WIBP (11.09)

ABC COMPANY

WORKPLACE INJURY BENEFIT PLAN

WIBP (11.09)

TABLE OF CONTENTS GENERAL INFORMATION .......................................................................................... 1 SECTION I DEFINITIONS Accident or Accidental........................................................................... 1 Beneficiary .......................................................................................... 1 Bodily Injury ...................................................................................... 2 Covered Employee .............................................................................. 2 Cumulative Trauma .............................................................................. 2 Disease .............................................................................................. 2 Disability or Disabled ........................................................................... 2 Effective Date ..................................................................................... 2 Elimination Period ............................................................................... 2 ERISA Plan ......................................................................................... 2 Hospital ............................................................................................. 2 Hourly Wage ...................................................................................... 3 Medical Expense .................................................................................. 3 Medically Necessary ............................................................................. 3 Nuclear Material .................................................................................. 3 Nurse ................................................................................................. 3 Occupational Disease ........................................................................... 3 Occurrence ......................................................................................... 4 Physician ........................................................................................... 4 Plan Benefits ...................................................................................... 4 Pre-existing Condition........................................................................... 4 Rehabilitation ..................................................................................... 4 Scope of Employment .......................................................................... 4 Skilled Nursing Facility .......................................................................... 4 Usual and Customary ........................................................................... 5 Weekly Indemnity ................................................................................ 5 SECTION II REQUIREMENTS FOR ELIGIBILITY Eligibility to Participate ......................................................................... 5 Cessation of Participation ..................................................................... 5 Miscellaneous Requirements .................................................................. 5 Subrogation ....................................................................................... 8 Reimbursement .................................................................................. 8 SECTION III LIMIT OF BENEFITS Medical Expense .................................................................................. 9 Weekly Indemnity ............................................................................... 9 Other Coverage and Coordination of Benefits ........................................... 9 Accidental Death, Dismemberment and Loss of Use .................................10 SECTION IV ADMINISTRATION Duties of the Plan Administrator ............................................................11 Duties of a Claims Administrator ...........................................................12

WIBP (11.09)

Notification of Adverse Benefit Determination..........................................12 Appeal of an Adverse Benefit Determination ...........................................14 Review of Adverse Benefit Determination ...............................................14 Notification of Benefit Determination on Review ......................................15 SECTION V AMENDMENT AND TERMINATION Amendment to the Plan .......................................................................16 Termination of Plan ............................................................................16 SECTION VI ADOPTION OF PLAN BY EMPLOYERS Adoption Procedure .............................................................................16 Effect of Adoption by Employer .............................................................17 Obligation of Employer ........................................................................17 SECTION VII MISCELLANEOUS Non-alienation of Benefits ...................................................................17 No Contract of Employment .................................................................17 Severability of Provisions .....................................................................17 Heirs, Assigns and Personal Representatives ..........................................17 Headings and Captions ........................................................................18 Gender and Number ...........................................................................18 Controlling Law ..................................................................................18 Title to Assets ....................................................................................18 Expenses ..........................................................................................18 Voluntary Payments: No Admission of Liability ........................................18 Information to be Furnished .................................................................18 Limitation of Right ..............................................................................18

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ABC COMPANY

WORKPLACE INJURY BENEFIT PLAN

General Information

ABC Company (“Company”) has adopted and established this Workplace Injury Benefit Plan for the exclusive benefit of employees of the Company, whose principal place of employment and residence, is in the State of Texas. The Company has elected to opt out of the Texas Workers’ Compensation Act for its Texas employees and has adopted this Workplace Injury Benefit Plan to provide the benefits set forth herein.

The effective date of this Plan is stated in the Schedule of Benefits, and it supersedes any and all prior Workplace Injury Benefit Plans, pertaining to the subject matter hereof, and all prior programs or policies of the Company concerning benefits for a bodily injury, occupational disease or cumulative trauma. Eligible covered employees who sustain a bodily injury, occupational disease or cumulative trauma while the Plan is in effect may be provided benefits in accordance with the terms and conditions of the Plan.

The purpose of the Plan is to provide a comprehensive level of benefits which will include payment for medical expenses, weekly indemnity (wage replacement benefits) during convalescence, as well as benefits in the event of Accidental Death, Dismemberment and Loss of Use for a covered employee who sustains a bodily injury, occupational disease or cumulative trauma as defined by the terms of this Plan. All benefits provided under this Plan will be paid from the general assets of the employer. No employee contributions are used or allowed. The employer has the right to obtain insurance contracts with one or more insurers to provide funds to the employer to pay certain benefits under the Plan. SECTION I DEFINITIONS The following terms shall have the following meaning when used in this Plan, whether capitalized or in bold font or not: Average annual earnings means the covered employee’s weekly wage multiplied by fifty two (52). Accident or Accidental means an event which:

1. was sudden, unforeseen, unplanned or unexpected; 2. occurred at a specifically identifiable time and place; and 3. occurred while this Plan was in effect.

Beneficiary means the person or persons eligible for death benefits as designated in writing by the covered employee. If there is no beneficiary designated, payment will be made in the following order of priority:

1. to the covered employee’s spouse;

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2. if none, to the covered employee’s living children (whether natural or legally adopted);

3. if none, to the covered employee’s estate. Bodily Injury means an identifiable physical injury to a covered employee, including resulting death, caused by an accident that occurs within the scope of employment. Bodily injury includes occupational disease or cumulative trauma that arises from an accident. Concurrent Care Decision means a decision by the Plan Administrator to terminate or reduce (other than by Plan amendment or termination) a previously-approved course or number of treatments to be provided to the covered employee over a period of time before the end of such period of time or number of treatments. Continuous care means the weekly, monthly, bi-monthly or quarterly monitoring and/or evaluation of the covered employee’s disability by a physician. Covered Employee means a person who, at the time of an occurrence, is employed in the regular business of, and receives his or her pay on a regular basis by means of a salary, wage, or commission directly from the employer as reported to the Internal Revenue Service. Covered employee does not include an independent contractor, leased employee, or third-party agent. Covered employee includes only those persons who, at the employer’s direction, work in Texas, or temporarily (less than 90 consecutive days) outside of Texas, in the employer’s regular business. The Covered employee must be acting within his or her scope of employment at the time and place of the occurrence causing the bodily injury. Cumulative Trauma means damage to the physical structure of the body of a covered employee occurring as a result of repetitious, physically traumatic activities that occur within the scope of employment with the employer while this plan is in effect. Cumulative trauma does not include bodily injury or occupational disease. Disease means a condition marked by a pronounced deviation from the normal healthy state or normal pregnancy of a covered employee. Disability or Disabled means bodily injury, occupational disease or cumulative trauma resulting from an occurrence which causes the covered employee to be unable to perform the material duties of the occupation, business or employment which the covered employee held at the time of the bodily injury. The covered employee must be under the continuous care of a physician during the period of disability. Effective Date means the date stated as the effective date of the Plan in the Schedule of Benefits. Elimination Period means the number of consecutive working days after accidental bodily injury occurs during which the injured covered employee must be disabled, but for which no weekly indemnity is payable. A working day is considered any day on which the covered employee would normally be at work. The elimination period is specified in the Schedule of Benefits in effect on the date of the occurrence. Employer means the Company and its affiliate or subsidiary companies that adopt this Plan pursuant to its terms.

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ERISA Plan or Plan means the Workplace Injury Benefit Plan, complying with the federal Employee Retirement Income Security Act of 1974, as amended, ("ERISA") that provides occupational injury benefits to covered employees. Hospital means a lawful institution that:

1. is licensed and operated according to the law of the jurisdiction in which it is located pertaining to hospitals for the care and treatment of sick and injured persons;

2. is open at all times; 3. functions chiefly for the care and treatment of sick and injured persons as admitted

inpatients; 4. is supervised by one or more licensed physicians at all times; 5. provides 24 hour services of nurses; and 6. has on its premises or available on a prearranged basis, organized facilities for

diagnosis and major surgery. An institution which provides for the care and treatment of mentally ill, emotionally ill or retarded persons, or persons confined for alcoholism or substance abuse may be considered a hospital, whether or not it has organized facilities on the premises for major surgery, so long as it meets the rest of the requirements listed above. Hourly Wage, for purposes of calculating a weekly wage, means the actual hourly rate paid to a covered employee during the most recent six weeks period, or shorter period if employed less than six weeks, prior to the occurrence giving rise to the bodily injury, cumulative trauma, or occupational disease. For salaried covered employees, the hourly wage shall be the salary paid to the covered employee during the most recent six weeks period, or shorter period if employed less than six weeks, prior to the occurrence, divided by the number of work hours applicable to that salary if known, or by forty (40) hours per week, if not known. For covered employees paid on commission, the covered employee’s hourly wage shall be his or her annualized compensation for the proceeding year divided by fifty two (52) to arrive at an average weekly compensation. That average weekly compensation will then be divided by forty (40) to determine the covered employee’s hourly wage for purposes of calculating a weekly wage. Medical Expense means a covered employee’s expense for medical or dental services, procedures or supplies, provided the expense is medically necessary, usual and customary and prescribed by a physician or dentist acting within the scope of his license. Medical expense includes confinement within a hospital or skilled nursing facility and the cost of medically necessary supplies and ambulance hire and those expenses incurred for rehabilitation. Medically Necessary means medical services, procedures or supplies that are:

1. required, recognized and professionally accepted nationally by physicians or dentists as the usual, customary and effective means of diagnosing or treating the condition;

2. the most economical supplies or levels of service that are appropriate and available for the safe and effective treatment of the covered employee; and

3. not primarily for the convenience of the covered employee, the covered employee's family or the covered employee's physician or other provider of medical services, supplies or procedures.

Even if the service, supply or procedure is medically necessary, this Plan will not cover services, procedures or supplies excluded under this Plan. Nuclear Material means “source material”, “special nuclear material” or “by-product material”, as these terms have been given meaning in the U.S. Atomic Energy Act of 1954 or in any law amendatory thereof.

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Nurse means a Registered Nurse (RN), Licensed Practical Nurse (LPN), Licensed Vocational Nurse (LVN) or person currently licensed as a nurse in the state in which the service was performed, practicing within the scope of such license. Occupational disease means a disease arising out of a covered employee's assigned duties in his/her scope of employment while this Plan is in effect that causes damage or harm to the physical structure of the body. Occupational disease does not include bodily injury or cumulative trauma. Occupational disease does not include ordinary diseases of life to which the general public is exposed outside of a covered employee's assigned duties in his scope of employment or a disease resulting directly from an accident. Occurrence means an accident or series of related accidents resulting in bodily injury to a covered employee that arises out of the covered employee’s scope of employment. As respects occupational disease or cumulative trauma, occurrence means the covered employee’s last date of last exposure to the conditions causing or aggravating such occupational disease or cumulative trauma. Physician means a duly qualified doctor of medicine or osteopathy who is legally licensed to practice medicine in the state where the service is performed. Plan Benefits means those benefits actually paid under the terms and conditions of this ERISA Plan for injuries that arise out of an occurrence. Post Service Claim means a claim for medical benefits which was submitted after the date the covered employee obtained the medical care for which plan benefits are sought. Pre-Existing Condition means a health condition for which a covered employee has sought or received medical advice or treatment at any time during the 90 days immediately preceding an occurrence. Pre-Service Claim means a claim for medical benefits which, under the terms of this plan requires approval of the benefits in advance of obtaining medical care. Rehabilitation means only those procedures that are performed for the purpose of restoring the function of motion, speech or vision lost as a result of bodily injury, occupational disease or cumulative trauma. Rehabilitative status means the period of time after an occurrence during which the covered employee is released to return to part-time or light-duty work by a physician or other healthcare provider, and due to the covered employee’s bodily injury, cumulative trauma or occupational disease, is not able to perform all of the duties of his or her job he or she performed prior to the occurrence, is able only to perform those duties on less than a full-time basis, or is able only to perform other limited, part-time or alternative work. Schedule of Benefits means the document bearing that title and distributed with the Summary Plan Description related to this plan. The Schedule of Benefits may be changed from year to year, at the Company’s discretion. Any changes to the Schedule of Benefits will only apply to occurrences occurring on or after the effective date of the Schedule of Benefits as stated therein. Scope of Employment means an activity of any kind or character that involves the furtherance of the employer’s business, trade or profession at the employer’s regular

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workplace(s) in Texas or while temporarily away from such regular workplace in furtherance of the employer’s business, trade or profession. Scope of Employment does not include transportation to and from the employer’s regular workplace, unless:

1. the transportation is furnished as a part of the contract of employment, or is paid for by the employer, or the means of such transportation are under the employer’s control; or

2. the covered employee is directed in his scope of employment by the employer to proceed from one place to another place.

Skilled Nursing Facility means a section, ward or wing of a hospital or a freestanding healthcare facility that:

1. provides room and board; 2. provides nursing care by or under the supervision of a nurse; 3. provides physical, occupational and speech therapy furnished by the facility or by

others under arrangements made by the facility; 4. provides medical social services; 5. provides drugs, biologicals, supplies, appliances and equipment ordinarily furnished

for use in such a facility; 6. provides medical services by staff physicians; 7. has an agreement with a hospital for diagnostic and therapeutic services, the

transfer of patients and exchange of clinical records; 8. provides other services necessary to the health and care of patients that are

generally provided by such facilities; and 9. is licensed or registered in accordance with local and state laws and regulations.

Urgent Care Claim means a claim for medical benefits which involves requested treatment for a condition which:

1. could seriously jeopardize the life or health of a covered employee or the ability of a covered employee to regain maximum function; or

2. in the opinion of a physician with knowledge of the covered employee’s condition, would subject the covered employee to severe pain that cannot be managed or controlled without the care that is the subject of the claim.

Usual and Customary means the expense is: 1. usual when it is the fee regularly charged that the patient is responsible to pay, in

the absence of insurance or other third party reimbursement, to a health care provider or physician for a given treatment, service or supply; and

2. customary in relation to what other physicians and health care providers in the same geographic area charge for the same and similar treatment, service or supply.

Weekly Indemnity means the wage replacement benefit payments paid to a covered employee under the terms and conditions of this Plan as a result of a disability. Weekly Wage means the covered employee’s hourly wage multiplied by forty (40).

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SECTION II REQUIREMENTS FOR ELIGIBILITY

Eligibility to Participate Each employee who was a covered employee on the effective date shall be eligible to participate in the Plan on the effective date. Each other employee shall be eligible to participate in the Plan as of the later of:

1. the date he or she is employed by the employer; or 2. the date on which he or she is classified as an employee by the employer.

Cessation of Participation A covered employee will cease to be a covered employee in the Plan, and no plan benefits will be paid, with respect to an occurrence which occurs after the earlier of:

1. the date on which the Plan is terminated; or 2. the date on which the covered employee is no longer an employee of the employer;

or 3. the date on which the covered employee provides written notice of withdrawal from

the Plan to the Plan Administrator.

Miscellaneous Requirements In order to receive payment of any benefits under this Plan, the covered employee must report every occurrence which the covered employee believes resulted in bodily injury, occupational disease or cumulative trauma. The report must be made immediately (by the end of the scheduled workday and/or the end of the scheduled shift on the day of the occurrence) to the covered employee’s Manager, Supervisor or other person in charge at the time. That person will then assist the covered employee in obtaining necessary medical treatment and in completing required report forms. A covered employee shall only be eligible for payment of benefits if the covered employee follows the procedures and policies set forth below. The first eligible charge must have been incurred within ninety (90) days of the date of the occurrence causing the bodily injury, occupational disease or cumulative trauma and only expenses which are medically necessary and usual and customary in amount and directly related to the bodily injury, occupational disease or cumulative trauma shall be payable under the Plan. To be eligible for payment, any post-service claim must be submitted by the covered employee within thirty (30) days after the date on which the medical expenses were billed to the covered employee. The Company will designate one or more physicians to administer medical treatment to a covered employee and the Company may change designated physicians at any time. Except as provided above, benefits shall not be paid under this Plan for treatment received from a health care provider that has not been designated as a physician in accordance with this Plan. Other than those required on an emergency basis, all medical procedures, including surgeries and rehabilitation procedures must be pre-approved as Pre-Service claims by the Plan Administrator, or Claims Administrator (if any) in order for the charges for such services to be eligible for payment under this plan. Contact information for the Claims Administrator (if any) is contained in the Schedule of Benefits.

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The covered employee must notify the employer of his or her expected recovery time immediately after primary medical treatment and after each succeeding appointment with a physician.

The covered employee must follow fully and completely the advice and course of medical treatment prescribed by a physician. The covered employee must keep and attend all scheduled appointments to fulfill the prescribed medical treatment plan. The covered employee shall be required to submit to drug and/or alcohol testing as requested by the employer. The covered employee shall be required to submit to examination by a physician of the Plan Administrator’s choice as often as is reasonably necessary. No benefits shall be provided, or benefits shall immediately terminate, with respect to an occurrence under the Plan for any loss or claim arising out of:

1. any workers' compensation law, unemployment compensation law, disabilities benefits law or other similar law.

2. an intentionally self-inflicted bodily injury, occupational disease or cumulative trauma, while either sane or insane, or bodily injury, occupational disease or cumulative trauma intentionally caused or intentionally aggravated by a covered employee.

3. a covered employee's participation in: a. an assault or a felony, except an assault committed in defense of the

employer’s persons, business or property; b. any illegal act; or c. service in the military of any country or any civilian non-combatant unit

serving with such forces. 4. directly or indirectly, contributed to, caused by, resulting from, or in connection with

any of the following regardless of any other cause or event contributing concurrently or in any other sequence to the loss:

a. war, invasion, acts of foreign enemies, hostilities, or warlike operations (whether war be declared or not), civil war, mutiny, revolution, rebellion, insurrection, uprising, military or usurped power, confiscation by order of any public authority or government de jure or de facto, martial law; or

b. riots, strikes, or civil disturbance. This exclusion also excludes benefits related to an occurrence directly or indirectly arising out of, contributed to, caused by, resulting from, or in connection with any action taken in controlling, preventing, suppressing, retaliating against, or responding to a. or b. above. 5. any diagnostic procedure, treatment, service or supply which is not medically

necessary. 6. that part of any medical expense that is in excess of the usual and customary

charge for that good, product, or service. 7. or occurring while the covered employee was under the influence of alcohol. 8. or occurring while the covered employee was under the influence of any chemical

substance that was obtained or consumed in violation of the U.S. Controlled Substances Act in force at the time and location of the occurrence.

9. exposure to the following: a. asbestos, asbestos fibers or asbestos containing products; b. silicon or silica; c. mold, microbes or fungus; d. the hazardous properties, including radioactive, toxic or explosive

properties, of nuclear material except nuclear or radiological medicine which is:

i. used for patient care and diagnosis;

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ii. approved by OSHA, JCAHO, or the American Hospital Accreditation Association; and

iii. not used for research purposes or clinical tests. 10. a heart attack, unless the heart attack was proximately caused by and arose out of

an accident. 11. charges for:

a. biofeedback and other forms of self-care or self-help training or any related diagnostic testing;

b. hypnosis, acupuncture, or chiropractic treatment unless referred by a physician;

c. the purchase, rental or repair of environmental control devices, including but not limited to, air conditioners, humidifiers or air purifiers; or

d. services performed by a person who normally lives with an injured covered employee, the spouse of an injured covered employee, a parent of an injured covered employee or the injured covered employee's spouse, a child of the injured covered employee or the injured covered employee's spouse or a brother or sister of the injured covered employee or of the injured covered employee's spouse.

12. a covered employee's participation in any recreational, social or athletic activity not constituting part of the covered employee's scope of employment, whether or not such participation occurs on the employer’s premises or during normal business hours.

13. any pre-existing condition. 14. a covered employee’s failure to comply with any of the requirements or provisions of

the Plan. 15. a covered employee’s failure to report for work immediately upon being released

(whether for full duty or to work on rehabilitative status) by a physician or other qualified healthcare provider.

Subrogation If the Plan pays or provides benefits for a bodily injury, occupational disease or cumulative trauma that was caused by an act or omission of any person or organization other than employer, the Plan will be subrogated to all of the covered employee’s rights of recovery to the extent of such benefits provided or the reasonable value of services or benefits provided by the Plan, including those rights of recovery against underinsured/uninsured automobile insurance coverage or no fault insurance coverage, such as personal injury or medical payments protection. Upon receiving any benefits from the Plan, the covered employee is considered to have assigned his/her rights of recovery to the Plan to the extent of such benefits. If the covered employee has retained an attorney to pursue his/her rights of recovery, the Plan is not responsible for paying any portion of his/her attorney’s fees or costs. The Plan’s rights will not be affected by any release affecting the Plan that is entered into without the written consent of the Plan Administrator. If the covered employee receives benefits under the Plan, he/she must immediately notify the Plan Administrator of the name of any individual or organization against whom he/she might have a claim as a result of his/her bodily injury, occupational disease or cumulative trauma (including any insurance company that provides coverage for the covered employee). For example, if the covered employee is injured in an automobile accident, and the person who hit the covered employee was at fault, the person who hit the covered employee (and his insurance company) is a person whose act or omission has caused the covered employee’s bodily injury, occupational disease or cumulative trauma. The covered

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employee must cooperate with the Plan to provide information about his/her bodily injury, occupational disease or cumulative trauma, and must agree to sign any necessary document for the Plan and provide all requested information sought by the Plan in furtherance of the Plan’s right to subrogate his/her claim. The Plan may:

1. place a lien against a third party or insurance company to the extent Plan benefits have been paid;

2. bring an action on its own behalf, or in the name of the covered employee, against the person, organization or insurance company; and

3. cease paying the covered employee Plan benefits until he/she provides the Plan with the documents necessary for the Plan to exercise its rights and privileges of subrogation.

Reimbursement If the Plan pays or provides the covered employee benefits for a bodily injury, occupational disease or cumulative trauma that was caused by an act or omission of an individual or organization, and/or if the covered employee has sought recovery from no fault insurance, the Plan has the right to be repaid first for any benefits from any settlement, judgment, or insurance proceeds the covered employee receives. The Plan has a right to reimbursement whether or not a portion of the settlement, judgment, or insurance proceeds was identified as a reimbursement of medical expenses. The covered employee agrees, by accepting benefits under the Plan, to provide the Plan with a lien, to the extent the Plan has paid benefits, to be filed with the responsible party or insurance company. If the covered employee does not reimburse the Plan from any settlement, judgment, or insurance proceeds, the Plan is entitled to reduce current or future benefits payable to the covered employee or payable on his/her behalf until the Plan has been fully reimbursed. Anyone receiving benefits under the Plan agrees that their spouse, children, estate, legal representatives, heirs, dependents and wrongful death beneficiaries will be bound to the subrogation and reimbursement provisions set forth above.

Other Coverage and Coordination of Benefits If any covered employee is covered under one or more other plans, including, but not limited to, insurance, indemnity or reimbursement, the benefits payable for expenses under this Plan shall apply only in excess of the other contract of insurance, indemnity or reimbursement. SECTION III LIMIT OF BENEFITS Subject to the limits listed on the Schedule of Benefits in effect on the date of the occurrence, the following limits shall apply for covered losses: Medical Expense Medical expense benefits are payable only for expenses which are eligible charges for treatment of a bodily injury, occupational disease or cumulative trauma. Medical expenses shall be paid by the Plan Administrator directly to a medical provider or to the covered employee as reimbursement for such expenses which have been paid directly by the covered employee to a medical provider. However, the first eligible charge must have been incurred within ninety (90) days of the date of the occurrence causing the bodily injury, occupational disease or cumulative trauma, and only expenses which are medically

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necessary and usual and customary in amount and directly related to the bodily injury, occupational disease or cumulative trauma shall be payable under the Plan. Medical expense, when combined with all other benefits paid under this Plan shall not exceed the Maximum Benefit Limit payable to any one covered employee for any one occurrence listed on the Schedule of Benefits in effect on the date of occurrence. Weekly Indemnity If a covered employee suffers a disability as the result of a bodily injury, occupational disease or cumulative trauma, the covered employee may be eligible for weekly indemnity benefits, subject to the elimination period and Maximum Weekly Disability Benefit Amount shown on the Schedule of Benefits in effect on the date of the occurrence, times the maximum weeks duration per covered employee per occurrence shown on that Schedule of Benefits. The disability must commence within:

1. 90 days after the date of the occurrence that caused the disability; or 2. 180 days after the date of the occurrence that caused the disability, provided:

a. the covered employee received medical treatment within 30 days from the date of the occurrence that caused the disability; and

b. the covered employee has remained under the continuous care of a physician. If an otherwise disabled covered employee returns to work for the employer while in rehabilitative status, he or she will be deemed continually disabled. Weekly indemnity will continue, however, such payment shall not exceed 100% of the disabled covered employee’s weekly wage. Weekly indemnity will continue up to a maximum of 12 months in any one period of disability while rehabilitative status continues. The Plan Administrator may require the covered employee to submit proof of continued disability and of continuous care. This may be done as often as the Plan Administrator considers necessary. Failure to submit the requested proof will result in suspension of weekly indemnity benefits until such proof is received. Accidental Death, Dismemberment and Loss of Use In the event a covered employee suffers a loss as listed in the schedule below, the covered employee or the covered employee’s beneficiary may be eligible for the lesser of 10 times the covered employee’s average annual earnings, or the amount as listed on the schedule below, for that loss, plus up to an additional $5,000 for burial costs in the event of death.

Death benefits payable to the covered employee’s beneficiary shall be paid as follows: 20%

lump sum as soon as administratively possible, and the remainder shall be paid in twelve (12) equal monthly installments (without interest) commencing on the first day of the month following the initial lump sum payment.

In the event of death or multiple losses, benefits will be paid for only the covered loss per covered employee with the largest benefit as specified below:

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Loss: Amount of Coverage: Stated as a percentage of the Maximum AD&D Benefit Limit in the Schedule of Benefits in effect on the date of occurrence Life ........................................................................................................ 100% Both Hands ............................................................................................. 100% Both Feet................................................................................................ 100% Sight of Both Eyes ................................................................................... 100% One Hand and One Foot............................................................................ 100% One Hand and Sight of One Eye ................................................................ 100% One Foot and Sight of One Eye .................................................................. 100% Speech and Hearing in Both Ears................................................................ 100% Use of Both Arms and Both Legs ................................................................ 100% Use of Both Arms or Both Legs.....................................................................75% Use of One Arm and One Leg.......................................................................75% Speech.....................................................................................................50% Hearing in Both Ears...................................................................................50% One Hand .................................................................................................50% One Foot ..................................................................................................50% Sight of One Eye........................................................................................50% Use of One Arm or One Leg .........................................................................50% One Thumb...............................................................................................25% If a bodily injury is covered as an accidental death or dismemberment, such bodily injury shall only be covered as an accidental death or dismemberment, and any benefit for the same bodily injury shall be applied to reduce the Maximum Benefit Limit per covered employee as shown in the Schedule of Benefits in effect on the date of the occurrence. SECTION IV ADMINISTRATION

The Company is responsible for administration of the Plan. The Plan Administrator shall be the person or persons, individual, corporate or otherwise, designated in writing by the Company. In the event that the Company does not designate a Plan Administrator, the Company will act as the Plan Administrator. An individual Plan Administrator will be indemnified by the employer against any and all liabilities arising by reason of an act or failure to act made in good faith and pursuant to the provisions of the Plan. The Company may remove a designated Plan Administrator at any time and either act as the Plan Administrator or name a successor. During any period in which the selection of an Administrator is pending, the Company will act as the Plan Administrator. ERISA requires that certain persons who are deemed “fiduciaries,” as defined in Section 3(21) (A) of ERISA, be designated as “Named Fiduciaries” in the Plan. The Plan Administrator is herby designated the Named Fiduciary and shall have only the powers, duties, and responsibilities specified by the Plan or delegated by the Company. The Named Fiduciary may designate another person or persons to carry out some of the Named Fiduciary’s duties. The Plan Administrator and each person designated by the Named Fiduciary will be furnished a copy of the Plan, and their agreement to carry out their responsibilities will be made in writing. No Named Fiduciary shall be liable for any act or omission of any person who is designated to carry out fiduciary responsibilities except to the

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extent that the Named Fiduciary did not act in accordance with the standard contained in Section 404(a) of ERISA with respect to allocation or designation, continuation thereof, or implementation or establishment of, the allocation or designation procedures. Duties of the Plan Administrator The Plan Administrator shall have all the powers necessary or appropriate to accomplish his duties under the Plan. The Plan Administrator shall have the discretionary power and authority to interpret the Plan to determine eligibility for participation, whether a bodily injury, occupational disease or cumulative trauma qualifies for benefits under the Plan, whether charges are usual and customary and medically necessary, eligibility of expenses for reimbursement under the Plan, and whether a covered employee has complied with Plan requirements. Except as required by ERISA, all determinations made by the Plan Administrator shall be final and not subject to review by anyone. The Plan Administrator shall interpret the Plan to ascertain the purpose of the provision or provisions in question and attempt to reasonably make application of the Plan with respect to the individual rights of the covered employee. During administration of the Plan, the Plan Administrator will exercise his authority in a non-discriminatory manner whenever he is required to make a discretionary decision so that all similarly situated covered employees will receive substantially the same treatment. The duties of the Plan Administrator shall include, but are not limited to:

1. Interpreting and construing the provisions of the Plan, deciding any disputes which may arise relative to the rights of a covered employee or his beneficiary under the Plan and directing the administration of the Plan;

2. Maintenance of complete and accurate records of all Plan transactions in a manner necessary for proper administration of the Plan and to meet any applicable disclosure and reporting requirements of ERISA;

3. Adoption of rules and procedures necessary for efficient administration of the Plan provided that the rules and procedures are consistent with the terms of the Plan;

4. Reviewing claims and rendering decisions on claims for benefits under the Plan; 5. Determining the eligibility of a claim for benefits under the Plan; 6. Enforcing the terms of the Plan and the rules or procedures that are adopted; 7. Ascertaining that the covered employee or their beneficiary received the benefits to

which they were entitled under the Plan; 8. Employing or appointing agents to manage or assist in the management of claims.

Duties of a Claims Administrator The Plan Administrator may appoint a third party as a Claims Administrator. The services and assistance of the third party Claims Administrator are provided pursuant to an agreement between the Company and the Claims Administrator. Notification of Adverse Benefit Determination In general, if any claim for disability benefits or medical expenses (including Urgent Care, Concurrent Care, Pre-Service, and Post-Service Claims) brought by a covered employee or a covered employee’s authorized representative under the Plan is:

1. wholly or partially denied; or 2. the Plan Administrator otherwise makes an adverse benefit determination as defined

in the Department of Labor regulations regarding claims procedures (in either case, referred to herein as an “adverse benefit determination”). See 29 C.F.R. & 2560.503-1(m)(4).

The Plan Administrator will notify the covered employee of the adverse benefit determination within a reasonable period of time, and no later than the time frame specified by ERISA.

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The notification of any adverse benefit determination must be in writing and may be delivered electronically. The initial notification shall be written in a manner to be understood by the covered employee and should include:

1. the specific reason or reasons for the adverse determination; 2. reference to the specific Plan provisions on which the determination was based; 3. a description or any additional material or information necessary for the covered

employee to perfect the claim and an explanation of why such material or information is necessary;

4. a description of the Plan’s review procedures, including a statement of the covered employee’s right to bring civil action under section 502(a) of ERISA following an adverse determination on review;

5. a description of any internal rule, guideline, protocol, or other criterion relied upon to make the adverse determination, and that a copy of such will be provided free of charge to the covered employee upon request;

6. an explanation of the scientific or clinical judgment for determining an adverse benefit determination based on the Plan’s limitations or exclusions for medically necessary or experimental treatment;

7. in the case of an adverse benefit determination concerning an Urgent Care Claim, a description of the expedited review process applicable to such claims.

The initial notification of an adverse benefit determination should be provided as soon as possible after receipt of the claim, but not later than the time frames specified as follows:

1. For Urgent Care Claims, if the covered employee fails to follow the plan’s procedures for filing the Urgent Care Claim, the covered employee will be notified of the failure and the proper procedures to be followed in filing a claim for benefits within twenty-four (24) hours following the failure. Notification may be oral, or in writing if requested by the covered employee. The initial notification of an adverse benefit determination on an Urgent Care Claim must be made within 72 hours. The initial notification may be provided orally, provided that a written notification is furnished to the covered employee no later than 3 days after the oral notification. If an Urgent Care Claim requires additional information in order for the Plan Administrator to render a decision, the Plan Administrator must notify the covered employee of the specific information necessary to complete the claim within twenty-four (24) hours of receipt of the Urgent Care Claim. The Plan Administrator will permit the covered employee at least forty-eight (48) hours to provide the specific information. The Plan Administrator must render a decision on an Urgent Care Claim that required additional information no later than forty-eight (48) hours after the earlier of the receipt of the additional information or the end of the time period the Plan Administrator gave the covered employee to provide the additional information.

2. For Pre-Service Claims, if the covered employee fails to follow the plan’s procedures for filing the Pre-Service Claim, the covered employee will be notified of the failure and the proper procedures to be followed in filing a claim for benefits within five (5) days following the failure. Notification may be oral, or in writing if requested by the covered employee. The initial notification of an adverse benefit determination with respect to a Pre-Service Claim must be made within 15 days. In the event circumstances outside of the Plan Administrator’s control require an extension of the period for rendering a decision and provided the Plan Administrator notifies the covered employee of the need for the extension prior to the expiration of the initial 15-day period, the period for determining the eligibility of the requested care may be extended one time for up to fifteen (15) days. If such an extension is necessary due to a failure of the covered employee to submit the information necessary to decide the claim, the notice of extension shall specifically describe the required

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information, and the covered employee shall be afforded at least 45 days from receipt of the notice within which to provide the specified information. In the event a covered employee is notified of the need for additional information, the time period for processing the claim will not begin to run again until the additional information is received from the covered employee or the covered employee’s authorized representative.

3. For Post-Service Claims the initial notification must be made within 30 days. This period may be extended one time for up to 15 days, due to matters beyond the control of the Plan Administrator and provided notice is given to the covered employee prior to the expiration of the initial 30-day period of the circumstances requiring the extension and the date by which the Plan Administrator expects to render a decision. If the extension is necessary because the covered employee failed to submit information necessary to decide the claim, the notice of extension shall specifically describe the required information, and the covered employee shall have at least 45 days from receipt of the notice to provide the specified information.

4. For Concurrent Care Decisions the initial notification will be made at a time sufficiently in advance of the reduction or termination of the covered employee’s ongoing course of treatment to allow the covered employee to appeal and obtain a determination on review of that adverse benefit determination before the benefit is reduced or terminated. Any request by a covered employee to extend the course of treatment beyond the period of time or number of treatments that meets the definition of an Urgent Care Claim shall be decided as soon as possible. The Plan Administrator shall notify the covered employee of the benefit determination on such Concurrent Urgent Care Claim, whether adverse or not, within 24 hours after receipt of the claim by the Plan Administrator, provided that any such claim is made to the Plan Administrator at least 24 hours prior to the expiration of the prescribed period of time or number of treatments.

5. For Disability claims, the initial notification must be made within 45 days. In the case of a claim regarding disability benefits, if the Plan Administrator determines that an extension of time for processing the claim is necessary due to matters beyond its control, the Plan Administrator may extend the initial 45-day period for up to 30 days, provided it gives the covered employee written notice of such extension within the initial 45-day period. If, prior to the end of the first 30-day extension period, the Plan Administrator determines that, due to matters beyond its control, a decision cannot be rendered within that extension period, such determination period may be extended for a second period of up to an additional 30 days, provided it gives the covered employee written notice of such extension within the first 30-day extension period. The extension notice shall indicate the special circumstances requiring an extension of time and the date by which the Plan Administrator expects to render the determination. The extension notices for processing a claim for disability benefits will contain:

a. the special circumstances requiring an extension of time; b. the date by which the Plan Administrator expects to render a decision; c. a specific explanation of the standards on which entitlement of a benefit is

based; d. the unresolved issues that prevent a decision on the claim; and e. the additional information needed to resolve those issues.

The covered employee will be afforded at least 45 days within which to provide the additional specified information. In the event a covered employee is notified of the need for additional information, the time period for processing the claim will not begin until the additional information is received from the covered employee or his authorized representative.

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Appeal of an Adverse Benefit Determination A covered employee may appeal an adverse benefit determination within 180 days after the date on which a covered employee receives a written notice of the determination. The appeal must be in writing and should include comments, documents, records, and other information relating to the claim for benefits that the covered employee desires the Review Committee to consider for a review of the adverse benefit determination. The covered employee, upon request and free of charge, may have reasonable access to, and copies of all documents, records, and other information relevant to the covered employee’s claim for benefits. Review of Adverse Benefit Determination The appeal for an adverse benefit determination will be reviewed by the “Review Committee”: One or more persons appointed by the Plan Administrator to review and determine all requests for review of a denial of benefits. The Review Committee, at its option, can consult outside firms or internal resources with expertise in regard to benefits as the Review Committee deems necessary or appropriate. A decision will be rendered within 72 hours after the request for review is received for an Urgent Care Claim, and within 30 days for Pre-Service Claims. A decision will be rendered on Concurrent Care and Post Service Claims within 60 days, and within 45 days on disability claims, unless the Review Committee determines that special circumstances require an extension of time for processing the claim. If the Review Committee determines that an extension of time for processing is required, written notice of the extension shall be furnished to the covered employee prior to the termination of the initial 60-day period (or 45-day period for disability claims). In no event shall such extension exceed a period of 60 days from the end of the initial period (or 45 days for disability claims). The extension notice shall indicate the special circumstances requiring an extension of time and the date by which the Review Committee expects to render the determination on review. The Review Committee will review the appeal of a denied Urgent Care Claim as soon as possible, taking into account the medical exigencies, but not later than seventy-two (72) hours of receipt of the appeal, and render a decision on the appeal within such time period. In reviewing an adverse benefit determination on an Urgent Care Claim, the Review Committee will provide the covered employee with an expedited review process pursuant to which a request for an expedited appeal of an adverse benefit determination may be submitted orally or in writing by the covered employee, and all necessary information, including the Review Committee’s benefit determination on review shall be transmitted between the Plan and the covered employee by telephone, facsimile, or other available similarly expeditious method. The Review Committee will provide a full and fair review of the claim, taking into account all comments, documents, records, and other information submitted by the covered employee relating to the claim, without regard as to whether such information was submitted or considered in the initial benefit determination. In conducting its review of an adverse benefit determination, the Review Committee will not afford deference to the initial adverse benefit determination, and the review will not be conducted by the individual who made the initial adverse benefit determination or by the subordinate of such individual.

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In reviewing an adverse benefit determination that is based in whole or in part on a medical judgment, including determinations, if applicable, with regard to whether a particular treatment, drug, or other item is experimental, investigational or not medically necessary, or that a requested service does not constitute appropriate care, the Review Committee will consult with a health care professional who has appropriate training and experience. Any such health care professional will not be the individual who was consulted in connection with the initial adverse benefit determination or the subordinate of such individual. In reviewing an adverse benefit determination on a claim for benefits, the Review Committee will provide the covered employee with the identification of medical or vocational experts whose advice was obtained on behalf of the Review Committee in connection with the appeal of the covered employee’s adverse benefit determination, regardless of whether the advice was relied upon in making the benefit determination. Subject to the foregoing, the Review Committee may, in its discretion, hold a hearing to make a benefit determination. Notification of Benefit Determination on Review The Review Committee will notify the covered employee of its decision on the appeal in writing. The Review Committee will notify the covered employee of its decision within a reasonable period, but not later than 5 days after the decision is made. The decision of the Review Committee on an appeal claim for disability Benefits or Medical Benefits (including Urgent Care, Concurrent Care, Pre-Service, and Post-Service Claims) will be in writing, and will be written in a manner to be understood by the covered employee, and will include:

1. the specific reason or reasons for the adverse determination; 2. reference to the specific Plan provisions on which the determination was based; 3. statement that the covered employee is entitled to receive upon request and free of

charge, reasonable access to, and copies of all documents, records, and other information relevant to the covered employee’s claim for benefits;

4. if an internal rule, guideline, protocol, or other criterion was relied upon to make the adverse determination, a statement that the covered employee is entitled to a copy of such rule and it will be provided free of charge upon request;

5. if the determination was based upon the Plan’s limitations or exclusions for medically necessary or experimental treatment, it has been so stated, and a detailed scientific or clinical explanation of this judgment will be provided free of charge upon request;

6. a statement that the covered employee may have other voluntary alternative dispute resolution options, such as mediation and one way to find out what may be available is to contact the local U.S. Department of Labor or the Plan Administrator;

7. a statement that the covered employee has the right to bring civil action under Section 502(a) of ERISA following an adverse determination on review.

SECTION V AMENDMENT AND TERMINATION

Amendment to the Plan The provisions of this Plan may be amended at any time and from time to time by the Company; provided, however, that no amendment shall deprive any covered employee or beneficiary of any of the benefits to which he or she is entitled under this Plan and which

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have become payable under the terms of this Plan. Each amendment shall be approved by resolution of the governing authority of the employer, and unless expressly provided otherwise, the employer shall be bound by any amendment adopted. Each employee shall be sent a copy of any material amendment to, or modification of, the Plan and shall be presumed to have consented thereto unless the employee withdraws as a covered employee in the Plan, in writing and delivered to the Plan Administrator within 30 days after receiving written notice of the modification or amendment. Termination of Plan The employer may elect, at any time and without advance notice or delay, to terminate this Plan and re-enter the statutory workers’ compensation system of the State of Texas. Furthermore, this Plan shall terminate if state law is changed such that it becomes unlawful to do business without subscribing to statutory workers’ compensation and/or for such other reasons that may make the Plan null and void. In the event the Plan is terminated, the benefits payable at the time of termination shall continue to be paid pursuant to the provisions of the Plan at the time of termination. SECTION VI ADOPTION OF PLAN BY EMPLOYERS

Adoption Procedure Any affiliated subsidiary or entity owned and controlled by the Company may become an employer under the Plan provided that:

1. the governing authority of the Company approves the adoption of the Plan by the subsidiary or affiliate and designates such subsidiary or affiliate as an employer for purposes of the Plan;

2. the subsidiary or affiliate adopts the Plan together with all amendments in effect; and

3. the subsidiary or affiliate agrees to be bound by any other terms and conditions which may be required by the Company, provided that such terms and conditions are not inconsistent with the purposes of the Plan.

Effect of Adoption by Employer Any subsidiary or affiliate of an employer which adopts the Plan pursuant to this Section shall be deemed to be an employer for all purposes hereunder unless otherwise specified by resolutions of the governing authority of the Company that designated the subsidiary or affiliate as an employer.

Obligation of Employer Each employer shall pay any amounts necessary to fund any benefits hereunder for its covered employees, but not for any covered employees who are employees of another employer. Each employer shall keep records and furnish the information with respect to its employees as the Plan Administrator shall require. Each employer may be required to pay its pro rata share of the costs of administering this Plan and benefits hereunder.

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SECTION VII MISCELLANEOUS Non-alienation of Benefits None of the payments, benefits, or rights of any covered employee shall be subject to any claim of any creditor, and, in particular, to the fullest extent permitted by law, all such payments, benefits, and rights shall be free from attachment, garnishment, trustee's process, or any other legal or equitable process available to any creditor of such covered employee. No covered employee shall have the right to alienate, anticipate, pledge, encumber, or assign any of the benefits or payments which he or she may expect to receive, contingently or otherwise, under this Plan. No Contract of Employment Neither the establishment of this Plan nor any modification thereof, nor the creation of any fund, trust or account, nor the payment of any benefits shall be construed as giving any employee, or any person whomsoever, the right to be retained in the service of the employer, and all employees shall remain subject to discharge to the same extent as if the Plan had never been adopted. In short, this Plan in no way changes the at-will employment status of any covered employee. Severability of Provisions If any provision of the Plan shall be held invalid or unenforceable, such invalidity or unenforceability shall not affect any other provision hereof, and this Plan shall be construed and enforced as if such provision had not been included. Heirs, Assigns and Personal Representatives This Plan shall be binding upon the heirs, executors, administrators, successors, and assigns of the parties, including each covered employee and beneficiary, present and future. Headings and Captions The headings and captions herein are provided for reference and convenience only, and shall not be considered part of the Plan, and shall not be used in the construction of the Plan. Gender and Number Except where otherwise clearly indicated by context, the masculine and the neuter shall include the feminine and the neuter, and the singular shall include the plural, and vice-versa. Controlling Law This Plan shall be construed and enforceable according to the laws of the State of Texas to the extent not preempted by Federal law, which shall otherwise control. This Plan is an unfunded employee welfare benefit plan as defined in Section 3 (1)(A) of ERISA, as a plan maintained for the purpose of providing medical, surgical, or hospital care and other benefits in the event of bodily injury, occupational disease or cumulative trauma. Title to Assets No covered employee shall have any right to or interest in, any assets of the Company or any employer upon termination of his or her employment or otherwise, except as provided from time to time under this Plan.

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Expenses All expenses for the management and administration of the Plan shall be paid by the employer. Voluntary Payments: No Admission of Liability Establishment and adoption of this Plan by the employer are voluntary and the Plan may be terminated at any time and for any reason. Such payments shall not in any way constitute an admission of liability or responsibility by the employer for bodily injury, occupational disease or cumulative trauma. Information to Be Furnished Covered employees shall provide the Company, employer, and Plan Administrator with such information and evidence, and shall sign such documents, as may reasonably be requested from time to time for the purpose of administration of the Plan. Failure to do so will result in forfeiture of all benefits under this Plan. Limitation of Right Neither the establishment of the Plan, nor any amendment thereof, nor the payment of any benefits, will be construed as giving to any covered employee or other person any legal or equitable right against the Company, the employer, or the Plan Administrator, except as provided herein. IN WITNESS WHEREOF this Plan has been executed by the Company this ______ day of __________, 200__, to be effective as of the Effective Date. ABC Company By: _____________________________________ Signature and Title

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(Insured Letterhead) Employer’s Comp Associates, Inc. 14350 Proton Road Dallas, Tx 75244-3511 Re: ABC Company Policy No. CERTIFICATION OF ERISA PLAN ADOPTION AND ROLL-OUT This is to certify that on ____________ (date) ABC Company adopted the ABC Company Workplace Injury Benefit Plan by duly-recorded vote of its board of directors (or other applicable governing corporate body) and that on ______________ (date), the Company distributed the Plan’s Summary Plan Description and Schedule of Benefits to each of the Company’s employees. The Company understands the need to provide the “Certification of ERISA Plan Adoption and Roll-Out” in order to be reimbursed for Plan claims/benefits covered by Great American. This further certifies that the Company will provide at the time of hire a copy of the Summary Plan Description and current Schedule of Benefits to each newly-hired employee and obtain Notification of No Workers’ Compensation acknowledging receipt of the Summary Plan Description and current Schedule of Benefits describing benefits provided for work related injuries. ABC Company By: ____________________________ (Owner’s/Officer’s Signature) Print Name: _____________________ Print Title: ______________________ Date: __________________________