(UWOPA) Police Association - that are Members of the for Regular Full-Time employees

 
for Regular Full-Time employees
   that are Members of the
    Police Association
         (UWOPA)
INTRODUCTION

               This booklet summarizes the key features of the Group Benefit Plans available to Regular Full-Time
               employees that are Members of the Police Association (UWOPA). Your benefits represent an important
               component of your overall compensation at the Western University. These benefits have
INTRODUCTION

               been strategically developed to provide protection against health and dental costs, protect your income if
               an illness or injury prevents you from working, and provide survivors with financial protection in the event
               of death.

               While every effort has been made to ensure the accuracy of this outline, this booklet does not contain all
               of the plan provisions. Your benefits and rights are governed by the terms of the Group Master Contract
               providing the group benefit coverage and the Collective Agreement between Western University and the
               Police Association.

               Human Resources - Benefits administers the Group Benefit Plans. Requests for information about
               coverage or relevant plan provisions of the governing document may be obtained by contacting a
               Human Resources - Benefits Representative.
TABLE OF CONTENTS

                                                                                                                                       TABLE OF CONTENTS
Contact Us . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .i

Benefits at a Glance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .ii

Claim Forms                  . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1

Extended Health Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2

Dental Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8

Life Insurance Plans . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12

Voluntary Personal Accident Insurance Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .16

Disability Income Program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .21

Other Benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .24

Cost of Benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .25
CONTACT US

                                 Western University
                                 Human Resources
                         Room 5100, Support Services Building
                                  London, Ontario
                                      N6A 3K7
CONTACT US

                               Inquiries: hrhelp@uwo.ca

                         Hours of Operation: 8:30 a.m. to 4:30 p.m.
                                Telephone: (519) 661-2194
                                   Fax: (519) 661-4104

                              Website: http://www.uwo.ca/hr

                       Please refer to our website for a list of
             Human Resources-Benefits representatives and email addresses.

                                             i
BENEFITS AT A GLANCE

The following summary is intended to give a brief overview of the Group Benefit Plans available to Regular
Full-Time employees that are Members of the Police Association (UWOPA).

             EXTENDED HEALTH PLAN

   • compulsory; however, if you are covered for similar benefits under your spouse’s plan you may
     exempt yourself

                                                                                                             BENEFITS AT A GLANCE
   • coverage for you and your eligible dependents
   • 85/15 Co-insurance Arrangement
   • Health Spending Account

                                                                                                                 FOR UWOPA
   • prescribed drugs legally requiring a prescription
   • those drugs not legally requiring a prescription which are in an injectable format or life sustaining
   • generic substitutions unless specifically prescribed by the attending physician or dentist
   • semi-private/private hospital room
   • medically necessary services and supplies
   • services of a licensed chiropractor: $15 a vist after the 15th visit per calendar year
   • services of a licensed chiropractor, podiatrist, physiotherapist, naturopath, masseur and speech
     therapist
   • a visioncare benefit: $300 per person every twenty-four (24) months
   • out-of-country emergency medical and travel assistance; limited to $200,000 per person per 90 day
      trip

                   DENTAL PLAN

   • compulsory; however, if you are covered for similar benefits under your spouse’s plan you may
     exempt yourself
   • coverage for you and your eligible dependents
   • 85/15 Co-insurance Arrangement
   • based on current year’s Dental Society Fee Guide for General Practitioners and/or Specialists
   • basic expenses - 85% reimbursement:
        Preventive services: routine dental examination and cleaning once every nine consecutive
        months, root canal therapy, bitewing X-rays, fluoride treatment, restorations, etc.
   • major expenses - 80% reimbursement:
        Restorative services: inlays and crowns, dentures, periodontal surgery, fixed bridgework, etc.
   • initial orthodontic consultation fee

             LIFE INSURANCE PLANS

  BASIC LIFE
  • compulsory
  • life insurance on your life
  • 2 times your normal basic annual salary (minimum $50,000)

  OPTIONAL LIFE
  • optional
  • additional life insurance on your life
  • coverage levels vary between 1/2 times to 2 times your normal basic annual salary

  DEPENDENT LIFE
  • optional
  • life insurance on your eligible dependents
  • $40,000 coverage on your eligible spouse and $10,000 coverage on your eligible dependent children

                                                   ii
VOLUNTARY PERSONAL ACCIDENT
                                     INSURANCE PLAN

                         •   optional
                         •   coverage for you and your eligible dependents
                         •   24 hour protection against accidents worldwide
BENEFITS AT A GLANCE

                         •   level of coverage between $20,000 and $250,000 (in multiples of $10,000)
    FOR UWOPA

                                 DISABILITY INCOME PROGRAM

                         • compulsory
                         • protection against loss of income due to injury or illness
                         • Sick Leave-Salary Continuance Plan - 100% of your normal basic monthly salary, continued up to a
                             maximum of 15 consecutive weeks
                         • Long Term Disability Insurance Plan - 70% of your normal basic monthly salary in effect immediately
                             prior to the commencement of your Sick Leave

                             ADMINISTRATIVE STAFF PENSION PLAN

                         • optional
                         • your monthly contribution is 2.5% of your normal basic monthly salary
                         • Western University monthly contribution:

                                  Service               University’s Contribution
                                                    (as a % of basic monthly salary)

                              Under 10 years                       7.5%
                                10-19 years                        8.0%
                             20 or more years                      8.5%

                         •   a wide range of investment options are available
                         •   vesting is immediate upon enrollment
                         •   monthly option to change investment direction
                         •   option available to make additional pension contributions and transfer funds in from an RRSP

                       For a complete description of your Group Benefit plans, refer to your applicable booklet or access the
                       information on our website at http://www.uwo.ca/hr.

                                                                            iii                                             April 2012
CLAIM FORMS

Need a claim form? Click here

You can also log into the Manulife website, any time to obtain a claim form. You will see the forms that are
the right ones for you. The forms will be pre-filled with the new Plan Contract Number and Plan Sponsor
Name every time you need a form.

After completion of the claim form(s), simply maintain a copy for your records and forward your claim with
the original receipts directly to Manulife Financial at the following address:

                                     Manulife Financial Group Benefits
                                              Health Claims
                                               PO Box 1653
                                         Waterloo ON N2J 4W1

                                                      1
EXTENDED HEALTH PLAN

     he University’s Extended Health benefit is           DEFINITION OF DEPENDENTS
T    issued as a supplement to the Ontario Health
Insurance Plan (O.H.I.P.) or equivalent which
                                                          You may also cover your spouse and dependents,
                                                          as defined below:
includes the University Health Insurance Plan
(U.H.I.P.). It provides payments towards usual and        Spouse/Partner: A spouse is defined as a person
customary charges for medically necessary health          who is legally married to the employee or, although
services and supplies (incurred by you and your           not legally married, has continuously cohabited in a

                                                                                                                    EXTENDED HEALTH PLAN
covered dependents) for which government                  common-law like relationship of the same or
legislation does not prohibit reimbursement.              opposite sex with the employee for not less than
                                                          one full year.
CO-INSURANCE ARRANGEMENT                                  Dependent Children: A dependent child is
Your Extended Health and Dental plans are subject         defined as unmarried (including legally adopted
to an 85/15 co-insurance arrangement. You are             children, foster or step-children), not engaged in
required to pay 15% of claims for eligible expenses       full-time employment, dependent on you for
submitted under these plans. The maximum you              financial support under the age of 21 unless the
would pay in a calendar year is $450 for Single           child is registered as a full-time student in which
coverage and $900 for Family coverage. Once the           case the child must be under the age of 25 or if
maximum is reached in any given calendar year,            incapable of self support due to mental or physical
you will no longer be required to pay 15% towards         infirmity which began while the child was covered
eligible claim expenses for the                           as the Employee’s dependent will continue to be
remainder of that calendar year. This co-insurance        eligible.
arrangement does not apply to the following:
                                                          HEALTH SPENDING ACCOUNT
    • the $6.11 dispensing fee cap                        For the purpose of payment of health related
    • any internal maximums already defined within        expenses as defined by the Income Tax Act,
      the plans                                           including out-of-pocket costs arising from the 85/15
      (i.e. Visioncare - $300 Orthotics - $400)           co-insurance arrangement and expenses incurred
                                                          above the dollar maximums for particular benefits.
PARTICIPATION IN THE PLAN
If you are a Regular Full-Time employee that is a         All members of the Police Association (UWOPA)
Member of the Police Association (UWOPA), you             will have a health spending account with a base
are eligible to participate in the Extended Health        amount of $200. This base amount may be
benefit.                                                  supplemented with an allocation (up to $300)
                                                          from a member’s Flex Credits. Flex Credits will
Participation is compulsory; however, if you are          increase to $500 in 2013 and $600 in 2014.
covered for similar benefits under your spouse’s
group plan, you may exempt yourself from our plan.        CHANGE IN STATUS
                                                          Coverage for an employee who acquires a spouse
Coverage is effective on the first day of your            or dependent(s) after becoming covered may be
Regular Full-Time appointment.                            changed upon notification to provide coverage for
                                                          the spouse or dependent(s) effective as of the date
COST OF THE PLAN                                          of eligibility or the date of application, whichever is
For a breakdown of the cost, refer to our web site        later. However, evidence of insurability is required if
or contact a Human Resources - Benefits                   the change is not received within 31 days of the
Representative.                                           change.

ENROLLMENT PROCEDURE
Enrollment is initiated by the completion of an
application form available in Human
Resources - Benefits.

                                                      2
EXPENSES FOR WHICH PAYMENTS ARE                          Licensed Psychologist
                       MADE INCLUDE THE FOLLOWING:
                                                                                    • group therapy (limited to $6 per hour per
                       Services and Supplies of a Licensed Hospital                   person)
                       For services and supplies of a licensed hospital             • family therapy (limited to $18 per half hour)
                       such as:                                                     • individual therapy and testing (limited to $15
                                                                                      per half hour)
EXTENDED HEALTH PLAN

                       Hospital Accommodation - the difference                      • all other visits (limited to $15 per visit)
                       between ward and semi-private or private
                       accommodation:                                           Licensed Osteopath, Naturopath,
                                                                                Chiropodist/Podiatrist, Acupuncturist, Speech
                          In Canada - no limit                                  Therapist, Physiotherapist, and Massage
                          Out of Canada (for Canadian residents                 Therapist
                          only)
                                                                                    • up to $15 a visit
                          • if an emergency while travelling or on                  • includes X-rays by a chiropractor (limited to
                            vacation, or while on leave of absence from               $35 a person per calendar year)
                            employer - no limit                                     • surgery performed by a licensed
                          • if a non-emergency or elective - limited to               podiatrist (limited to $200 a calendar year
                            $200 a day                                                per person)
                          • if a referral (approved by O.H.I.P. or
                            equivalent) - no limit                                Licensed Chiropractor
                                                                                  • up to $15 a visit after the 15th visit per
                       Services of Physicians & Surgeons                          calendar year
                       For services of physicians & surgeons such as:             • includes X-rays by a chiropractor (limited to
                                                                                  $35 a person per calendar year)
                       Out of Province for Canadian residents, over the
                       amount allowed under O.H.I.P. or equivalent:             Note: Any difference between the benefits paid by
                                                                                O.H.I.P. or equivalent for services rendered and
                          • if an emergency while travelling or on              the fees charged by the above practitioners is not
                            vacation, or while on leave of absence from         eligible.
                            employer - unlimited less the amount
                            covered by O.H.I.P. or equivalent
                          • if a non-emergency - unlimited less the             Optometrist/Ophthalmologist
                            amount covered by O.H.I.P. or equivalent               • eye examinations not covered under O.H.I.P.
                          • if elective - up to the amount in the Medical            or equivalent (limited to $25 per visit)
                            Fee Schedule of the province where you                 • for visual training and remedial eye
                            reside                                                   exercises (limited to $10 per half hour)
                          • if a referral (approved by O.H.I.P. or                 • contact lenses or eyeglasses due to a
                            equivalent) - unlimited less the amount                  medical condition such as after cataract
                            covered by O.H.I.P. or equivalent                        surgery (limited to $100 per eye per lifetime)
                       Note: All expenses are paid in Canadian funds.
                                                                                Note: For information on additional benefits for
                       Other Services                                           visioncare see Visioncare Benefit section on
                                                                                page 5.
                       Diagnostic and X-Ray Services - eligible charges
                       for diagnostic and x-ray services when carried out
                       by a hospital or private laboratory such as:             Dentist
                            • laboratory services                                  • for accidental injury to natural teeth from an
                            • x-ray examination                                      external blow (excluding biting accident)
                                                                                     within twelve (12) months of the accident

                                                                            3
Ambulance                                                               to $350 per calendar year)
  • if condition requires it, to the nearest hospital               •   respirators
    where treatment facilities are available                        •   dialysis equipment
                                                                    •   equipment for the administration of oxygen
Private Duty Nursing                                                •   obus formes (limited to $100 per five (5)
Services of private duty nursing in your home by a                      calendar years)
Registered Nurse (RN) and/or a Registered                           •   crutches, canes, walkers

                                                                                                                            EXTENDED HEALTH PLAN
Practical Nurse (RPN).                                              •   transcutaneous nerve stimulator referred to
                                                                        as a TENS machine (limited to payment at
Pre-approval is required.                                               50%)
                                                                    •   essential ostomy supplies
Further information can be found under the Private                  •   custom-made orthopaedic shoes (limited to
Duty Nursing Claim Predetermination Submission                          one (1) pair per calendar year minus a $75
Guidelines.                                                             deductible) or modifications to street
                                                                        shoes such as insoles or molded arch
Prosthetic Appliances & Supplies
                                                                        supports (limited to one (1) pair per calendar
Prosthetic appliances and supplies such as:                             year)
   • artificial limbs                                               •   custom-made orthotics (limited to $400 for
   • splints                                                            one (1) pair per calendar year)
   • braces                                                         •   hearing aid and repairs
   • cervical collars
   • surgical brassieres (limited to six (6) per                Note: Many of the above prosthetic devices and
      calendar year)                                            medical supplies may require a written
   • stump socks (limited to six (6) per calendar               recommendation of a physician. As well, if due to
      year)                                                     an extended illness or disability it is felt the need for
   • tracheotomy supplies                                       any of the above-mentioned items will be long term,
   • surgical elastic stocking (limited to two (2)              a purchase may be approved rather than a rental.
      pairs per calendar year)
   • wigs for permanent or temporary hair loss                  CO-ORDINATION OF BENEFITS
      (limited to $700 lifetime maximum)                        If you or your dependent(s) are entitled to benefits
                                                                under this plan and any other plan for the same
Note: Replacement will not be a benefit unless the              expense, the amount payable under this plan will
replacement is required due to normal wear and                  be reduced to ensure that the total amount payable
tear or pathological change.                                    under all plans does not exceed the actual expense
                                                                incurred.
Medical Supplies and Assistive Devices
Medical supplies and assistive devices such as:                 DRUGS AND MEDICINES
    •   surgical bandages/dressings                             Prescription Drugs
    •   burn pressure garments                                  In the treatment of an injury or illness, the following
    •   rental of a hospital bed                                drugs will be considered eligible expenses if
    •   rental of a wheelchair                                  dispensed by a licensed physician or dentist, or by
    •   equipment for the treatment of cystic fibrosis          a licensed pharmacist on the written prescription of
    •   equipment for the treatment and control of              a licensed physician or dentist:
        diabetes such as: glucometer (limited to $200
        per claim) or Preci-Jet insulin injector (limited           • drugs legally requiring a prescription, in
                                                                      accordance with the Food and Drug Act,
                                                                      Canada or similar provincial legislation

                                                            4
• eligible fertility drugs (limited to a lifetime       (HCP) Pharmacy Component brochure available in
                             maximum of $12,000)                                   Human Resources - Benefits or access information
                           • contraceptive devices (limited to $50 per             on our web site: www.uwo.ca/humanresources.
                             calendar year per person)
                           • eligible smoking cessation products (limited          EXAMPLES OF EXPENSES NOT COVERED
                             to a lifetime maximum of $500)                        Listed below are a few examples of expenses not
                           • drugs not legally requiring a prescription, but       eligible for coverage:
EXTENDED HEALTH PLAN

                             which are in an injectable format, or are life
                             sustaining and identified under the following             • duplicate payments from the Provincial
                             headings in the Therapeutic Guide section of                Health Insurance or any Worker’s
                             the then current Compendium of                              Compensation Coverage - this limitation
                             Pharmaceutical and Specialities:                            does not apply to the differences between
                                                                                         ward and semi-private or private
                             anti-anginal agents                                         accommodations in a licensed hospital
                             anticholinergic preparations                              • food and dietary supplements
                             antiparkinsonism agents                                   • cosmetic or hygienic products
                             anti-arrhythmic agents                                    • experimental drugs
                             bronchodilators                                           • any hospitalization or service rendered
                             glaucoma therapy                                            concerning general health examinations for
                             antihyperlipidemic agents                                   “check-up” purposes
                             insulin preparations                                      • travel for health, dental services, or cosmetic
                             hyperthyroidism therapy                                     surgery
                             oral fibrinolytic agents                                  • expenses resulting from an act of war or
                             parasympathomimetic agents                                  hostilities of any kind
                             potassium replacement therapy                             • any health services provided without cost to
                             tuberculosis therapy                                        you or your dependent(s) or expenses for
                             topical enzymatic debriding agents                          which coverage is provided under any other
                             anti-inflammatories                                         insurance plan or policy to the extent of such
                             anti-histamines                                             coverage
                                                                                       • drugs not considered by the Canadian
                       Generic Substitutions                                             Medical Association, or by the Medical
                       Where the drug dispensed is interchangeable with                  Association of the province of residence of
                       any other drug, the charges will not exceed the                   the employee, to be therapeutically useful
                       cost of the lowest priced interchangeable drug,
                       unless specifically prescribed by the attending             VISIONCARE BENEFIT
                       physician or dentist.                                       The Extended Health plan provides a Visioncare
                                                                                   benefit for reasonable and customary charges for
                       Dispensing Fee                                              necessary expenses for eyeglass lenses or
                       You may visit any pharmacy to have your                     contact lenses prescribed by a physician or
                       prescription filled, however, the maximum allowed           surgeon legally licensed to practice medicine or an
                       for reimbursement is $6.11.                                 optometrist for the correction of impaired vision,
                                                                                   and frames for such lenses recommended by a
                       A partnership has been set up with various                  physician or optometrist. Laser Eye Surgery may
                       pharmacies referred to as the Southwestern                  also be claimed as an expense under the
                       Ontario Health Care Partnership (HCP). HCP                  Visioncare benefit.
                       pharmacies charge less for dispensing/
                       professional fees while providing competitive drug          VISIONCARE BENEFIT:
                       ingredient prices and professional advice. For
                       further details on participating pharmacies such as:            $300 per person every twenty-four (24)
                       address, telephone number, hours of operation,                  months.
                       delivery services available and agreed dispensing
                       fee, please refer to the Health Care Partnership

                                                                               5
General Limitations for the Visioncare benefit              Note: If hospitalization occurs due to accident or a
Visioncare benefits are designed to reimburse you           sudden unexpected illness, the Assistance Centre
only for your out-of-pocket expenses. No                    must be contacted within 24 hours of the
reimbursement will be made for the following                admission. Your coverage will be validated and
expenses:                                                   payment to the health care provider guaranteed.

    • safety glasses (paid through Occupational             As well, Deluxe Travel pays for the reasonable
      Health & Safety)                                      and customary charges for the following

                                                                                                                     VISIONCARE BENEFIT
    • non-corrective glasses or sunglasses,                 eligible expenses:
    whether prescribed or not
    • glasses or contact lenses for cosmetic or             Repatriation
      decorative purposes                                   Extra costs of return economy fare by the most
                                                            direct route (air, bus, train) when an illness is such
DELUXE TRAVEL                                               that the covered person must return home and be
Deluxe Travel provides various benefits as a result         accompanied by a qualified medical attendant (not
of an accident or a sudden unexpected illness               a relative). Written authorization is required from
incurred outside the employee’s province of                 the attending physician. On a commercial aircraft
residence in Canada or outside Canada while this            this coverage includes:
plan is in effect. Coverage is only for the first 90             • two economy seats by most direct route to
days of being out of the country and has a limit of                the covered person’s home city in Canada
$200,000 per person per trip. These benefits include:              (one for the covered person and one round
                                                                   trip fare for a medical attendant)
Medical Assistance Services                                      • the number of economy seats required to
   • provides emergency response in any major                      accommodate the covered person if on a
     language                                                      stretcher and one round trip for a medical
   • referrals to an appropriate physician, clinic or              attendant, and the attendant’s overnight hotel
     hospital                                                      and meal expenses if required
   • confirms you have coverage                                  • economy seats to return any covered
   • guarantees or arranges payment to the                         person of the immediate family who is
     hospital or physician for eligible expenses                   travelling with the patient
   • provides assistance in contacting your family,
     place of business or family physician                  Vehicle Return
   • supervises the medical treatment and keeps             An allowance of up to $1,000 Canadian will be
     the family informed                                    reimbursed for the cost of driving the patient’s
   • arranges for transportation of a family                vehicle, either private or rental, to the patient’s
     member to the patient’s bedside                        residence or nearest appropriate vehicle rental
   • arranges for transportation home of the                agency when the patient or any travelling
     patient                                                companion is unable to return it due to sickness or
                                                            accident.
Non-Medical Assistance Services
   • arranges for local care of dependent                   RETURN OF DECEASED
     child(ren) and coordinates the safe return             Up to $5,000 Canadian towards the cost or
     home if the person is hospitalized                     preparation (including cremation) and homeward
   • arranges the transmission of urgent                    transportation of a deceased covered person
     messages to family members                             (excluding the cost of a coffin) to the point of
   • provides assistance in the event of loss of            departure in Canada by the most direct route.
     passport(s) or airline ticket(s)                       Up to $2,000 Canadian towards these same costs if
   • provides legal counsel referral in the event of        the deceased is not returned to Canada.
     a serious accident
   • coordinates claims processing and                      Meals & Accommodation Allowance
     negotiation of health care provider discounts          Up to $1,500 Canadian ($150 per day) per calendar
   • provides pre-departure information                     year for extra costs of commercial accommodation
     concerning Visa’s and Vaccines
                                                        6
and meals incurred by the employee or by a                 BENEFITS AFTER TERMINATION OF
                       covered dependent when the trip is delayed due to          COVERAGE
                       illness or accident to a covered person. This must         If you are totally disabled at the time your
                       be verified by the attending physician and                 coverage terminates and disability continues, this
                       supported with receipts from commercial                    benefit may be continued for a period up to ninety
                       organizations.                                             (90) days.
EXTENDED HEALTH PLAN

                       Transportation to Visit the Covered Person                 If any of your dependents are confined in a
                       One return economy fare by the most direct route           licensed hospital when this coverage terminates,
                       for transportation costs (air, bus, train) when the        the benefit for that dependent may be continued,
                       covered person is confined to hospital for at least        during the period of hospital confinement, for a
                       seven days or has died and the attending                   eriod up to ninety (90) days.
                       physician advised the necessary attendance of a
                       family member or close friend of the covered               If following termination you are interested in
                       person.                                                    purchasing alternate coverage, our current
                                                                                  insurance carrier offers a Group Conversion
                       BENEFITS WHILE ON LEAVE OF ABSENCE OR                      Program for employees who have recently left a
                       TRAVELLING                                                 Group Benefit Plan. The benefits available
                       If you are going on a leave of absence, you may            include: Extended Health benefits, prescription
                       arrange to continue your coverage by contacting            drugs, semi-private hospital and dental benefits.
                       Human Resources - Benefits to cover the cost of
                       your benefits prior to leaving.                            Did you know...

                       When travelling outside of the country, you and
                       your dependent(s) will continue to be covered.             If you are planning on leaving Canada for a period
                                                                                  exceeding six months, the Ministry of Health in your province
                       Reimbursement for any eligible claims will be              of residence must be notified to request approval for
                       made in Canadian funds.                                    continued Provincial Health Insurance. You must complete a
                                                                                  Change of Information form for you and/or your dependents.
                                                                                  To obtain this form or to request further information, contact
                       TERMINATION OF COVERAGE
                                                                                  the Ministry of Health branch below:
                       Coverage will terminate on the earlier of one of the
                       following:                                                                       Ministry of Health
                                                                                                    217 York Street, 5th Floor
                           (1) the end of the month in which you                                     P.O. Box 5700, Station A
                               terminate your employment                                            London, Ontario N6A 5P9
                                                                                                          (519) 675-6800
                           (2) the date on which you are no longer                            Forms are also available on the OHIP website at
                                                                                         http://www.health.gov.on.ca/en/public/forms/ohip_fm.aspx
                               eligible to participate in the plan
                                                                                     It is your responsibility to maintain your Provincial
                           (3) the date the plan is cancelled for any                                 Health Insurance.
                               reason

                       DEPENDENT TERMINATION OF COVERAGE
                       A dependent’s coverage ceases on the earlier of:
                       the date the person is no longer an eligible
                       dependent under Definition of Dependents, and/or
                       the date your coverage terminates.

                       If you should die prior to termination, benefits for
                       your covered dependent(s) will be continued for an
                       additional thirty-six (36) months at no additional
                       cost to the surviving dependent(s).

                                                                              7
DENTAL PLAN

    he University’s Dental benefit provides           although not legally married, has continuously
T   payment towards usual and customary
charges for necessary dental services (incurred by
                                                      cohabited in a common-law like relationship of the
                                                      same or opposite sex with the employee for not
you and your covered dependents) up to the            less than one full year.
current Fee Guide.

CO-INSURANCE ARRANGEMENT                              Dependent Children: A dependent child is
Your Extended Health and Dental plans are             defined as unmarried (including legally adopted
subject to an 85/15 co-insurance arrangement.         children, foster or step-children), not engaged in
You are required to pay 15% of claims for eligible    full-time employment, dependent on you for

                                                                                                               DENTAL PLAN
expenses submitted under these plans. The             financial support under the age of 21 unless the
maximum you would pay in a calendar year is           child is registered as a full-time student in which
$450 for Single coverage and $900 for Family          case the child must be under the age of
coverage. Once the maximum is reached in any          25 or if incapable of self support due to mental or
given calendar year, you will no longer be required   physical infirmity which began while the child was
to pay 15% towards eligible claim expenses for        covered as the Employee’s dependent will
the remainder of that calendar year. This co-         continue to be eligible.
insurance arrangement does not apply to the
following:
                                                      CHANGE IN STATUS
    • the major restorative benefits under the        Coverage for an employee who acquires a spouse
      Dental plan                                     or dependent(s) after becoming covered may be
      (already subject to an 80/20 co-insurance)      changed upon notification to provide coverage for
                                                      the spouse or dependent(s) effective as of the
PARTICIPATION IN THE PLAN                             date of eligibility, or the date of application,
If you are a Regular Full-Time employee that is a     whichever is later. However, evidence of
Member of the Police Association (UWOPA), you         insurability is required if the change is not received
are eligible to participate in the Dental benefit.    within 31 days of the change.

Participation is compulsory; however, if you are
covered for similar benefits under your spouse’s      FEE SCHEDULE
group plan, you may exempt yourself from our          All eligible expenses are based on the current
plan.                                                 Dental Society Fee Guide for General
                                                      Practitioners and/or Specialists in the provider’s
Coverage is effective on the first day of your        province of residence. Claims for specialists will
Regular Full-Time appointment.                        be payable up to 120% of the General
                                                      Practitioners Fee Guide amount with the exception
COST OF THE PLAN                                      of Denturists which will be payable based on the
For a breakdown of the cost, refer to our web site    current Denturists Fee Guide in the provider’s
or contact a Human Resources - Benefits               province of residence. Claims incurred outside
Representative.                                       Canada will be reimbursed at the current Dental
                                                      Society Fee Guide for General Practitioners and/or
ENROLLMENT PROCEDURE                                  Specialists in the employee’s province of
Enrollment is initiated by the completion of an       residence.
application form available in Human
Resources - Benefits.
                                                      BASIC DENTAL EXPENSES
DEFINITION OF DEPENDENTS                              You may recover the usual and customary
You may also cover your spouse and dependents,        charges for Basic Dental expenses such as:
as defined below:
Spouse/Partner: A spouse is defined as a
person who is legally married to the employee or,

                                                      8
PREVENTIVE DENTAL SERVICES

              Diagnostics                                                Restorative Services (Basic)
              Clinical Oral Examination:                                    • amalgam (metal) and tooth coloured (plastic)
                                                                              restorations
                  • complete oral examination of a new patient              • tooth coloured veneer applications
                    (limited to once every three (3) calendar               • porcelain staining (chairside)
                    years)                                                  • prefabricated steel crowns (primary teeth)
                  • recall oral examination (limited to once every
                    nine (9) consecutive months)
DENTAL PLAN

                  • emergency oral examination                           Endodontics Services
                  • specific oral examination                               • treatment of pulp chamber - pulpotomy and
                                                                              pulpectomy
              Radiographs                                                   • root canal therapy - root canals and
                 • periapical                                                 apexification
                 • sialography                                              • periapical services - root amputation,
                 • postero-anterior and lateral skull and facial              retrofilling, exploratory endodontics surgery,
                   bone                                                       canal and/or pulp chamber enlargement,
                 • use of radiopaque dyes                                     surgical and non-surgical root repair or pulp
                 • cephalometric films                                        chamber repair
                 • cephalometric tracing
                 • tomography                                            Periodontic Services (Basic)
                 • full mouth series, including bitewings (limited           • non-surgical services - application of
                   to once every five (5) years)                               displacement dressings, management of oral
                 • panoramic (limited to once every five (5)                   infections, desensitization
                   calendar years)                                           • adjunctive periodontal services - occlusal
                 • occlusal                                                    adjustment, root planning, topical application
                 • bitewing (limited to once every nine (9)                    of antimicrobial agent
                   consecutive months)
                 • extraoral                                             Oral Surgery (Basic)
                 • tests and laboratory examinations                        • extractions of erupted teeth, impacted teeth,
                 • microbiological tests                                       residual roots, surgical exposure of teeth,
                 • pulp vitality tests                                         surgical movement of teeth
                 • lab reports                                              • oral surgical procedures including the
                 • emergency services                                          removal of teeth, but excluding periodontal
                                                                               surgery
                                                                            • surgical excisions and incisions
              Preventive Services                                           • other oral surgery services such as: post
                 • polishing (limited to once every nine (9)                   surgical care, repairs, lacerations, fractures,
                   consecutive months)                                         replantation of avulsed teeth, repositioning of
                 • fluoride treatment (limited to once every nine              traumatically displaced teeth
                   (9) consecutive months)
                 • scaling                                               Adjunctive General Services
                 • preventive recall packages (limited to once              • local anaesthesia (not in conjunction with
                   every nine (9) consecutive months)                         operative or surgical procedures)
                 • pit and fissure sealants                                 • general anaesthesia
                 • space maintainer appliances - including                  • provisions of dental and anaesthetic
                   maintenance and repair                                     facilities, equipment and supplies
                 • interproximal disking of teeth                           • conscious sedation - inhalation technique,
                 • recontouring of teeth for functional reasons               intravenous sedation, intramuscular injections
                   (not associated with delivery of prosthesis)               of sedative drugs

                                                                     9
MAJOR DENTAL EXPENSES                                   CO-ORDINATION OF BENEFITS
You may recover up to 80% of the reasonable             If you or your dependent(s) are entitled to benefits
customary charges for Major Dental expenses such        under this plan and any other plan for the same
as:                                                     expense, the amount payable under this plan will
                                                        be reduced to ensure that the total amount payable
RESTORATIVE SERVICES                                    under all plans does not exceed the actual expense
                                                        incurred.
Restorative Services (Major)
   • inlay and onlay restorations (limited to once      EXAMPLES OF EXPENSES NOT COVERED
     per tooth per five (5) consecutive years) -        Listed below are a few examples of expenses not

                                                                                                               DENTAL PLAN
     metal, composite and porcelain/ceramic             eligible for coverage:
   • retentive pins and posts
   • indirect overdenture restorative services              • services other than those provided by a
   • crowns (limited to once per tooth per five (5)           dentist, except those services which may be
     consecutive years)                                       performed by legally qualified auxiliary
   • recontouring of existing crowns                          personnel under the supervision of a dentist,
   • removal of inlays, onlays and crowns                     or those services which may be performed
                                                              by periodontal practitioner under the terms of
Prosthodontics Services                                       the practitioner’s license
   • complete dentures (limited to one (1)                  • cosmetic services
     complete upper and one (1) complete lower              • dentures and bridgework (including crowns
     denture in five (5) calendar years)                      and inlays forming the abutments) to replace
   • partial dentures (limited to one (1) partial             any teeth removed before the covered person
     upper and one (1) partial lower denture in five          became insured under this benefit
     (5) calendar years)                                    • dentures which have been lost, stolen or
   • transitional dentures (limited to one (1)                mislaid
     complete upper and one (1) complete lower              • prosthetic devices which were ordered before
     denture in five (5) calendar years)                      the covered person was insured under this
   • denture adjustments, repairs and additions               benefit
   • denture reline and rebase                              • replacement of an existing partial or full
   • denture remake                                           denture or fixed bridgework unless
   • fixed bridge                                             (i) the existing denture or bridgework is at
   • fixed bridge repairs                                          least five (5) years old, OR
                                                              (ii) the replacement is required to replace
Oral Surgery (Major)                                               an immediate temporary denture which
   • remodelling and recontouring oral tissues                     was installed while the covered person
                                                                   was insured under this benefit
Periodontic Services (Major)                                • the addition of teeth to an existing partial
    • periodontic surgical services                           denture or fixed bridgework unless the
    • adjunctive periodontic services                         addition is required to replace one or more
    • periodontal appliances - maintenance,                   teeth removed while the covered person is
      adjustments, repairs and relines (limited to            insured under this benefit
      any one (1) maxillary (upper) and any one (1)         • orthodontic services other than initial
      mandibular (lower) appliance in two (2)                 consultation
      calendar years)
                                                        PREDETERMINATION OF DENTAL CLAIMS
                                                        If your dentist has recommended dental treatment
Miscellaneous Services                                  that is expected to cost more than $500, you
   • diagnostic casts                                   should have your dentist prepare a pre-treatment
   • initial orthodontic consultation                   plan. This will allow you to determine your own
                                                        financial obligation prior to the commencement of
                                                        treatment.

                                                       10
GENERAL LIMITATIONS                                             DEPENDENT TERMINATION OF COVERAGE
              Dental benefits are designed to reimburse you only              A dependent’s coverage ceases on the earlier of:
              for your out-of-pocket expenses. Listed below are               the date the person is no longer an eligible
              a few examples of expenses not eligible for                     dependent under Definition of Dependents, and/or
              coverage:                                                       the date your coverage terminates.
                   • services payable under any Workers                       If you should die prior to termination, benefits for
                     Compensation Act or any other statute                    your covered dependent(s) will be continued for an
                   • self-inflicted injuries                                  additional thirty-six (36) months at no additional
                   • services required as a result of war or                  cost to the surviving dependent(s).
                     hostilities of any kind
DENTAL PLAN

                   • services required as a result of your                    BENEFITS AFTER TERMINATION OF
                     participation in a criminal offence                      COVERAGE
                   • services performed by a person who is                    If you are totally disabled at the time your
                     ordinarily a resident in the covered person’s            coverage terminates and disability continues, this
                     home                                                     benefit may be continued for a period up to ninety
                   • services for which reimbursement is payable              (90) days.
                     due to the legal liability of any other party, to
                     the extent of such reimbursement                         If following termination you are interested in
                                                                              purchasing alternate coverage, our current
                                                                              insurance carrier offers a Group Conversion
                                                                              Program for employees who have recently left a
              BENEFITS WHILE ON LEAVE OF ABSENCE OR                           Group Benefit Plan. The benefits available
              TRAVELLING                                                      include: Extended Health benefits, prescription
              If you are going on a leave of absence, you may                 drugs, semi-private hospital and Dental benefits.
              arrange to continue your coverage by contacting
              Human Resources - Benefits to cover the cost of
              your benefits prior to leaving.

              When travelling outside of the country, you and
              your dependent(s) will continue to be covered.

              Reimbursement for any eligible claims will be
              made in Canadian funds.

              TERMINATION OF COVERAGE
              Coverage will terminate on the earlier of one of the
              following:

                  (1) the end of the month in which you
                      terminate your employment

                  (2) the date on which you are no longer
                      eligible to participate in the plan

                  (3) the date the plan is cancelled for any
                      reason

                                                                         11
LIFE INSURANCE PLANS

      he University’s Life Insurance plans provide life          site or contact a Human Resources - Benefits
T     insurance on your life and on your dependent’s
life payable to your beneficiary in the event of
                                                                 Representative

death. The plans available are:                                              OPTIONAL LIFE

    •   Basic Life                                         PARTICIPATION IN THE PLAN

                                                                                                                   LIFE INSURANCE PLANS
                                                              • participation is optional
    •   Optional Life                                         • you are eligible to participate on the first day
    •   Dependent Life                                          of your Regular Full-Time appointment,
                                                                however, if you do not make an application
If you are a Regular Full-Time employee that is a               within 31 days of first becoming eligible,
Member of the Police Association (UWOPA), you                   evidence of health is required and is subject
are eligible to participate in the following Life               to approval by the insurance carrier
Insurance plans:
                                                           COVERAGE AMOUNT
                       BASIC LIFE                          The Optional Life Insurance plan provides you with
                                                           the opportunity to purchase additional life insurance
PARTICIPATION IN THE PLAN                                  coverage on your life at a level of one half times,
   • participation is compulsory                           one times, one and a half times or two times your
   • coverage is effective on the first day of your        annual basic salary rounded to the next higher
     Regular Full-Time appointment                         $1,000.

COVERAGE AMOUNT                                            COST OF THE PLAN
The Basic Life Insurance plan provides coverage            You pay the full cost of the coverage which is
on your life based on two times your annual basic          dependent on your age and whether you are a
salary rounded to the next higher $1,000 with              smoker or non-smoker. For a breakdown of the
minimum coverage of $50,000.                               cost, refer to our web site or contact a Human
                                                           Resources - Benefits Representative.
COST OF THE PLAN
                                                                            DEPENDENT LIFE
  • the University pays the full cost of the first
    $25,000 of coverage
                                                           PARTICIPATION IN THE PLAN
           As the University provides a Sick Leave            • participation is optional
            Benefit that qualifies for a reduction in         • if you have eligible dependent(s), you may
        Employment Insurance Premiums, a portion                participate in the plan on the first day of your
        of the reduction (5/12) is used to pay the full         Regular Full-Time appointment, however, if
          cost of an additional amount of the Basic             you do not make an application within 31
        Life Insurance plan. Currently this reduction           days of first becoming eligible, evidence of
          amount provides sufficient funding for an             health is required on your dependent(s) and
          additional $25,000 of coverage. (For the              is subject to approval by the insurance carrier
         most up-to-date additional amount of Basic
                                                              • if you do not have a dependent(s) when you
        Life being funded through this arrangement,
                    refer to our web site or
                                                                first became eligible to participate in the plan
           contact a Human Resources - Benefits                 as outlined above, you may make an
                        Representative)                         application when you have a dependent(s),
                                                                however, if you do not make an application
    • you pay the remaining cost of the coverage                within 31 days of the dependent(s) becoming
    • the cost being paid by the University is a                eligible, evidence of health is required on
      taxable benefit                                           your dependent(s) and is subject to approval
    • for a breakdown of the cost, refer to our web             by the insurance carrier

                                                          12
COVERAGE AMOUNT                                           AMOUNT OF BENEFIT PAYABLE
                       The Dependent Life Insurance plan provides you            The Life benefit pays 100% up to the maximum
                       with the opportunity to purchase life insurance on        benefits provided by the plans.
                       your spouse’s life at $40,000 and for each of your
                       eligible dependent children at $10,000.                   MAXIMUM BENEFIT
                                                                                 The combined maximum benefit for the Basic and
                       COST OF THE PLAN                                          Optional Life Insurance plans is $500,000.
LIFE INSURANCE PLANS

                       You pay the full cost of the coverage. For a
                       breakdown of the cost, refer to our web site or           BENEFICIARY DESIGNATION
                       contact a Human Resources - Benefits                      You may designate whomever you wish as your
                       Representative.                                           named beneficiary and may initiate a change at
                                                                                 any time. However, if the named beneficiary is
                       DEFINITION OF ELIGIBLE DEPENDENTS FOR                     under the age of 18, a trustee must be designated.
                       THE DEPENDENT LIFE PLAN
                                                                                 You are automatically the named beneficiary for the
                       Spouse/Partner: A spouse is defined as a person           Dependent Life plan.
                       who is legally married to the employee or, although
                       not legally married, has continuously cohabited in a      DELAYED EFFECTIVE DATES IN CASE OF
                       common-law like relationship of the same or               DISABILITY
                       opposite sex with the employee for not less than
                                                                                 Employees not actively at work on the date the life
                       one full year.
                                                                                 insurance plan becomes effective are not entitled to
                                                                                 coverage at that time. In such cases, coverage will
                       Dependent Children: A dependent child is
                                                                                 commence upon return to active full-time
                       defined as unmarried (including legally adopted           employment.
                       children, foster or step-children),
                       not engaged in full-time employment, dependent on
                                                                                 CHANGES IN AMOUNTS OF COVERAGE
                       you for financial support under the age of 21 unless
                       the child is registered as a full-time student in
                                                                                 Basic and Optional Life
                       which case the child must be under the age of 25          The total amount of Basic and Optional Life
                       or if incapable of self support due to mental or          Insurance coverage changes whenever your basic
                       physical infirmity which began while the child was
                                                                                 annual salary is adjusted. If you are not at work at
                       covered as the Employee’s dependent will continue
                                                                                 that time, the change will be made on the date you
                       to be eligible.
                                                                                 return to work.
                       Note: A dependent child confined to hospital              Optional Life
                       when becoming eligible is not insured until released
                                                                                    • you may elect to change the level of your
                       from the hospital. Children confined to hospital
                                                                                      Optional Life Insurance coverage without
                       since birth will be insured when they are 15 days
                                                                                      evidence of health when any change in
                       old.
                                                                                      marital status takes place provided you make
                                                                                      application within 31 days of the date of the
                       GENERAL PLAN PROVISIONS FOR ALL                                change
                       LIFE PLANS:                                                  • you may elect to increase or apply for new
                         (BASIC, OPTIONAL AND DEPENDENT LIFE)                         coverage for any other reason, however,
                                                                                      evidence of health is required and is subject
                       ENROLLMENT PROCEDURE                                           to approval of the insurance carrier
                       Enrollment is initiated on the completion of an              • you may elect to decrease or cancel
                       application form available in Human Resources -                coverage at any time
                       Benefits.

                                                                            13
Dependent Life                                             you directly. A Human Resources - Benefits
   • there is not an option to change the level of         Representative will assist you with the processing
     coverage as outlined above in the “Changes            of the claim.
     in Amounts of Coverage” section
   • you may elect to cancel your coverage at any          TERMINATION OF COVERAGE
     time
                                                           Basic and Optional Life

                                                                                                                  LIFE INSURANCE PLANS
BENEFITS WHILE ON LEAVE OF ABSENCE OR                      Your Basic and Optional Life Insurance plans cease
TRAVELLING                                                 on the earlier of one of the following dates:
If you are going on a leave of absence, you may
arrange to continue your coverage by contacting                (1) 31 days after you terminate your
the Human Resources - Benefits to cover the cost                   employment
of your benefits prior to leaving.                             (2) 31 days after you retire
                                                               (3) on your death
When travelling outside of the country, you and                (4) the date the plan is cancelled for any
your dependent(s) will continue to be covered.                     reason

Reimbursement for any eligible claims will be made         Dependent Life
in Canadian funds.                                         Your Dependent Life Insurance plan ceases on the
                                                           earlier of one of the following dates:
TOTAL DISABILITY BENEFIT
If you become totally disabled before your normal              (1) 31 days after you terminate your
retirement date, your life benefits continue as                    employment
follows:                                                       (2) 31 days after you retire
                                                               (3) on your death
    • your Basic Life Insurance plan will be kept in           (4) when your dependent(s) are no longer
      force without cost to you                                    eligible
    • your Optional Life and Dependent Life                    (5) the date the plan is cancelled for any
      insurance plans may be kept in force without                 reason
      cost to you if the premiums are waived by the
      insurance carrier based on acceptable proof          BENEFITS AFTER TERMINATION OF
      of disability. If the premiums are not waived        COVERAGE
      by the carrier, the plans may be continued at
      full cost to you.                                    Basic and Optional Life
                                                              • your life insurance coverage may be
DEATH BENEFIT                                                   converted to an individual policy
                                                              • application for this individual policy must be
Basic and Optional Life                                         made within 31 days of termination of
In the event of your death, the Basic and Optional              employment or retirement
Life Insurance plan coverage amount in effect prior           • the individual policy issued will be without
to your death will be paid to your named                        disability or double indemnity benefits and not
beneficiary. Note: If death is the result of suicide or         in excess of the amount of your group life
any attempt thereof, sane or insane, a limitation               insurance
clause will apply. A Human Resources - Benefits               • no medical examination is necessary to
Representative will assist beneficiaries with the               convert your insurance and the premium rate
processing of the claim.                                        will be the same as would apply to a new
                                                                policy
Dependent Life
In the event of the death of your dependent(s), the
Dependent Life Insurance plan coverage amount in
effect prior to the dependent’s death will be paid to

                                                          14
Dependent Life
                          • the life insurance coverage you have on
                            your spouse can be converted to an
                            individual policy
                          • no medical evidence is required providing an
                            application for the individual insurance is
                            made within 31 days of termination of
LIFE INSURANCE PLANS

                            employment, retirement or death
                          • the conversion privilege does not apply to
                            the coverage on your children

                                                                           15
VOLUNTARY PERSONAL ACCIDENT
                   INSURANCE PLAN

    here are two Voluntary Personal Accident                 THE PLANS
T   Insurance Plans available. You may purchase
any amount of insurance in multiples of $10,000
                                                             The Plans offer 24 hour, full year protection against
                                                             accidents anywhere in the world, whether you are
subject to a minimum of $20,000 and a maximum                on or off the job.

                                                                                                                      VOLUNTARY PERSONAL ACCIDENT
of $250,000 covering yourself, or yourself and your
dependents.                                                  Plan 1 - Staff Member Only
                                                             You may purchase any amount of insurance in
PARTICIPATION IN THE PLAN                                    multiples of $10,000 subject to a minimum of
If you are a Regular Full-Time employee that is a            $20,000 and a maximum of $250,000. You are

                                                                                                                            INSURANCE PLAN
Member of the Police Association (UWOPA), you                insured for the principal sum elected.
are eligible to participate in the Voluntary Personal
Accident Insurance benefit.                                  Plan 2 - Staff Member and Family
                                                             You may purchase any amount of insurance in
Participation is optional.                                   multiples of $10,000 subject to a minimum of
                                                             $20,000 and a maximum of $250,000. You are
Coverage may be effective on the first day of your           insured for the principal sum elected. Your spouse
Regular Full-Time appointment.                               and children will be insured as follows:

COST OF THE PLAN                                                 • if there are no eligible children, your spouse
You pay the full cost of the coverage. For a                       will be insured for a spouse’s principal sum
breakdown of the cost, refer to our web site or                    which is equal to 60% of your principal sum
contact a Human Resources - Benefits                             • if there are eligible children, your spouse will
Representative.                                                    be insured for a spouse’s principal sum which
                                                                   is equal to 50% of your benefit, and each
ENROLLMENT PROCEDURE                                               eligible dependent child will be insured for a
Enrollment is initiated by the completion of an                    child’s principal sum which is equal to 15% of
application form available in Human                                your principal sum to a maximum of
Resources - Benefits.                                              $100,000
                                                                 • if there is no spouse, each eligible dependent
DEFINITION OF DEPENDENTS                                           child will be insured for a child’s principal
Spouse/Partner: A spouse is defined as a person                    sum which is 20% of your principal sum to a
who is legally married to the employee or,                         maximum of $100,000
although not legally married to the employee, has
continuously cohabited with the employee for a               An example:
period of one year immediately before a loss is
incurred under the policy, and who is publicly               Under Plan 2 - Staff Member and Family
represented as the employee’s spouse.                        You elect $50,000 on your life and wish to insure
                                                             your family consisting of spouse and three children.
Dependent Children: A dependent child is                     The amounts insured would be as follows:
defined as unmarried (including legally adopted
children, foster or step-children), not engaged in           Employee.......$50,000 (Employee’s Principal Sum)
full-time employment, dependent on you for                   Spouse...........$25,000 (Spouse’s Principal Sum)
financial support under the age of 21 unless the             Each Child......$ 7,500 (Child’s Principal Sum)
child is registered as a full-time student in
which case the child must be under the age of 25
or if incapable of self support due to mental or
physical infirmity which began while the child was
covered as the Employee’s dependent will continue
to be eligible.

                                                        16
BENEFITS
                               If injuries result in death, dismemberment or loss of use within 365 days after the date of the accident,
                               the plan provides the following benefits:
VOLUNTARY PERSONAL ACCIDENT

                              Benefit Entitlement                                  You or Your Spouse                   Your Child
                                                                                   (based on you or your spouse’s       (based on your child’s
                                                                                   your spouse’s principal sum)         principal sum)
      INSURANCE PLAN

                              Loss of Life                                         Principal Sum                         Principal Sum
                              Loss of Both Hands, Both Feet or Both Eyes           Principal Sum                        4x Principal Sum
                              Loss of One Hand and One Foot                        Principal Sum                        4x Principal Sum
                              Loss of One Hand and One Eye or One Foot
                              and One Eye                                          Principal Sum                        4x Principal Sum
                              Loss of Speech & Hearing in Both Ears                Principal Sum                        4x Principal Sum
                              Loss of Use of Both Arms or Both Hands               Principal Sum                        4x Principal Sum
                              Loss of Use of Both Feet                             Principal Sum                        4x Principal Sum
                              Loss of One Arm or One Leg                           Principal Sum                        2x Principal Sum
                              Loss of Use of One Hand or One Foot                  2/3 of Principal Sum                 1.5x Principal Sum
                              Loss of Use of One Arm or One Leg                    3/4 of Principal Sum                 2x Principal Sum
                              Loss of One Hand or One Foot                         2/3 of Principal Sum                 2x Principal Sum
                              Loss of One Eye                                      2/3 of Principal Sum                 2x Principal Sum
                              Loss of Speech or Hearing in Both Ears               2/3 of Principal Sum                 1x Principal Sum
                              Loss of Thumb and Index Finger of Same Hand
                              or at least Four Fingers                             1/3 of Principal Sum                 1/2x Principal Sum
                              Loss of Hearing in One Ear                           1/3 of Principal Sum                 1/4x Principal Sum
                              Loss of All Toes of the Same Foot                    1/4 of Principal Sum                 1/2 of Principal Sum
                              Loss of Both Arms or Both Legs                       Principal Sum                        4x Principal Sum
                              Quadriplegia (total Paralysis of both Upper
                              and Lower Limbs)                                     2x Principal Sum                     4x Principal Sum
                              Paraplegia (total Paralysis of both Lower Limbs)     2x Principal Sum                     4x Principal Sum
                              Hemiplegia (total Paralysis of both Upper and
                              Lower Limbs of One Side of the Body)                 2x Principal Sum                     4x Principal Sum

                                                                                   17
The definition of “Loss” in the previous chart shall     COMMON DISASTER
mean:                                                    If as a result of a “common accident” you and your
                                                         spouse should both lose your lives, the spouse’s
    • with respect to hand or foot, the actual           loss of life benefit shall be increased to equal 100%

                                                                                                                   VOLUNTARY PERSONAL ACCIDENT
      severance through or above the wrist or            of the insured employee’s Principal Sum to a
      ankle joint but below the elbow or knee joint      maximum of $1,000,000.
    • with respect to arm or leg, the actual
      severance through or above the elbow or                “Common accident” means the same accident
      knee joint                                             or separate accidents occurring within the same

                                                                                                                         INSURANCE PLAN
    • with respect to eye, the total and                     24 hour period.
      irrecoverable loss of sight
    • with respect to speech, the total and
      irrecoverable loss of speech which does not        REHABILITATION BENEFIT
      allow audible communication in any degree          When “injuries” to you shall result in a payment
    • with respect to hearing, the total and             being made by the Plan under the “specific loss
      irrecoverable loss of hearing which cannot be      benefits” section of the policy, the Plan will pay in
      corrected by any hearing aid or device             addition:
    • with respect to thumb, the actual severance
      through or above the first phalange                The reasonable and necessary expenses actually
    • with respect to fingers, the complete loss of      incurred up to a limit of $10,000 for your special
      two (2) entire phalanges of the finger             training provided:
    • with regard to toes, the complete loss of one
      (1) entire phalanx of the big toe, and all             (a) such training is required because of such
      phalanges of the other toes                                “injuries” and in order for you to be qualified
                                                                 to engage in an occupation in which you
                                                                 would not have been engaged except for
The definition of “Loss” in the previous chart shall             such “injuries”
mean the complete and irrecoverable paralysis by:
                                                             (b) expenses be incurred within two (2) years
    • quadriplegia (paralysis of both upper and                  from the date of the accident
      lower limbs)
    • paraplegia (paralysis of both lower limbs)             (c) no payment will be made for ordinary living,
    • hemiplegia (total paralysis of both upper and              travelling or clothing expenses
      lower limbs of one side of the body)

The definition of “Loss of Use” in the previous          OCCUPATIONAL TRAINING BENEFIT (FOR
chart shall mean:                                        YOUR SPOUSE)
                                                         When injuries to you shall result in a payment being
    • the total and irrecoverable loss of function of    made by the Plan under the section entitled
      an arm, hand or leg, provided such loss of         “Benefits”, of this policy, the Plan will pay in
      function is continuous for twelve (12)             addition:
      consecutive months and such loss of function
      is thereafter determined on evidence               The expenses actually incurred by your spouse,
      satisfactory to the carrier to be permanent        within 365 days of the date of accident, for a formal
                                                         occupational training program for the purpose of
                                                         specifically qualifying your spouse to gain active
AMOUNT OF BENEFIT PAYABLE                                employment in an occupation for which your
The Voluntary Personal Accident Insurance benefit        spouse would otherwise not have sufficient
pays 100% up to the maximum benefit provided by          qualifications. The maximum payable hereunder is
the plan.                                                $10,000.

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