UFCW LOCAL 1776 and PARTICIPATING EMPLOYERS                                   HEALTH and WELFARE FUND

 

Accidental Death and Dismemberment Insurance

The Fund also provides you with Accidental Death & Dismemberment (AD&D) benefits under a policy of insurance with Standard Insurance Company )("Standard").. You will receive AD&D benefits if you are seriously injured in an accident. AD&D benefits are also paid to your beneficiary if you die in an accident. Only participants, not dependents, are covered for AD&D benefits. The amount of your AD&D benefit is based on two factors - the extent of your injury and length of your service. The maximum benefit you are eligible to receive is based on the same chart used for life insurance. Check the chart below for your maximum benefit amount.

If you are a...	Your coverage is...
Part-time participant with less than 2 years of service	$1,000
Part-time participant with at least 2 but less than 5 years of service	$1,500
Part-time participant with at least 5 but less than 10 years of service	$2,500
Part-time participant with 10 or more years of service	$10,000
If you have an accident at or away from work, and suffer any of the losses listed on the chart below within 180 days as a result of that accident, you or your beneficiary will receive the percentage of your maximum benefit shown on the chart below. No more than 100% of your AD&D insurance will be paid for all losses resulting from one accident
Lost of:	Percentage of AD&D Benefit:
Life	100%
Both hands; both feet; sight in both eyes; one hand and one foot; one hand and sight in one eye; or one foot and sight on one eye.	100%
One hand; one foot; or sight in one eye.	50%
For example, if a participant with six years of service loses one hand in an accident, he or she will be eligible for 50 percent of $2,500, or $1,250. Claims must be filed within 90 days of the date of the loss; however, if the claim cannot be filed within such 90 days, it must be filed not later than one year after that 90-day period. Seat Belt Benefit Your AD&D benefit includes a seat belt benefit. The amount of the seat belt benefit is the lesser of (1) $10,000 or (2) the amount of the AD&D insurance benefit payable for loss of life. The seat belt benefit will be paid if all of the following requirements are met: You die as a result of an automobile accident for which an AD&D insurance benefit is payable for loss of your life; and You are wearing and properly utilizing a seat belt system at the time of the accident, as evidenced by a police accident report. Seat belt system means a properly installed combination lap and shoulder restraint system that meets the Federal Vehicle Safety Standards of the National Highway Traffic Safety Administration. Seat belt system will include a lap belt alone, but only if the automobile did not have a combination lap and shoulder restraint system when manufactured. Seat belt system does not include a shoulder restraint alone. Automobile means a motor vehicle licensed for use on public highways. Exclusions No AD&D insurance benefit is payable if any of the following cause or contribute to the accident or loss:    War or act of war. War means declared on undeclared war, whether civil or international, and any substantial armed conflict between organized forces of a military nature.    Suicide or other intentionally self-inflicted injury, while sane or insane.    Committing or attempting to commit a felony, or actively  participating in a riot. Actively participating does not include being at the scene of riot while performing your official duties or being a spectator.    The voluntary use or consumption of any narcotic, unless prescribed by a physician.    Sickness existing at the time of the accident.    Medical or surgical treatment for any of the above. Please note: This AD&D benefit is provided pursuant to a policy of insurance.  That policy of insurance is incorporate by reference as if fully set forth herein. If there are any differences between the benefit description set forth in this booklet and the policy of insurance, the policy of insurance prevails. If you wish to review the policy of insurance, please contact the Fund office.