Eights Act and their regulations and state equivFlants (such as the Texas Roman Rights Act) a a right to nrc lunar (or aqulvalest) Is issued (If applicable), Ond any otbOr Dispute between you and the Employer arising under common law or any statute, regulation, ordinance or governmental regulation. - E: 5. Administrative proceedings while within the exclusive jurisdiction, if any, of the Texas Division of Workers' Compomation, duo Texas Wcdcforce Commission ("VNC'), the Equal Employment Opportunity Commission ("EEOC") or other govctnmem agency, dusagresmemsa arising from and the enforcement of any nondisclosure end noncompets agreement, and disagremnerne not actionable at law or in equity under federal or state law, all shall not be submitted to arbitration audits not Included in the term "Dispute" 6, MedIstloor You and the EmpLoyer agree to confidentially mediate any Dispute before a neutral mediator jointly chosen arid paid by yOu mid the Employer before binding arbitration or other proceeding under this Agreanint is Initiated maileus yen arid the Employer agrue to not mMi You end IhO Employer also agree to enthaust all applicable IdmhniOtnative or informal remedies before to include but not limited to any such procedures maintained by the Employer, the EEOC, TWC, end/or other a,toh,lassdv., non-binding preliminary proceedings. 7. A.EB1'TRATIOP{PROCEDURIS. You end the Employer agree that all sibitrationns will be according to the tennis of this Agreement, .3 nipuvlsed Unddi the ipplicable employment dispute resolution rules for arbitration ("Service Rules") of the indcpcedmnt arbitration satvlce dCsignated by the Employer in writing ('Servlce"). The taunts of the Agreement arid the Service Rules shall collectively be referred to herOcfter as the 'Rnlea." If no Service Is designated by the Employer, than the Texas Arbitration and Mediation Service. Ian. ("rAMS") CC El Paao, Texas or it. miccessor shall be the Service supervising the arbitration. If tbme Is a confllOtbOlwësn the Agreernsirt and the Service Rules, the Agreement controls. Arbitretions will be In El Paso. Texas. All aspeen of the axbbmticxt shall be cotifidiattisi. 8. Fees & Costs. The parties to the .ibrs*lon mail equally share all fees end expenses of the Setvice sod the arbitrator C'Aibturafion Costa") once the award is final, as follows. You will not be requited to initially pay more than $300.00 In Arbitration Coats befnte an Eward or decision Is raridilud. The Employer will advance to the Service (.nd arbitrator, as applicable) any balance due (cc Arbitration Costs. ThereOfter, you will not be lequired to pay any amount of Arblñtion Coats that exceed whatOver amount, if soy, tint Is awarded to you by the ubitnetor as damages. The arbitrator shall award remoeshhe attorneys' foes to either party If allowed by applicable law or this Agreement, utif incunied bye parry to compel arbitration. Fees to compel arbitration and a party's unpaid ,haue of Arbitration Costs shall be ofet against any award. The parties shall bear all other costs (deposition coats, attorneys' fees, etc.) themaelv ) CCopitje 2012 cciuy. Baucks& Sw* LL.P 01)0 i 4'I Case 3:14-cv-00200-DCG Document 1 Filed 05/28/14 Page 72 of 110 (E.hihttmpp. 15 l.2 3.41 9 ATbIIIIUOI decIngi shall he binding ch't Issued in writing, reflecting the names of the paflies, a brief Summary the of law to relevant theta, and a description of the remedies ordered, ifany. The only binding remedies em of those expressly id led quantified In the written decision. The decision shall not be pnblicimd, shall be the exclusive remedy, and tim!) be ai and an all parties, k he exeomo naccmeors and mel if the mmedy of the decision Is not fully and promptly perlbrmcd after receipt of the decision, then the arbitration decision may be judicially confirmed and aitsed ofrecord as ajudginem in a coii of cesnpetantjwisdictlon. The party required to pay any award may tcuzdarpay,ncnt to the awardee by deducting any amounts authorized by law or this Agreement (e.g., taxes, attorneys' fees gwgrded by the atbitrator, etc.) arid any Mbltaa*fon Costs advanced purenant to Section & 10. PartIes. hi this Agreement the term "you mesas all pes of employees of the Employer, temporary or leased employees assigned to the Employer, and applicants (whether hired or not) of the Employer. You nod ill ofyour heirs, spouse, eatale, bleeficimies and anyone who could teke legal action by or through you, including for loss of conacrthim and derivative claims, are bound by this Agrerdieni and any decision Issued wider it. The term "Employer" includes .11 of the Employer's aIl.iire emoessors. parent entities mid subsidiaries end essiaried manes that may exist from time to time. The Employer mid all of the officers, directors, owners, partners, sharcholdars, managmi, rapreacowlyss, agents and czmtouners of the Employer and ill persons and entities in privlty with Employer sic intended beneficiaries of this Agreement and you and the Employer agree to sibtirwo say Dispute involvlrgthun. tauue anO .ppuianlon bing abri athIoo 11. Annulesblt law for arbitration is the Pederel Axbkraticn Act ('MA'. The parties agree that their employment relationship, any benefit plans and policies associated therewith, and this Agreement are transactions involving commerce as defined by the FAA, 9 U.&C. § 1. The arbitrator shall apply federal or Texas substantive law as agreed herein or as approprlatc end applicable to the Disputes presented, the same as if the dispute was brought in court, except as pr.r,lded herein. Any portion of this Agreement dotarmined to be rmanh'cesble or Invalid for any reason shall be severed herefrom or modified by the cowt or arbitrator to enforce the remainder. All arbitratloin between the parties shall be controlled by the terms and conditions of this Arbitration Agreement, which replaces and aupercedes arty prior stion Igreemenu, which the parties agree tarmhwted when this Agreement Is cctive. Arbitintion baa been a mandatory condition of arnployinenz for all employees aana em 1,2001. This Agreement Is the 3 gmv4I v.eslon of the Employer's mandatory arbitration condition. The Employer mayJune Issue reasonable amenthamita to this Agreement (far example, to comply with applicable law or to clarIs' terms or procedures) or tarnthtsc It. However, anch anmedinenta or termination muss be In writlng signed by the Employer's chief exerartive officer, mid may only be applied prospectively to cleans occwiing more than ten days aflei reasonable written notice of any amendment or twmirint,n baa been given to yen and you continue yaw employment after the tan day notice period. If you arid your employment before or within the tarn day notice period, the prior terms remain effective mid imobangod. Termination is also not efibotive fee disputes which scorned, arose or were made the subject of a legal on prior to the termination date. ( 12. WAIVER OP TRIAL BY JURY. IN AJ)DmOri TO AGREEING TO BINDING ARBrrRATI0N, YOU AND THE EMPLOYER HEREBY KNOWINGLY, UNCONDI1IONALLY AND VOLUNTAEILY AGREE TO WAWE ANY RIGHT TO A JURY TRIAL fOR ANY DISPUTE BETWEEN YOU AND TRF. EMPLOYER. This jury waiver applies to the pestles if the rest of this Agreement is imuifocceeble, void, If for any reason arbitratIon Ian bean waived, not enforced, voided or made inapplicable by law or other reason, such that any Dispute not subject to arbitration shall proceed by bench trial without a jury Ins cowl of competentjurisdiction in El Paso County, Texas. 12. EmaIajasaa1 atesffi. Nothing herein Is i,.d to add to ercate or Imply arty cotsectual ci other riglan of employment other than bindiüg egreinent to arbitrate Disputes and for waiver ofjuiy trials. Your employment relationship with the Employer is terminable at the will ofeither party and no other Infcisnce Is to be thawn Seen this Agreement This Agi.emerma*itu in effect as to any Disputes Ifyou are an applicant who Is not hired or if you em no longer mnplcyedby the Employeror l reemployed. You may voluntarily decline to agree to this Agreement only by resigning your employment In writing to the Employer's CEO prior to the Effective Date orby the arid of the third full business day after you begh work or submit your application, whichever is later. rLzAan rema mt aadss Ii In En2tsb cc p 1.2, and b fresilated te Spesish os prpu 3-4. The Spaebh teastIas te Itwassysikace. Tho tern of the EagItsveatsesrecsateeUIa. "1 1 oc,pydja nttt coecn, noah, * Smith. UJ .rbIttatoa A5'ewoaw 01)0 :i 48 a iwy Case 3:14-cv-00200-DCG Document 1 Filed 05/28/14 Page 73 of 110 ( 4EIid ioipp. 1-2. wu,hongç 1.4) ACUEIWO DEARB1TXAJE V RENUNCL& o nw-o vou3NTARiO (3nMoJ1csc$) ?A*A TODOS SOLICITANTES V EMPLEADOS L_) i. _pccs ne&ir Icl confiiccc1a1 y eficicote rasolucido de disputes legolsa, asic Acucodo do Asbitiaje y Rccwicia do Juado Vohmtazio (3 Modificecida) (ci 'Aoierdo as aitie Usted (deficldo cc Scccidn 10) y su emplendor, W. Sllvcc, Inc. C'EmpIcodoe1 Esic AcueTdD do dos (2) pughas e efectivo y obiigstotio sabre ued y cc Emplasdor cc y dcspu do 12:01 m- ci din IS do Mey, 2012 ('FeChi Efectiva") ci uctcd bans tisbajo pass .1 bemcScio cc pegs ace peed. pagar $ tated o par pazte do acted par ci ipie*dar a ci acted solicits an tribajo Eapleador, can ci asapicedor dccpudo do is Fàás Efectiva Seccicces 11 y 13. Un ocuerdo finuodo O cc necesarlo, pea else in pido quo firma mi racibô do reconocinuatto sobre ode AQzerdo. ntio. C icl6p ceomblo do cots Acuerdo lucluye, paso no asia litnitado 51 scuasdo comdn do acted you Emplesdor disj,utas legalea (sin mi jurodo) y otis concidorsalda valioso. Eec catnodido quo coabios at compnsscldo, posicidit, bEneflcios, cabeltins a ofertes y otice tfemfnos y condicionos do caplco 0 bemieficica no cc tcnnIca id eambian ode Actierdo. Eec Acuerdo Lobrevive is tcnniiacldn do ic empico y tambldn cc optics a emaiptea cc ci Muro como eec e.cxftoamSOocldn II. 2. do ir a sibltno so'óeC lao pIii.c" 3. quo USTED V EL EMPLEADOR ESTAN DE ACUERDO lIE RES LYE POR ARBITRAJE OBLIGATOIUO EN YES DE POE DEMANDA 0 lUCID DE JURADO (EL CIAL ESTA RENUNCJADO p.r pert. do 12), INCLUYE CVALQUIER V TODAS RECLAMACIONES LEGALES 0 DISPUTAS CDiIPUIU") quo eidstn boy o quo puedno existir dontia do misted y el Empleador,yEQUITATIVOS ACCIONES V cmáicc con procosabics por Is Icy a eqidiativas y so pudiocca ser tialdas coma dncia cc una tribunal (Procasabks"). Enchiycsdo sin Iiuiitaddn son disputes copocifloss cc' Scccldn 40 cuslquier disputa Isgil relacionada a proceco tie iollcitsr tznbsjo o alqullarsc1 proceso do anteWdeuds do capito, roMemaiss, a lon tie p 5. exhmenec, evaluacioces, emoplea dci paso o cc ci fiduro, todos ice tdin,lnos y ccmmdlcmoocc do eniptea, polidca y procedanlentos dcl Empleador Is tsrntthaci6n a camblo do cmi amplea par cuslqmer iszdn, Is bIduicl6n ovtolsctdn tic acts Acuesdo, disputes rthalonadu act alcnitce o apticaclOn tie act. Acucodo yb cusiquier a disputa, amend. sea Procesables. Lu Exciuslones cilia hi Soccido S .bJo. D.t.cSaH eaam 4. bejo oce Acuerdo Laclaycci, paso no eats tim a todas violaclones reclA1udI tic enaiquler Icy tie d iicboi ciiIcc b uhk(iili dusalminaclOn. ropreasllu, macac despedida ln3uMo do ampiso quo cc portenecacpis us ha ciolado aialquicr Icy fedasi, dcl cstado yb regis Ioeal, omdamsaen a eagle dcl gimblemno o Icy cantOn; calquias compamascidim, bntiflslo a Dispats do emplea; lqI. CUAITs lIE NRGLIGIA PARA INCUIIR 1IEGLIGENa& CRAY!. dolo. ifesidoL Ullita 61I' a . àalqulas diMuaclin a tizec inamcionsl cusiquico viotacidd do adiquier obligecido legal, fduciarlz o tic acuasda; todsa violaclones dcl Acts do Dlsasiminacitin am Empico sabre Stied, Ado do Dlicapecidad Amasicanos, Ado de Demecboa Civilcs y cue regius y los eqwvclaucs tic catado (canto ci Aod do Dasechos Hansoos tic Tejas) despuds tie una bert dasdo Ia detedia do hacar demeads (0 ci equivalent.) , y cualquuer one Dispute cane ucted y ci Emplesdor baja una icy ccmCm o mma esiatuto, regis. ordoneddu' a megia dcl ãt.c ) frsiI T0 àNdal biI. gobmcrno. 5. gigI ComnpeamciOn pass Tréajidcrsc Proceduzaicato edmalnistrotivas dentro Ia jurisdiocitin exciuslva, ci *lgdn, do 1* Dtvisitin tic delejas, 'taCumisltin doTabajadosas dotsjas is ComlsI6n do Oportunidad do Empteo Igual a atm suicIs gbccnslivo, dOciduados dedvadac y Is iplicucitin do ntialquler scuerdo do no divulgacitin a scuasdo do no ccnlpe*, y tissacuerdos sin predeesbic cci te.y a eqidded ba3cmas Icy fodessi odd eaiado,todsa no sasdo occatidass smb(teaje yea can inctuides en .1 tasmino 'Disputes." Ii 6. Usted y ci Emnplcsdcr calM do acmucdo do medico confiticaclaluiente cusiquler Dispute notes tie an modlador nutra1 cscdgidti jlmtcs y pagado par mated y ci Empicador noses do midas aibluoje obligatodo notro procodimlento bcjo asic Acuerdo soismonte quo tated y ci Empleedot coda tie atuasdome no mneduar. Usted y ci Empicadarlamblia coda tie acuerdo tie ego todos los ranodids acbithzistrativos 0 Infixasles sates do arbitrer, eato inciuye paso no acts limitudo a too procedinioiiOs mmteu'idos por ci Ethpleador. .1 EEOC. TWC,yIo otine procedimlados admbd*ativosy no abligatorios. 7. PR(FDThNT0BE ARIlTRAJf Usted yet Eaplesdar eslin tie scuerdo quo todoc los srbltis3es saM bajo los tirmmos do esto idd, is vliIcibajo las tie aibiteaje do rosoluclOn tie disputes do empico rEoglac do ServiclO") del serviclo hidependiaste tie aibiloaje desigusdo par ci Empleadoc par esanto ('Servicto") Los tàniinoe del Anierdo y las linglas do Serviclo caM refasiziss juntas tie aqul Ca sdeiant* cacao las "Rapiss" SI .1 Emplcador no actabra tnt Servlcfo edotices Texas Azbbrtetoo mid Medladoc Service, lao, rTAMS") do El Paso, Incas o cc succour 'on Las quo supeovican ci arbitraje. St tyim conflict. astre ci Accoido y las Reglac do Serviclo, ci Aamado controlea. Los Ambitrijec seem en El Paso, Tacos. Todas losaspecto do los mbitisj comM cordidamolal. iil.i fts.L..J-°° '\ ) psr*ida *1 arbltreje compaflirdn todac Ins boacesrios y gastos dci SezvLcio ydel arbitro I. eGaslos 6. Azbltm1aje") ctm510 Ii cisccstdcm/dmnbiscldn cc final, canto algae. Inlclalmamts tiered no tendrã quo pegar ass tic $300.00 In Gastas do Azbltrije sates quo I. coacesltin a datermmnacido cc dada. El Empleatior avanari aol SeMcio (y ci aibicro, ci splice) cusiquier bslciva debido pat los Gastos do Axbltraje. Despuis do esto, utcd no flame quo pogar cusiquier cactidad tic los 00,I1Cet.BCOte*5ed.0 Aiblaniot Acs&My ( OflOCi Case 3:14-cv-00200-DCG Document 1 Filed 05/28/14 Page 74 of 110 E*UthUaip. 1-2. Sjmskt,i,jpiJ.4) Oidoi d &bfti*Je que e!(eatO di 1* fl ttdi4, at cusiqulot, qua s au pat3utelos. El *xbilxo a4judicsci honorerios di adjudivadoi mtsd par patti dci arbitro y clasificido ahogados qua son tazcnable a cualqwot psitido at is Icy a once Acua'do lo pattidos on toner obIi atblasjc. Gsstci pena tc qué obilgar arbhrie y los Gaston di Arbitrajo quo no ban Mdi pspdo par uno do Los put dos quo amen onnhrsisitados urn cualquier concisld&detejmg6n Las pstMdos tondthi qué pagw todos tros gastos (gasto di decisracloocs, bonotatios di *bogado, etc.), eLla. mismos. pmkc. osi son incwildo pot usa do 10 9. Dstat&iii.ea di .rblbnla sa final y vinculante cuando cite publicado pot esasito, roflejando los nombres di partidoc, ma breve reatinon do las cuestiones y aphoacido deli icy a Los bechos, y ins deaulpctôn di los runedics udatrados, at necciarlo. El dilcb romodlo vlocdlate act cios qué estdo expreudos sepeafficamante y cusntiflci4os an Is dcaisl& eectha. La no and pablicad, aut at mtnodio oncluatys, y sari final y vutculania en todes los pwtkios, son heredero albaceas, adinml,tridoccs, atacescres y aatgnados. Si .1 ratncdio do Is decislài di arbitrajc no cite resllzida totalmaste dsepuéi diii recibo di Is declaida, ontonces Is decigidu di bitrsjc ci puede cci*inar y is jurudiccion competente. El psitido do qulen so requiero toner qua pegar pu.d. opinido so puode ñglstrar con ins tthusal con dir pego .1 otro partido pot media do deduc las ewH,I autOrirado pot La Oy a par e Acumdo (e.g Inpuestos, honomnos do abogadsi Indemnizido pot ci axbitro, etc.) y cusiqular Osatcé dO Aibitrajo qua fuoton avanzados bÔ Secci6n S. Los 10. Partld En este Acuardo ci termbio "asiad" sits definida do sot todas tipos di ctplcedos do ci Empiesdcr, di tunporaria o ampleado r y asigriado ii Empleador, y solicitantes (it aiquilado a no) dcl Empleador. Usted y todos sits hsimlotoe, meposo/a, psfrhnnaio, beneficlarios y cusiqitier persona quo pudlara tornar riado di perdida di coeaorcio y tic naciociea dCnvativas, catin litultados a cue scctdn legal pot patti di ustid, lxhyendo par Acuerdo y cualquler dccistdn publicada baja ci Acucrdo. El tarmino "Ens$sodor" thcLUye tndos as ampri s fl1ialcs sucesares, citidédes posits,, filial y notnbrsi onpucitas dcl Empleador qua existi di lampo a tiampo. El Emplrddcr y todos sits oficialci, directoma, . sociOc, socloelana, gotescas, agenras y clientesdci Emplesdor y todis emonas y entidades on confinars ceo ci EtOpleadot son bensflciazios do sate Acuardoy ustad y ci Empleidor salOn dOacusido di Ir asibtirije par cualqulcr Dispute on cual so onvuOlven. f J II. Lev esv6ziats pita ci arbltrajc ciii Acto di Azbhrqe Federal ("FAA"). Las podidos satin di acuerdo quo Is retacldn di eciplea, cusiqiuct plan di benoficlos y polftxms asocisdo con, cite y Acuatdo son unasacciane, di comerclo come eats defltddca per ci FAA, 9 U.S.C. §1. El aibifro aplicir Is Icy federal o Is Icy suatantiva do Tijas coma do aciando aquf o apropiadainont. y aplicible a Iii Dispuam presonladas, to inlamo coma ii Is disputa fits tralda on us trlbeo.sl, a excepctdu como eats equL Qisiquier poriVat dc aito Acutedo quo so datarmini quo no sO paid, eitbcsar o quo sits invalido pot cusiqular mum sari sepsasdo di aqul o otodificads par ci trlbuáal o ublan pate inw lo damis dcl icuardo. Todoi los aebiajcs entu los pertidos aarOn cintroisdos pot los tdimlno. y oondlcicsama diode Acuardo di Azbltrija ma! rapists y sudituys taiqitis scuardo di atbifruje interior y qua los psrtidos satin di .cuerdo as terminsa cuado cite Acucttio eats an efectivo AzbltraJe ha sido ins cundictdn mitIál di ompioo pun todos Loi unpisidos dcidc I di Jimlo del 2001. Este Acuerdo ci ci 3rd modlfloscidn di lacoodloide di arbinqc lo del Emplcador. El Epicsdor puods erwinr modiflcsclonca rizicables pars ide Acuarda (par qjsinplo, pus eanplir coo itt icy spIlabti a pain ebaificar inns t&minos a condickiocs) o reschithr ci Acuardo s modificuctonca 0 tciotdir ci Acuardo Mets qua sitar saraitsa, thinadas par pate del jefe ejscudvo principal dcl Ernpleadcr,Parc, y eatOn splicadso solainaitte panel fubiro sicciamu ocurnetido quo so lea dada muds dies (10) dIms do aviso eactito do Is modlflcscido o rescindir ii Acuerdo y tasted continua on ãnptao dcspuOs dii perlodo do dice thu di avno Si tasted tctmbia on cmplco antis die darude los dies thai dcl potlodo di iviso, los tfeinlnás unlerkans odin Ofcctivis y no cambian. Tsrmhiacidn no ci otbcdvo pars Ii disputes que fucron snimuladas, surglstun o son ci sato di ins dernanda antis di Is fuchs detuminacldfl. RENUNCIA DE .IIJIC1O C0T4 3URJiIX). ADEMAS A FSI' AZ DE ACUERDO CON FETE ARBITMAJE USTED Y EL EMPIZADOR TA1thWN ESTAN DE ACUERDO SIN CONDICION V VC)LUNTARIAMENTE PARA RENUNCIAR CUALQUIFR DERECHO A UN JUICIO DE JURADO POR CUALQUIER DISPUTA ENTME liSTED V EL EMPLEADOR. Eats rinuncla di juasdo voluntarla so aplica a Los partidos ci ci ride di ide Acuerdo no so puede es**1*r, vscI6 o Itiepilcabic par Is icy o aba razdn, cusi quo cusiquier Dispute no sujeto a arbateje ii puede proosder con julcic dejues sin jurado en in tribunal dsjurlsdlccidn conipetCnts sails condado dc El Palo, Tcjiz. 12. VINCULMe'r}, Eesetmo a 'vitiated. Nida conterrido squl sits protuetido pots dir mu, ar 0 implicit cusiqulot &ccho dc coo derecito di ainpido solameate pita hacot tat acuatdo di arblw*je vancuinnts pate Dispussa y tans ramnicas di juicla con jinedo Sit reladdo di ompiso con ci Eniplesdar sot pied. termbisr a Ia volunuad dc aiaiqwer partido y nose bade sot inOneutia pot periods cite Acusido. EiiÔ Aciardo eàresclbcto baits áualqularDisputs ii usted an solickante qua no Ii oinccn ampico osi ustCdja no ci am empico dci Eanple.dcr oil dispiads inlod vuelve a trabajar peril Emplesdor. Ustid puedo dc0lbr di aciptar ode Acuetdo pare solantente pot resignar sit cmpleo on esciito ii jefe ejecutivo principal dci Empleador miss do Is Paiha Efectiva osi dial dcl tamer dli detrsbajo dsipuis di quo coinferan suabujar a onbagalu iplicacido pan trsbajo, ctalquka ticinpo as anal odde. 13. acusido u rAVOat 05 NOTAR2 Sci avlioe.b ii Los tb*I.os di layetsidi 5. lajlm itaictap. as (. 3QI C.on it psØu. 14, mm Irididde it Eipa*iI it pnit 3.4. La WidardM on E.puIit it pars BmoI& Side,. LLP Mbiatit oIJo:!5o it Ansa S Jiay Wvir Case 3:14-cv-00200-DCG Document 1 Filed 05/28/14 Page 75 of 110 ( NOTICE TO EMPLOYEES CONCERNING WORKERS' COMPENSATION IN TEXAS COVERAGE: W. SILVER, INC. has elected not to obtain workers' compensation insurance coverage. As an employee of a non-covered employer, you are not eligible to receive workers' compensation benefits under the Texas Workers' Compensation Act. However, a non-covered employer can and may provide other benefits to Injured employees. You should contact your employer regarding the availability of other benefits or compensation for a work-related injury or Illness. In addition, you may have rights under the common law of Texas should you suffer an on the job injury or illness. Your employer is required to provide you with coverage Information, in writing, when you are hired or whenever the employer becomes, or ceases to be, covered by workers' compensation Insurance. SAFETY HOTUNE: The Division has established a 24 hour toft-free telephone number for reporting unsafe conditions in the workplace that may violate occupational health and safety laws. Employers are prohibited by law from suspending, terminating, or discriminating against any employee because he or she in good faith reports an alleged occupational health or safety violation. Contact Workers' Health & Safety at 1800-452-9595. AVISO A EMPLEADOS SOBRE COMPENSACIÔN PARA TRABAJADORES EN TEXAS ( COBERTURA: W. SILVER. INC. ha elegido no obtener cobertura de compensaclôn pare trabajadores. Como empleado de un empleador qua ha etigido no obtener seguro de compenaaciOn pars trabajadores usted no as elegible pars recibir beneficlos de compensaclOn bajo Is Lay de CompensaclOn pars Trabajadores de Texas. Sin embargo, un empleador In cobertura puede y debe proparcionar otros beneficlos a los empleados leslonados. Ustad debe comunlcarse con su ernpleador pars obtener Informac$On acerca de Ia dlsponibilidad de otros beneficlos o compensaclOn par una lesIon o enfermedad releelonada con ci trabalo. Adernás, usted puede tenor derechos bajo Ia Icy do ComCin" de Texas, ii usted ha sufiido una lesion o enfermedad relacionada con su traajo. Es requerido que su empleador Ia proporcione informaclOn acerca de Is cobertura, par escrito, cuando es contratado o cuando su empleador obtiene o deja de tener cobertura de aeguros de compenaaclbn pare trabajadores. tit1EA DIRECTA PARA REPORTAR CONDICIOPIES INSEGURA8: La DivIalón ha establecido una lines telefOnica gratulta las 24 horas, pare reportar condlclones inseguras en at lugar de trabajo que pudesen violar las Ieyes ocupaclonales de salud y seguridad. La lay prohibe que los empleadores suspendan, despldean 0 discrimtnen contra un empleado o empteada porque èl a ella, de buena fe, reports una presunta vlo%aclOn ocupaclonat do salud o seguridad. Comuniquese con Is Secclbn de Seguirdad y Salud at teléfono 1-800-452-9595. DVNcd 5 Afl EgICS2012 QOO151 ( Case 3:14-cv-00200-DCG Document 1 Filed 05/28/14 Page 76 of 110 NOTICE OF PRIVACY PRACTICES BY ThE SILVEROPTIONS WORK INJURY PLAN RELATING TO YOUR PERSONAL HEALTh INYORMJTION ) To be ditfrlbatadta ("PB]') all.eplpeu upon hire and eveiy three (3)teora. This NOTICE IS ABOUT HOW THE PLAN USES AND DISCLOSES YOUR MEDICAL INFORMATION, PRIVACY RIGH'IS AND HOW YOU CAN REVIEW SUCH INFORMATION. PLEASE REVIEW THIS CAREFULLY. I. USE AND DISCLOSURE p1ffl. This notice Is provided by W. Silver, Inc., Plan Sponsor and Plan Administrator for the Silveroptions Wotir Injury Plan ("Plan") ins manner designed to be consistent with the medical information privacy regulations issued by the Secre*aiy of Health and Human Services under the lieehh Insiasnoc Portability and Accountability Act of £996 ("HIPA.A") Although HIPAA may nut apply to this particularPlan, his the Plan's intent to mhweb, the privacy sad confidentiality ofyour health information and to comply with all applicable law, to include federal, te and local law. To that end, the Plan authorizes use cad thsclo.wi of the personal hmith iafmmatiott("Pm") of claimants and persons ("you" or "your") who report injuries or health conditions or wake claims under the Plan within the guidelines end rsstrk*ions explained below. (a) Scan. of disdeaurea, The Plan authorlam disclosure of your PHI to tain persons employed or hired by the Plan Sponsor to cemy out various plart administration timotions for the Plan. The Plan Sponsor will not use PHI for any purpose other than that related to the administration of the Plan, unless there Is written permission from you (or your authorized rapresenretive), or unless there isa Legal right or obligation In do so. For example, PHI related solely to a claim under the Plan will not be used by the Plan Sponsor In Its capacity as your purposes, unless there is written permission. Pill disclosures will be employer for personnel matters or other unrelated limited to the minimum amount of Information neceumay for e.ch person to carry out his or her role In plan and d*im administration only, arid that which Is either ipecificuDy authorized in wrlth,g by you (or your authorized representative) or Is otherwise coosisamt with the following disclosures, which see permitted by rule without written consent: ( ) 1. DIrect disciesue to you crycir designated representative or relative. 2. Disclssarns .etad to medical treatment and its coordination, management, preapprovaJ, second opinions sod referrals mid confurels with other healthmec providers. For example, this might involve the Plan infonning your Provider ofthe name of a specialist that you already saw, so that die Provider could request records or information from that specialist 3. Disclosures related to the psymeat of bills, including Plan reimbursement, coordination of benefits, sidiroption, review of medical necessity, utilimtion review, pro-approval and related coverage determinations. For emmple, this might Involve the Plan Informing your Provider of whether or not there is coverage foe treatment cad what level of coverage is provided under the Plan. 4. Dtseloasires for health ears operations such as quality control and administrator supervision, risk analysis and management, compliance with underwriting and innirsoce application or claim hives*iptioa activities, legal and safety review, audit or analysis, customer and claim service planning, developreant and and In order to de.identWy ceatain PHI. For example, this might Involve die Plan abmitig Information about your treatment to an auditor or consultant to project fittere costs or to amass the efficiency ofbenefit administration. 5. DIsclosures to regulakny agencies. For example, the Occupational Safety & Health Administration ("OSHAI; the Texas Department of insurance, Division ofWorkers' Compensation ("IDI-DWC") or the Department ofHealth & Human Services C'DI(HSI, pursuant to applicable regulations or legal process. Jescensan sad Persia (b) whme PHI may be dinl"d. Pill may be disclosed to the Benefits Administrator, bitiber asSistants or designena, as well as the Plan Sponscr' ienlor management designated to mçcrvrss the Benefits Adinittintator to benefits under the Plan and to comply with applicable law. See the Plan's Sununary Plant Description for details about the Benefits Administrator and plan administration. Limited disclosures may also be made to pomona consistent with the equlemeatsof the Plan and Its privacy end confidentiality tul.s. Such other recipients ofPHI may include, but me not limited to, those in Judicial and administrative proceedings(Including, but not linuted to, dii parties to a legs1 ectien or ciabo relating to your injury or Benefits wider the Plan. and any of those cbmged with reviewing and deciding any internal appeal you may file regerding claim or Plan decisions), safety representatives and upeclalista and security pomcemnol. healdecere professionals, plan eccownanta, attorneys and conaneilsuts, adjustors snd other business associates so that they cmi perfoun igreed upon services for the Plan, end In certain cbmmistances, to insurers (If any) of the Plan Sponsor or the Plan and their auditors, underwriters and agents, as well as to others designated as recipients of PHI. ) ( Notice Of Privacy Prscticea o ccpht 2012 Co.istangv. Smoke & Seetik L1.P Case 3:14-cv-00200-DCG Document 1 Filed 05/28/14 Page 77 of 110 ( _J Other purposes for which your PHI may be used or diaciceed Include public health activities, health oversight acdvt*Ies authorlmd or required by law or customary practices (audi an audits, investigations and roporthig), law erforcerrient purpose; to respond to a perceived serious threat to health or ualbty, specialized govànmont functiocs, national emsrgaicies or disaster,, state or national security and Intelligence activities, military or governmental service inquiries, and the like. The above is not Intended to be an exhaustive list of all purposes and pessocs fcc which the Plan may use or disclose your PHI, but rather Is intended to provide erraraplea to you. aerfre. (c) Diadusare and ma'.blab 'sea The Plan will not make use cc disclosure ofyour PHI accept as provided in this notice, unless you luthotini it hr writing. At any time you may reveke your mrthcrlioo by giving written notice to the Benefits Admitilatratce. Upon receipt the Plan will dixontinue its use or dinclojure based cc the reasOns hi your wrl authorjreton. However, the Plan may still use and disclose your PHI for other reasons as provided in this notice, it may retain all Infonnadosi already In he records, and the Plan has no obligation (and often, no ability) to take back any prior use or disclosureS which ocëwred with your frlorpmmlasioir. (d) Ceafldsndefltv sad asearfiv °fljt. The Plan Sponsor nminzanre files and records of your PHI which are maintained bra aãcwi location, ieiSte frOm your EOrplo)er's personnel file or other iwthic borneo resource records so that they remain craifidenfial and undisclosed, accept as described in this notice. Your PHI maintained by the Plan is restricted to access by persons with a right and need to use or access Plan records consistent with applicable laws and regulations. £iJjyaynrnadc. (a) The Plan reserves the tight to change its practices regarding PIll, privacy and confidandality and to revise this notice at any time. such change occurs, the revised notice will be effcctive as to the information the Plan already has about you as well as any inlbrmation it has thereafter. You will be given timely notice of such changes as required by applicable law, usually by no later then shay (60) days alter any material change to the notice or the Pise. (f) If Re,aodflcetinn The Plan will provide you with a currant notice at least every three (3) ysess. JNDflqDUM PRIVACY PIGRTS CbL (a) As a an. ew a ,..1tt. resaeat to the Benefits Administrator regarding the matters listed below. The Binethi Administiator will respond to yorz written Inquiries, requ and quOmons within a reasonable lime. You may make the foU -- ) - I. 2. 3. To propose in writing that the Plan limit the use or disclosure of your P141, or that the Plan communicate with you by alternative means or locetioris, if such request is reasonable and clearly states a need fec the aliamativea (eg, that you would be erularigered otherwise). In certain clrcienstances, the Plan may not be obligated or able to comply with auth a request, as determined by the Benefits Administrator. For access to review or copy your PHI that Is kept for payment activitIes, subject to certain limitations if To amend or correct your PHI kept In Plan records you feel die Plan's records am incorrect or incomplete. Such a request is subject to denial, such as the PHI ii not kept for payment activities or is accurate. you are lttfesmned of this by the Plan, you may submit a stememer of disagreement to be added to your Plan records. The Plan may file a rebuttal to your statement if If 4. 5. (in list form) of disclosures of your PH] after 04/14/2004, subject to cxceptios and Include disclosures (a) for treatment, payment or certain testrictiore. For example, such a list would health care operations, (b) to you (or your representative), (c) to persona involved in your ome or payment for that care, or (d) which you authorized. For an accounting For a printed copy of this notice about yore PHI privacy rights, electronic copy of the notice. If for example you were provided only an Rinht of review. If you disagree with the decision of the Benefits Adnimistator In response to one or (b) more of your mqnmts in subrEragrsph (a) above, then you may request that the decision be reviewed on appeal using the tlmeframes and process explained for appeals of benefit decision, in the Plan's Summary Plan Destxiplion. Privas esamlainta. You may complain about possible privacy violations by writing to the Plan (C) Sponsors HIPAA Privacy Officer at P.O. Box 12904, El Paso, TX 79913. You may also submit a complaint to die Secretary ofthe DUllS. You will not be penalized for making audi aconiplaint Notice OfPrivacy Practices 0 Cop'pfghr 2012 Coiegw,, flroob & Sm1IF LLP OOOE3 (