Short Term Disability Insurance Summary

Offered by Life Insurance Company of North America Short Term Disability Insurance Summary of Benefits Prepared for: Elkhart Community Schools class 1 Eligibility: All active Employees of the Employer classified as Administrator or Certified, regularly working a minimum of 20 hours per week in the United States, who are citizens or permanent resident aliens of the United States. Employee: You will be eligible for coverage the first of the month following the date of hire. Available Coverage: Maximum Benefit Gross Weekly Maximum Gross Benefit Waiting Period Disability Benefit Weekly Benefit Period (includes benefit waiting period) Employer Paid - Your 13 weeks for Employer provides 60% of your weekly 14 days for Accident Accident the following $1,000 covered earnings 14 days for Sickness 13 weeks for coverage at no cost Sickness to you. Employee Paid - 13 weeks for You have the option 60% of your weekly 30 days for Accident Accident to elect this plan to $1,000 covered earnings 30 days for Sickness 13 weeks for enhance what your Sickness Employer provides. Monthly Rate per $10 of Weekly Benefit = $0.440 Actual per pay period premiums may differ slightly due to rounding. Rates may be subject to change in the future. How to Calculate Your Monthly Cost: Step 1: Divide your annual salary by 52 to calculate your weekly earnings. Step 2: Multiply your weekly earnings by the benefit percentage defined above in the Available Coverage section. For example, 60% would be .60. Now, you have your Gross Weekly Benefit. Step 3: Use the chart above to find your Monthly rate. Multiply this rate by your Gross Weekly Benefit, or the Maximum Gross Weekly Benefit of $1,000, whichever is less. Step 4: Divide the total by 10. The result is your Monthly cost. Important Definitions and Policy Provisions: Disability -

How Long Benefits Last - Once you qualify for benefits under this plan, the maximum number of weekly Disability benefits is 13 weeks for an Accident and 13 weeks for a Sickness. Disability benefits will end sooner if you no longer qualify for benefits. When Coverage Takes Effect - Your coverage takes effect on the later of the policy9s effective date, the date you become eligible, the date we receive your completed enrollment form if required, or the date you authorize any necessary payroll deductions if applicable. If you9re not actively at work on the date your coverage would otherwise take effect, your coverage will take effect on the date you return to work. If you have to submit proof of good health, your coverage takes effect on the date we agree, in writing, to cover you. Benefit Reductions, Conditions, Limitations and Exclusions: Effects of Other Income Benefits - This plan is structured to prevent your total benefits and post-disability earnings from equaling or exceeding pre-disability earnings. Therefore, we reduce this plan9s benefits by an amount equal to any Social Security retirement and/or disability benefits payable to you, your dependents, or a qualified third party on behalf of you or your dependents. Your disability benefits will not be reduced by any Social Security disability benefits you are not receiving as long as you cooperate fully in efforts to obtain them and agree to repay any overpayment when and if you do receive them. Disability benefits will be reduced by amounts received through other government programs, sick pay, employer funded retirement benefits, workers9 compensation, franchise/group insurance, auto no-fault, and damages for wage loss. For details, see your Certificate of Insurance. Pre-existing Condition Limitation - Benefits are not payable for medical conditions for which you incurred expenses, took prescription drugs, received medical treatment, care or services (including diagnostic measures), or for which a reasonable person would have consulted a physician during the 3 months just prior to the most recent effective date of insurance. Benefits are not payable for any disability resulting from a pre-existing condition unless the disability occurs after you have been insured under this plan for at least 6 months after your most recent effective date of insurance. Termination of Disability Benefits - Your benefits will terminate when your Disability ceases, when your benefit duration period is exceeded, you earn more than your allowable Covered Earnings, or the date benefits end because you did not comply with the terms and conditions of the policy. Exclusions - This plan does not pay benefits for a Disability which results, directly or indirectly, from any of the following: Suicide, attempted suicide, or intentionally self-inflicted injury while sane or insane; War or any act of war, whether or not declared; Active participation in a riot; Commission of a felony; The revocation, restriction or non-renewal of an Employee9s license, permit or certification necessary to perform the duties of his or her occupation unless due solely to Injury or Sickness otherwise covered by the Policy; Any cosmetic surgery or surgical procedure that is not Medically Necessary; An Injury or Sickness for which the Employee is entitled to benefits from Workers' Compensation or occupational disease law; An Injury or Sickness that is work related. In addition, the plan does not pay disability benefits any period of Disability during which you are incarcerated in a penal or corrections institution. 1. Your benefit amount will be reduced by any amounts payable to you by any of the sources listed under the