Attachment L – Disability Benefits.pdf

NOTICE OF

PROTECTION PROVIDED BY

VIRGINIA LIFE, AND ACCIDENT AND SICKNESS

INSURANCE GUARANTY ASSOCIATION

This notice provides a brief summary of the Virginia Life, Accident and Sickness Insurance Guaranty

Association ("the Association") and the protection it provides for policyholders. This safety net was created under Virginia law, which determines who and what is covered and the amounts of coverage.

The Association was established to provide protection in the unlikely event that a life, annuity or accident and sickness insurance company (including a health maintenance organization) licensed in the

Commonwealth of Virginia becomes financially unable to meet its obligations and is taken over by its

Insurance Department. If this should happen, the Association will typically arrange to continue coverage and pay claims, in accordance with Virginia law, with funding from assessments paid by other life and health insurance companies licensed in the Commonwealth of Virginia.

The basic protections provided by the Association are:

• Life Insurance o $300,000 in death benefits o $100,000 in cash surrender or withdrawal values

• Health Insurance o $500,000 for health benefit plans o $300,000 in disability income insurance benefits o $300,000 in long-term care insurance benefits o $100,000 in other types of accident and sickness insurance benefits

• Annuities o $250,000 in withdrawal and cash values

The maximum amount of protection for each individual, regardless of the number of policies or contracts, is $350,000, except for health benefit plans, for which the limit is increased to $500,000.

Note: Certain policies and contracts may not be covered or fully covered. For example, coverage does not extend to any portion(s) of a policy or contract that the insurer does not guarantee, such as certain investment additions to the account value of a variable life insurance policy or a variable annuity contract. There are also various residency requirements and other limitations under Virginia law.

To learn more about the above protections, please visit the Association's website at www.valifega.org or contact:

VIRGINIA LIFE, ACCIDENT AND SICKNESS

INSURANCE GUARANTY ASSOCIATION

c/o APM Management Services, Inc.

1503 Santa Rosa Road, Suite 101

Henrico, VA 23229-5105 804-282-2240

STATE CORPORATION COMMISSION

Bureau of Insurance

P.O. Box 1157 Richmond, VA 23218-1157

804-371-9741 Toll Free Virginia only: 1-800-552-7945 http://scc.virginia.gov/boi/index.aspx

Insurance companies and agents are not allowed by Virginia law to use the existence of the

Association or its coverage to encourage you to purchase any form of insurance. When selecting an insurance company, you should not rely on Association coverage. If there is any inconsistency between this notice and Virginia law, then Virginia law will control.

http://scc.virginia.gov/boi/index.aspx jessica.meyers Typewritten text GCPS Paid STD Benefit

COMMONWEALTH OF VIRGINIA

REQUIRED POLICY INFORMATION

In the event you need to contact someone about this policy for any reason, please contact your agent.

If you have additional questions, you may contact the insurance company issuing this policy at the address and telephone number listed below.

If you have been unable to contact or obtain satisfaction from the company or the agent, you may contact the Virginia Bureau of Insurance at the address and telephone number listed below.

Written correspondence is preferable so that a record of your inquiry is maintained. When contacting your agent, company or the Bureau of Insurance, have your policy number available.

Name and address of the Insurance Company Standard Insurance Company P.O. Box 711 Portland, OR 97207

Telephone Number (503) 321-7000

Insurance Department Address Virginia Bureau of Insurance

Life and Health Division P.O. Box 1157 Richmond, VA 23218

Telephone Number In state: 1-800-552-7945 Out-of-state: (804) 371-9741

Gloucester County Public Schools

PROGRAM DOCUMENT

SHORT TERM DISABILITY INCOME BENEFIT PROGRAM

Program Sponsor has established a short term disability income benefit Program and agreed to provide

STD Benefits according to the terms of this Program Document. Program Sponsor is solely responsible for payment of STD Benefits payable under the terms of this Program.

Program Sponsor has retained Standard Insurance Company as Claims Administrator for the Program. Standard shall receive, process, investigate and evaluate claims for benefits. Standard has authority to make initial decisions to approve, deny or close claims for benefits. Standard is also authorized to review and decide appeals of denied or closed claims, if requested by claimants as provided in the appeal provision of the Program. Thereafter, Program Sponsor may elect to hear and decide any further appeals by claimants. In each case, Program Sponsor retains the right of final review and decision on all claims and appeals.

Standard will also perform certain administrative services for the Program, including advising and assisting Program Sponsor with preparation and revision of the Program and providing actuarial services. Standard has no authority or obligation with respect to management or investment of the assets of the Program or Program Sponsor's right of subrogation under the Program.

This Program and the individual applications, if any, of the Members constitute the entire Program.

Program Sponsor has the right at any time to amend or terminate this Program or to require or change the amount of Member contributions. No change in this Program will be valid unless approved by

Program Sponsor and evidenced by an amendment. No agent has authority to change this Program or to waive any of its provisions.

For purposes of effective dates and ending dates under this Program, all days begin and end at 12:00 midnight Standard Time at Program Sponsor's address.

All provisions on this and the following pages are part of this Program. "You" and "your" mean the

Member. "We", "us", and "our" mean Standard Insurance Company acting in its capacity as Claims Administrator on behalf of the Program Sponsor. Other defined terms appear with their initial letters capitalized. Section headings, and references to them, appear in boldface type.

PROGRAM SPONSOR

By

Signature(s) and Title(s) of Authorized Representative(s)

Table of Contents

COVERAGE FEATURES

GENERAL PROGRAM INFORMATION

SCHEDULE OF COVERAGE

MEMBER CONTRIBUTIONS

STATEMENT OF COVERAGE

BECOMING COVERED

WHEN YOUR COVERAGE BECOMES EFFECTIVE

ACTIVE WORK PROVISIONS

WHEN YOUR COVERAGE ENDS

REINSTATEMENT OF COVERAGE

DEFINITION OF DISABILITY

RETURN TO WORK PROVISIONS

TEMPORARY RECOVERY

WHEN STD BENEFITS END

PREDISABILITY EARNINGS

DEDUCTIBLE INCOME

EXCEPTIONS TO DEDUCTIBLE INCOME

RULES FOR DEDUCTIBLE INCOME

BENEFITS AFTER COVERAGE ENDS OR IS CHANGED

EFFECT OF NEW DISABILITY

DISABILITIES EXCLUDED FROM COVERAGE

LIMITATIONS

CLAIMS

LIMITED AGENCY APPOINTMENT OF STANDARD

TIME LIMITS ON LEGAL ACTIONS

CLERICAL ERROR

TERMINATION OR AMENDMENT OF THE PROGRAM

CONTINUED COVERAGE DURING SCHOOL VACATIONS

DEFINITIONS

Index of Defined Terms

Active Work, Actively At Work, 4 Allowable Periods, 6

ATP Number, 1

Benefit Waiting Period, 2, 14

Claims Administrator, 1 Class Definition, 1

Contributory, 14

Deductible Income, 8 Disabled, 5

Eligibility Waiting Period, 1 Employer, 14

Employer(s), 1

Hospital, 14

Injury, 14

L.L.C. Owner-Employee, 14

Maximum Benefit Period, 2, 14 Maximum STD Benefit, 1

Medical History, 4 Member, 1

Mental Disorder, 14

Noncontributory, 14

P.C. Partner, 14

Physical Disease, 14 Physician, 14

Plan Effective Date, 1 Plan Sponsor, 1

Predisability Earnings, 7

Pregnancy, 15 Prior Plan, 15

Proof Of Loss, 11

STD Benefit, 1, 15

Temporary Recovery, 6

War, 10

Work Earnings, 6

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COVERAGE FEATURES

This section contains many of the features of your short term disability (STD) coverage. Other provisions, including exclusions, limitations, and Deductible Income appear in other sections. Please refer to the text of each section for full details. The Table of Contents and the Index of Defined Terms help locate sections and definitions.

GENERAL PROGRAM INFORMATION

Program Sponsor: Gloucester County Public Schools

Employer(s): Gloucester County Public Schools

Claims Administrator: Standard Insurance Company

ATP Number: 763369-A

Program Effective Date: October 1, 2024

Member means:

1. A regular employee of the Employer;

2. Actively At Work at least 30 hours each week (for purposes of the Member definition, Actively At Work will include regularly scheduled days off, holidays, or vacation days, so long as the person is capable of Active Work on those days); and

3. A citizen or resident of the United States or Canada.

Member does not include a temporary or seasonal employee, a full-time member of the armed forces of any country, a leased employee, or an independent contractor.

Class Definition: None

SCHEDULE OF COVERAGE

Eligibility Waiting Period: You are eligible on one of the following dates, but not before the Program Effective Date:

If you are a Member on the Program Effective Date, you are eligible on the first day of the calendar month following

30 consecutive days as a Member.

If you become a Member after the Program Effective Date, you are eligible on the first day of the calendar month following 30 consecutive days as a Member.

Eligibility Waiting Period means the period you must be a Member before you become eligible for coverage.

Your Eligibility Waiting Period will be reduced by any continuous period as an employee of the

Employer immediately prior to the date you become a Member.

STD Benefit: 66 2/3% of the first $2,250 of your Predisability Earnings, reduced by Deductible Income.

Maximum: $1,500 before reduction by Deductible Income.

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Benefit Waiting Period:

For Disability caused by accidental Injury: 14 days

For Disability caused by Physical

Disease, Pregnancy or Mental

Disorder: 14 days

Please note: Pursuant to the requirements of Virginia law, if you are insured and eligible, STD Benefits will be payable immediately following the date you give birth to a child. Except as stated, all other terms and conditions of the Group Policy apply.

Maximum Benefit Period: 180 days. However, STD Benefits will end on the date long term disability benefits become payable to you under a group plan provided by your Employer, even if that occurs before the end of the Maximum Benefit Period.

Please note: Pursuant to the requirements of Virginia law, if you are insured and eligible, STD Benefits will be payable for a minimum of twelve weeks immediately following the date you give birth to a child. Except as stated, all other terms and conditions, including the Definition of Disability of the Group Policy apply.

If you are Disabled for less than one full week, one-seventh of the STD Benefit will be payable for each day of Disability.

MEMBER CONTRIBUTIONS

Coverage is: Noncontributory

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STATEMENT OF COVERAGE

If you become Disabled while covered under the Program, STD Benefits will be payable according to the terms of the Program after we receive Proof Of Loss satisfactory to us.

(ASO) ST.IC.OT.1

BECOMING COVERED

To become covered you must be a Member, complete your Eligibility Waiting Period, and meet the requirements in Active Work Provisions and When Your Coverage Becomes Effective.

You are a Member if you are:

1. A regular employee of the Employer;

2. Actively At Work at least 30 hours each week (for purposes of the Member definition, Actively At Work will include regularly scheduled days off, holidays, or vacation days, so long as you are capable of Active Work on those days); and

3. A citizen or resident of the United States or Canada.

You are not a Member if you are a temporary or seasonal employee, a full-time member of the armed forces of any country, a leased employee, or an independent contractor.

Eligibility Waiting Period means the period you must be a Member before you become eligible for coverage. Your Eligibility Waiting Period is shown in the Coverage Features.

(ASO_VAR MBR DEF) ST.BI.OT.1

WHEN YOUR COVERAGE BECOMES EFFECTIVE

A. When Coverage Becomes Effective

Subject to the Active Work Provisions, your coverage becomes effective as follows:

1. Coverage Subject To Medical History

Coverage subject to Medical History becomes effective on the date we approve your Medical

History.

2. Coverage Not Subject To Medical History

The Coverage Features states whether coverage is Contributory or Noncontributory.

a. Noncontributory Coverage

Noncontributory coverage not subject to Medical History becomes effective on the date you become eligible.

b. Contributory Coverage

You must apply in writing for Contributory coverage and agree to pay Member contributions. Contributory coverage not subject to Medical History becomes effective on:

i. The date you become eligible if you apply on or before that date; or

ii. The date you apply if you apply after the date you become eligible.

Note: If you do not apply during the Enrollment Period, then until you have been covered under the Program for 12 consecutive months, you will have a longer Benefit

Waiting Period for Disabilities caused by Physical Disease, Pregnancy or Mental

Disorder. The Enrollment Period and applicable Benefit Waiting Periods are shown in

Coverage Features.

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B. Medical History Requirement

Medical History satisfactory to us is required:

a. For Members eligible for more than 31 days but not covered under the Prior Plan.

b. For reinstatements if required.

Providing Medical History means you must:

1. Complete and sign our Medical History statement;

2. Sign our form authorizing us to obtain information about your health;

3. Undergo a physical examination, if required by us, which may include blood testing; and

4. Provide any additional information about your medical history that we may reasonably require.

(VAR EOI_ASO_WITH 60 DAY PD) ST.EF.OT.3

ACTIVE WORK PROVISIONS

A. Active Work Requirement

You must be capable of Active Work on the day before the scheduled effective date of your coverage or your coverage will not become effective as scheduled. If you are incapable of Active Work because of Physical Disease, Injury, Pregnancy or Mental Disorder on the day before the scheduled effective date of your coverage, your coverage will not become effective until the day after you complete one full day of Active Work as an eligible Member.

Active Work and Actively At Work mean performing with reasonable continuity the Material Duties of your Own Occupation at your Employer's usual place of business.

B. Changes In Coverage

This Active Work requirement also applies to any increase in your coverage.

(ASO) ST.AW.OT.1

WHEN YOUR COVERAGE ENDS

Your coverage ends automatically on the earliest of:

1. The date the last period ends for which a contribution was made for your coverage.

2. The date the Program terminates.

3. The date your employment terminates.

4. The date you cease to be a Member. However, your coverage will be continued during the following periods when you are absent from Active Work, unless it ends under any of the above.

a. During the first 90 days of a temporary or indefinite administrative or involuntary leave of absence or sick leave, provided your Employer is paying you at least the same Predisability

Earnings paid to you immediately before you ceased to be a Member. A period when you are absent from Active Work as part of a severance or other employment termination agreement is not a leave of absence, even if you are receiving the same Predisability Earnings.

b. During a leave of absence if continuation of your coverage under the Program is required by a state-mandated family or medical leave act or law.

c. During any other temporary leave of absence approved by your Employer in advance and in writing and scheduled to last 30 days or less. A period of Disability is not a leave of absence.

d. During the Benefit Waiting Period and while STD Benefits are payable.

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(ASO) ST.EN.OT.1

REINSTATEMENT OF COVERAGE

If your coverage ends, you may become covered again as a new Member. However, the following will apply:

1. If you cease to be a Member because of a Disability that is not covered solely because of the exclusion for work related Disabilities, your coverage will end. However, if you become a Member again immediately after workers' compensation temporary benefits end, the Eligibility Waiting

Period will be waived.

2. If your coverage ends because you cease to be a Member for any reason other than item 1 above, and if you become a Member again within 90 days, the Eligibility Waiting Period will be waived.

3. If your coverage ends because you fail to make a required Member contribution, you must provide a satisfactory Medical History to become covered again.

4. If your coverage ends because you are on a federal or state-mandated family or medical leave of absence, and you become a Member again immediately following the period allowed, your coverage will be reinstated pursuant to the federal or state-mandated family or medical leave act or law.

5. In no event will coverage be retroactive.

(ASO_NONOCC) ST.RE.OT.4

DEFINITION OF DISABILITY

You are Disabled if you meet the following Own Occupation definition of Disability:

You are required to be Disabled only from your Own Occupation. You are Disabled from your Own

Occupation if, as a result of Physical Disease, Injury, Pregnancy or Mental Disorder:

1. You are unable to perform with reasonable continuity the Material Duties of your Own

Occupation; and

2. You suffer a loss of at least 20% in your Predisability Earnings when working in your Own

Occupation for your Employer.

You may work in another occupation while you meet the Own Occupation definition of Disability.

However, you will no longer be Disabled when your Work Earnings from another occupation exceed

80% of your Predisability Earnings.

Your Work Earnings may be Deductible Income. See Return To Work Provisions and Deductible

Income.

Own Occupation means the job you are regularly performing for your Employer when Disability begins.

Material Duties means the usual duties you perform in your regular job with your Employer, that cannot be reasonably modified or omitted. In no event will we consider working more than 8 hours per day or an average of more than 40 hours per week to be a Material Duty.

(OWN JOB DEF_WITH 40_WITH PARTL) ST.DD.VA.2

RETURN TO WORK PROVISIONS

A. Return To Work Responsibility

No STD Benefits will be paid for any period of Disability when you are able to work in your Own

Occupation and able to earn at least 20% of your Predisability Earnings, but you elect not to work.

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B. Return To Work Incentive

You may serve your Benefit Waiting Period while working if you meet the Own Occupation definition of Disability.

You are eligible for the Return To Work Incentive on the first day you work after the Benefit

Waiting Period if STD Benefits are payable on that date.

Your Work Earnings will be Deductible Income as determined in 1., 2. and 3.

1. Determine the amount of your STD Benefit as if there were no Deductible Income, and add your Work Earnings to that amount.

2. Determine 100% of your Predisability Earnings.

3. If 1. is greater than 2., the difference will be Deductible Income.

C. Work Earnings Definition

Work Earnings means your gross weekly earnings from work you perform while Disabled, plus the earnings you could receive if you worked as much as you are able to, considering your Disability, in work that is reasonably available in your Own Occupation. Work Earnings includes sick pay, vacation pay, annual or personal leave pay or other salary continuation earned or accrued while working.

Earnings from work you perform will be included in Work Earnings when you have the right to receive them. If you are paid in a lump sum or on a basis other than weekly, we will prorate your

Work Earnings over the period of time to which they apply. If no period of time is stated, we will use a reasonable one.

In determining your Work Earnings we:

1. Will use the financial accounting method you use for income tax purposes, if you use that method on a consistent basis.

2. Will not be limited to the taxable income you report to the Internal Revenue Service.

3. May ignore expenses under section 179 of the IRC as a deduction from your gross earnings.

4. May ignore depreciation as a deduction from your gross earnings.

5. May adjust the financial information you give us in order to clearly reflect your Work Earnings.

If we determine that your earnings vary substantially from week to week, we may determine your

Work Earnings by averaging your earnings over the most recent four-week period. You will no longer be Disabled when your average Work Earnings over the last four weeks exceed 80% of your

Predisability Earnings.

(RTW RESP) ST.RW.OT.2

TEMPORARY RECOVERY

You may temporarily recover from your Disability during the Maximum Benefit Period, and then become Disabled again from the same cause or causes, without having to serve a new Benefit Waiting

Period. Temporary Recovery means you cease to be Disabled for no longer than the applicable allowable period. See Definition Of Disability.

A. Allowable Period

The allowable period of recovery during the Maximum Benefit Period is: a total of 90 days of recovery.

B. Effect Of Temporary Recovery

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If your Temporary Recovery does not exceed the Allowable Period, the following will apply.

1. The Predisability Earnings used to determine your STD Benefit will not change.

2. The period of Temporary Recovery will not count toward your Maximum Benefit Period.

3. No STD Benefits will be payable for the period of Temporary Recovery.

4. No STD Benefits will be payable after benefits become payable to you under any other disability coverage plan under which you become covered during your period of recovery.

5. Except as stated above, the provisions of the Program will be applied as if there had been no interruption of your Disability.

(ASO) ST.TR.OT.2

WHEN STD BENEFITS END

Your STD Benefits end automatically on the earliest of:

1. The date you are no longer Disabled.

2. The date your Maximum Benefit Period ends.

3. The date you die.

4. The date long term disability benefits become payable to you under a group long term disability insurance policy issued to Program Sponsor as policyholder, even if that occurs before the end of the Maximum Benefit Period.

5. The date benefits become payable to you under any other disability plan under which you become covered through employment during a period of Temporary Recovery.

6. The date you fail to provide proof of continued Disability and entitlement to STD Benefits.

(ASO_REV LTD LIM) ST.BE.OT.3

PREDISABILITY EARNINGS

Your Predisability Earnings will be based on your earnings in effect on your last full day of Active

Work. Any subsequent change in your earnings will not affect your Predisability Earnings.

Predisability Earnings means your weekly rate of earnings from your Employer, including:

1. Contributions you make through a salary reduction agreement with your Employer to:

a. An Internal Revenue Code (IRC) Section 401(k), 403(b), 408(k), 408(p), or 457 deferred compensation arrangement; or

b. An executive nonqualified deferred compensation arrangement.

2. Commissions averaged over the prior 52 weeks or over the period of your employment if less than 52 weeks.

3. Shift differential pay.

4. Amounts contributed to your fringe benefits according to a salary reduction agreement under an IRC Section 125 plan.

Predisability Earnings does not include:

1. Bonuses.

2. Overtime pay.

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3. Stock options or stock bonuses.

4. Your Employer's contributions on your behalf to any deferred compensation arrangement or pension plan.

5. Any other extra compensation.

If you are paid on an annual contract basis, your weekly rate of earnings is one fifty-second (1/52nd) of your annual contract salary.

If you are paid hourly, your weekly rate of earnings is based on your hourly pay rate multiplied by the number of hours you are regularly scheduled to work per week, but not more than 40 hours. If you do not have regular work hours, your weekly rate of earnings is based on the average number of hours you worked per week during the preceding 52 weeks (or during your period of employment if less than

52 weeks), but not more than 40 hours.

(REG WITH COM_NO STOCK) ST.PD.OT.1

DEDUCTIBLE INCOME

Subject to Exceptions To Deductible Income, Deductible Income means:

1. Your Work Earnings, as described in the Return To Work Provisions.

2. Any amount you receive or are eligible to receive because of your disability under a state disability income benefit law or similar law.

3. Any amount you receive or are eligible to receive because of your disability under another group coverage.

4. Any disability or retirement benefits you receive or are eligible to receive under your Employer's retirement plan, including a public employee retirement system, a state teacher retirement system, and a plan arranged and maintained by a union or employee association for the benefit of its members. You and your Employer's contributions will be considered as distributed simultaneously throughout your lifetime, regardless of how funds are distributed from the retirement plan.

If any of these plans has two or more payment options, the option which comes closest to providing you a monthly income for life with no survivors benefit will be Deductible Income, even if you choose a different option.

5. Any earnings or compensation included in Predisability Earnings which you receive or are eligible to receive while STD Benefits are payable.

6. Any amount you receive or are eligible to receive under any unemployment compensation law or similar act or law.

7. Any amount you receive by compromise, settlement, or other method as a result of a claim for any of the above, whether disputed or undisputed.

(ASO_PUB_NONOCC_WITH RTW_NO OTHR OFFST_NO 3RD) ST.DI.OT.1

EXCEPTIONS TO DEDUCTIBLE INCOME

Deductible Income does not include:

1. Any cost of living increase in any Deductible Income other than Work Earnings, if the increase becomes effective while you are Disabled and while you are eligible for the Deductible Income.

2. Reimbursement for hospital, medical, or surgical expense.

3. Reasonable attorneys fees incurred in connection with a claim for Deductible Income.

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4. Benefits from any individual disability insurance policy.

5. Group credit or mortgage disability insurance benefits.

6. Accelerated death benefits paid under a life coverage plan or life insurance policy.

7. Benefits from the following:

a. Profit sharing plan.

b. Thrift or savings plan.

c. Deferred compensation plan.

d. Plan under IRC Section 401(k), 408(k), 408(p), or 457.

e. Individual Retirement Account (IRA).

f. Tax Sheltered Annuity (TSA) under IRC Section 403(b).

g. Stock ownership plan.

h. Keogh (HR-10) plan.

(ASO_PUB_NO OTHR OFFST) ST.ED.OT.1

RULES FOR DEDUCTIBLE INCOME

A. Weekly Equivalents

Each week we will determine your STD Benefit using the Deductible Income for the same weekly period, even if you actually receive the Deductible Income in another week.

If you are paid Deductible Income in a lump sum or by a method other than weekly, we will determine your STD Benefit using a prorated amount. We will use the period of time to which the

Deductible Income applies. If no period of time is stated, we will use a reasonable one.

B. Your Duty To Pursue Deductible Income

You must pursue Deductible Income for which you may be eligible. We may ask for written documentation of your pursuit of Deductible Income. You must provide it within 60 days after we mail you our request. Otherwise, we may reduce your STD Benefits by the amount we estimate you would be eligible to receive upon proper pursuit of the Deductible Income.

C. Pending Deductible Income

We will not deduct pending Deductible Income until it becomes payable. You must notify us of the amount of the Deductible Income when it is approved. You must repay us for the resulting overpayment of your claim.

D. Overpayment Of Claim

We will notify you of the amount of any overpayment of your claim under the Program. You must immediately repay any overpayment. You will not receive any STD Benefits until the overpayment has been repaid in full. In the meantime, any STD Benefits paid, including the Minimum STD

Benefit, will be applied to reduce the amount of the overpayment. We may charge you interest at the legal rate for any overpayment which is not repaid within 30 days after we first mail you notice of the amount of the overpayment.

(ASO) ST.RU.OT.2

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BENEFITS AFTER COVERAGE ENDS OR IS CHANGED

During each period of continuous Disability, STD Benefits will be payable according to the terms of the Program in effect on the date you become Disabled. Your right to receive STD Benefits will not be affected by:

1. Any amendment to the Program that is effective after you become Disabled; or

2. Termination of the Program after you become Disabled.

ST.BA.OT.1

EFFECT OF NEW DISABILITY

If a period of Disability is extended by a new cause while STD Benefits are payable, STD Benefits will continue while you remain Disabled. However, 1 and 2 below will apply.

1. STD Benefits will not continue beyond the end of the original Maximum Benefit Period.

2. All provisions of the Program, including the Disabilities Excluded From Coverage and

Limitations sections, will apply to the new cause of Disability.

(ASO) ST.ND.OT.1

DISABILITIES EXCLUDED FROM COVERAGE

A. War

You are not covered for a Disability caused or contributed to by War or any act of War. War means declared or undeclared war, whether civil or international, and any substantial armed conflict between organized forces of a military nature.

B. Intentionally Self-Inflicted Injury

You are not covered for a Disability caused or contributed to by an intentionally self-inflicted

Injury, while sane or insane.

C. Work Related

You are not covered for a Disability arising out of or in the course of any employment for wage or profit.

D. Violent Or Criminal Conduct

You are not covered for a Disability caused or contributed to by your committing or attempting to commit an assault or felony, or actively participating in a violent disorder or riot. Actively participating does not include being at the scene of a violent disorder or riot while performing your official duties.

E. Loss Of License Or Certification

You are not covered for a Disability caused or contributed to by the loss of your professional license, occupational license or certification.

(NONOCC) ST.XD.OT.1

LIMITATIONS

A. Care Of A Physician

You must be under the ongoing care of a Physician in the appropriate specialty as determined by us during the Benefit Waiting Period. No STD Benefits will be paid for any period of Disability

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B. Occupational Benefits

No STD Benefits will be paid for any period when you are eligible to receive benefits for your

Disability under a workers' compensation law or similar law. If your claim for these benefits is accepted, compromised or settled (whether disputed or undisputed), you must repay us for the full amount of any payments Program Sponsor makes to you while your claim for occupational benefits is pending.

C. Paid Sick Leave Or Other Salary Continuation

No STD Benefits will be paid for any period when you are receiving paid sick leave pay, annual or personal leave pay, or other salary continuation, including donated amounts, (but not vacation pay) from your Employer.

D. Imprisonment

No STD Benefits will be paid for any period of Disability when you are confined for any reason in a penal or correctional institution.

E. Return To Work Responsibility

No STD Benefits will be paid for any period of Disability when you are able to work in your Own

Occupation and able to earn at least 20% of your Predisability Earnings, but you elect not to work.

F. Rehabilitation Program

No STD Benefits will be paid for any period of Disability when you are not participating in good faith in a plan, program or course of medical treatment or vocational training or education approved by us unless your Disability prevents you from participating.

(ASO_NONOCC_RTW RSP_MAND REHB) ST.LM.OT.1

CLAIMS

A. Filing A Claim

Claims should be filed on our forms. If you do not receive our forms within 15 days after you ask for them, you may submit your claim in a letter to us. The letter should include the date Disability began, and the cause and nature of the Disability. You must notify us of a claim in writing within 20 days after you become disabled. If you cannot do so, you must notify us as soon as reasonably possible.

B. Time Limits On Filing Proof Of Loss

You must give us Proof Of Loss within 90 days after the end of the Benefit Waiting Period. If you cannot do so, you must give it to us as soon as reasonably possible, but not later than one year after that 90-day period. If Proof Of Loss is filed outside these time limits, your claim will be denied. These limits will not apply while you lack legal capacity.

C. Proof Of Loss

Proof Of Loss means written proof that you are Disabled and entitled to STD Benefits. Proof Of

Loss must be provided at your expense.

For claims of Disability due to conditions other than Mental Disorders, we may require proof of physical impairment that results from anatomical or physiological abnormalities which are demonstrable by medically acceptable clinical and laboratory diagnostic techniques.

D. Documentation

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Completed claims statements, a signed authorization for us to obtain information, and any other items we may reasonably require in support of a claim must be submitted at your expense. If the required documentation is not provided within 45 days after we mail our request, your claim may be denied.

E. Investigation Of Claim

During the pendency of your claim, we may investigate your claim at any time.

At our expense, we may have you examined at reasonable intervals by specialists of our choice.

We may deny or suspend STD Benefits if you fail to attend an examination or cooperate with the examiner.

F. Time Of Payment

Program Sponsor will pay STD Benefits within 60 days after you satisfy Proof Of Loss.

STD Benefits will be paid to you at the end of each week you qualify for them. STD Benefits remaining unpaid at your death will be paid to your estate.

G. Notice Of Decision On Claim

We will evaluate your claim promptly after you file it. Within 45 days after we receive your claim we will send you: (a) a written decision on your claim; or (b) a notice that we are extending the period to decide your claim for 30 days. Before the end of this extension period we will send you:

(a) a written decision on your claim; or (b) a notice that we are extending the period to decide your claim for an additional 30 days. If an extension is due to your failure to provide information necessary to decide the claim, the extended time period for deciding your claim will not begin until you provide the information or otherwise respond.

If we extend the period to decide your claim, we will notify you of the following: (a) the reasons for the extension; (b) when we expect to decide your claim; (c) an explanation of the standards on which entitlement to benefits is based; (d) the unresolved issues preventing a decision; and (e) any additional information we need to resolve those issues.

If we request additional information, you will have 45 days to provide the information. If you do not provide the requested information within 45 days, we may decide your claim based on the information we have received.

If we deny any part of your claim, you will receive a written notice of denial containing:

a. The reasons for our decision.

b. Reference to the parts of the Program on which our decision is based.

c. A description of any additional information needed to support your claim.

d. Information concerning your right to a review of our decision.

H. Review Procedure

If all or part of a claim is denied, you may request a review. You must request a review in writing within 180 days after receiving notice of the denial.

You may send us written comments or other items to support your claim. You may review and receive copies of any non-privileged information that is relevant to your request for review. There will be no charge for such copies. You may request the names of medical or vocational experts who provided advice to us about your claim.

The person conducting the review will be someone other than the person who denied the claim and will not be subordinate to that person. The person conducting the review will not give deference to the initial denial decision. If the denial was based on a medical judgment, the person conducting the review will consult with a qualified health care professional. This health care professional will

09/24/2024 - 13 - 763369-A be someone other than the person who made the original medical judgment and will not be subordinate to that person. Our review will include any written comments or other items you submit to support your claim.

We will review your claim promptly after we receive your request. Within 45 days after we receive your request for review we will send you: (a) a written decision on review; or (b) a notice that we are extending the review period for 45 days. If the extension is due to your failure to provide information necessary to decide the claim on review, the extended time period for review of your claim will not begin until you provide the information or otherwise respond.

If we extend the review period, we will notify you of the following: (a) the reasons for the extension;

(b) when we expect to decide your claim on review; and (c) any additional information we need to decide your claim.

If we request additional information, you will have 45 days to provide the information. If you do not provide the requested information within 45 days, we may conclude our review of your claim based on the information we have received.

If we deny any part of your claim on review, you will receive a written notice of denial containing:

a. The reasons for our decision.

b. Reference to the parts of the Program on which our decision is based.

c. Information concerning your right to receive, free of charge, copies of non-privileged documents and records relevant to your claim.

I. Assignment

The rights and benefits under the Program are not assignable.

(ASO_REV PUB WRDG) ST.CL.VA.2

LIMITED AGENCY APPOINTMENT OF STANDARD

Program Sponsor has appointed Standard to act on its behalf as Claims Administrator for the Program and grants Standard authority to fulfill the Obligations of Claim Administration as provided herein.

Standard is empowered to act on behalf of Program Sponsor in connection with the Program only as expressly stated in this Program. Standard has no authority or obligation with respect to (1) an

Program Sponsor's right of subrogation under the Program, or (2) management or investment of the assets of the Program. In performing its obligations under this Agreement, Standard is acting solely as the agent of Program Sponsor.

Standard's decisions are subject to the review procedures of the Program Sponsor.

(ASO) ST.AP.OT.1

TIME LIMITS ON LEGAL ACTIONS

No action at law or in equity may be brought until 60 days after you have given us Proof Of Loss. No such action may be brought more than three years after the earlier of:

1. The date we receive Proof Of Loss; and

2. The time within which Proof Of Loss is required to be given.

(ASO) ST.TL.OT.1

CLERICAL ERROR

Clerical error by Program Sponsor, your Employer, Claims Administrator, or their respective employees or representatives will not:

09/24/2024 - 14 - 763369-A

1. Cause a person to become covered.

2. Invalidate coverage under the Program otherwise validly in force.

3. Continue coverage under the Program otherwise validly terminated.

(ASO) ST.CE.OT.2

TERMINATION OR AMENDMENT OF THE PROGRAM

Program Sponsor may terminate the Program in whole, and may terminate coverage for any class or group of Members, at any time.

Benefits under the Program are limited to its terms, including any valid amendment. No change or amendment will be valid unless approved by Program Sponsor and evidenced by an amendment.

No agent has authority to change or amend the Program or to waive any of its terms or provisions.

Any such change or amendment of the Program may apply to current or future Members or to any separate classes or groups of Members.

(ASO) ST.TA.OT.2

CONTINUED COVERAGE DURING SCHOOL VACATIONS

If you cease to be a Member because of a school break or vacation, your coverage will be continued during that period.

ST.SV.OT.1

DEFINITIONS

Benefit Waiting Period means the period you must be continuously Disabled before STD Benefits become payable. No STD Benefits are payable for the Benefit Waiting Period. See Coverage Features.

Contributory means coverage under the Program is elective and Members pay all or part of the cost of coverage.

Employer means an employer (including approved affiliates and subsidiaries) for which coverage under the Program is approved in writing by us.

Hospital means a legally operated hospital providing full-time medical care and treatment under the direction of a full-time staff of licensed physicians. Rest homes, nursing homes, convalescent homes, homes for the aged, and facilities primarily affording custodial, educational, or rehabilitative care are not Hospitals.

Injury means an injury to the body.

L.L.C. Owner-Employee means an individual who owns an equity interest in an Employer and is actively employed in the conduct of the Employer's business.

Maximum Benefit Period means the longest period for which STD Benefits are payable for any one period of continuous Disability, whether from one or more causes. It begins at the end of the Benefit

Waiting Period. No STD Benefits are payable after the end of the Maximum Benefit Period, even if you are still Disabled. See Coverage Features.

Mental Disorder means any mental, emotional, behavioral, psychological, personality, cognitive, mood or stress-related abnormality, disorder, disturbance, dysfunction or syndrome, regardless of cause

(including any biological or biochemical disorder or imbalance of the brain) or the presence of physical symptoms. Mental Disorder includes, but is not limited to, bipolar affective disorder, organic brain syndrome, schizophrenia, psychotic illness, manic depressive illness, depression and depressive disorders, anxiety and anxiety disorders.

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Noncontributory means (a) coverage under the Program is nonelective and Program Sponsor or the Employer pay the entire cost of coverage; or (b) Program Sponsor requires all eligible Members who meet the Active Work requirements to have coverage and to pay all or part of the cost of coverage.

P.C. Partner means the sole active employee and majority shareholder of a professional corporation in partnership with Program Sponsor.

Physical Disease means a physical disease entity or process that produces structural or functional changes in your body as diagnosed by a Physician.

Physician means a licensed M.D. or D.O., acting within the scope of the license. Physician does not include you or your spouse, or the brother, sister, parent, or child of either you or your spouse.

Pregnancy means your pregnancy, childbirth, or related medical conditions, including complications of pregnancy.

Prior Plan means your Employer's short term disability Program in effect on the day before the effective date of your Employer's coverage under the Program and which is replaced by the Program.

Program means the group short term disability income benefit Program established by Program

Sponsor and identified by the ATP Number.

STD Benefit means the weekly benefit payable to you under the terms of the Program.

(ATP) ST.DF.OT.1

VA/STDP2000 (ASO)

STANDARD INSURANCE COMPANY

A Stock Life Insurance Company

900 SW Fifth Avenue Portland, Oregon 97204-1282

(503) 321-2700

DISABILITY PROGRAM ADMINISTRATIVE SERVICES AGREEMENT

Program Sponsor: Gloucester County Public Schools

Program Administrator: Gloucester County Public Schools

Claims Administrator: Standard Insurance Company

ATP Number: 763369-A

Effective Date: October 1, 2024

Note: The terms of this Agreement are not governed under the terms of any Master Service Agreement issued by Standard Insurance Company in conjunction with any other services provided to Client.

Program Sponsor has adopted a self-funded short-term disability income benefit program (Program) for certain of its employees. Program Sponsor is solely responsible for all risks, liabilities, benefits and claims under the Program.

Program Sponsor has requested Standard to provide administrative services to the Program as described in this Agreement. Standard is willing to provide such services, according to the terms of this Agreement, without assuming any financial responsibility under the Program.

Standard's willingness to provide administrative services is conditioned upon Program Sponsor's agreement that Standard is not responsible for any risk, liability, benefit or claim under the Program and upon Program Sponsor fulfilling its obligations as provided herein.

Created 09/24/2024 - 1 - Agreement No. 763369-A

LIMITED AGENCY APPOINTMENT OF STANDARD

Program Sponsor hereby appoints Standard to act on its behalf as Claims Administrator for the

Program and grants to Standard authority to fulfill the Obligations of Claims Administrator, as provided herein. Standard is empowered to act on behalf of Program Sponsor in connection with the

Program only as expressly stated in this Agreement. Standard has no authority or obligation with respect to (1) Program Sponsor's right of subrogation under the Program, or (2) management or investment of the assets of the Program. In performing its obligations under this Agreement, Standard is acting solely as the agent of Program Sponsor.

OBLIGATIONS OF CLAIMS ADMINISTRATOR

Standard, acting as Claims Administrator for the Program, shall provide the following services, consistent with the terms of the Program :

A. Claims Services

1) Investigate claims for benefits under the Program, determine eligibility for coverage, make initial claim decisions to approve, deny or close claims for benefits, and notify claimants and

Program Sponsor in writing of its decisions, subject to Program Sponsor’s right of final review and decision on all claims.

2) If an appeal is requested by the claimant, provide an independent review and notify claimant and Program Sponsor in writing of Standard’s decision, subject to Program Sponsor's right of final review and decision on all appeals.

3) Advise and assist Program Sponsor on procedures to be followed in submission of claims, including the preparation of forms necessary for submission and processing of claims.

4) Create and maintain a current and complete claim file for any claim presented to Standard for administration under the Program.

5) Submit to Program Sponsor all claims Program Sponsor may request to review.

6) Prepare benefit statements for claimants setting forth the benefit schedule applicable and explaining any adjustments.

7) Have medical and vocational examinations of claimants performed as Standard deems advisable

8) If required under the terms of the Program, advise claimants concerning the need to apply for deductible income and periodically verify application for or receipt of deductible income.

9) Review claims to determine continued eligibility for benefits as frequently as claimant's condition warrants.

B. Program Document Services

1) Advise and assist Program Sponsor with regard to the initial preparation of the Program and recommend subsequent revisions as may be appropriate.

2) Advise and assist Program Sponsor with regard to the preparation and review of Program summaries, descriptive booklets, certificates of coverage and similar material for distribution to covered employees.

C. Actuarial Services

Upon written request, submit to Program Sponsor periodic reports summarizing the financial experience of the Program and provide data required for compliance with state and federal disclosure legislation.

Created 09/24/2024 - 2 - Agreement No. 763369-A

D. Performance Standards

Standard shall exercise ordinary care and reasonable diligence in the performance of its duties under this Agreement. Standard will not be liable for any mistake of judgment or other action taken in good faith. Further, Standard shall not be considered to have failed to perform its obligations under this Agreement if any delay or nonperformance on its part is due, in whole or in part, to Program Sponsor's failure to discharge its own obligations promptly.

OBLIGATIONS OF PROGRAM SPONSOR

Program Sponsor shall:

A. Retain full financial responsibility for the Program and its operation.

B. Furnish any information reasonably required by Standard to carry out Standard’s duties under this Agreement, including but not limited to relevant program documents and any other administrative guidance necessary to administer the program.

C. Execute authorizations or corollary agreements necessary for Standard to execute its obligations under this Agreement.

D. Review Standard's claim and appeal decisions in a timely manner. If Program Sponsor fails to notify Standard in writing of any objection it may have to any such decision within 45 days after notice thereof from Standard, Program Sponsor shall be deemed to have waived such objection and shall be conclusively presumed to have ratified and approved Standard's decision.

E. Defend claim litigation arising out of or relating to, in whole or in part, the financial responsibility of Program Sponsor for the risks, liabilities and benefits of the Program, regardless of whether such liability, claim, lawsuit, or administrative proceeding is rightfully or wrongfully brought or filed. Program Sponsor agrees that Standard may, at Standard’s option and expense, assume the defense obligation of any such liability, claim, lawsuit, or administrative proceeding.