Teamsters Local 805 Welfare Fund

SUMMARY PLAN DESCRIPTION -

DEATH BENEFITS

The Plan provides for payments of benefits to a designated Beneficiary upon the death of a Participant who dies while covered by this Plan. The Plan also provides accidental death, dismemberment, and loss of sight benefits.

The death benefit is payable in a lump sum payment, subject to the exclusions listed below, to the person or persons designated by you as Beneficiary. Payment will be made upon the submission of satisfactory proof of death to the Fund.

Amount of Benefits:

• $15,000 member benefit
• $3,000 spouse
• $2,000 child

No death benefit will be paid for death caused by intentional self-destruction, consumption of alcohol or illegal narcotics. No death benefit will be paid if death results from engagement in the commission of a crime. Your death benefits terminate when you leave covered employment.

A. ACCIDENTAL DEATH, DISMEMBERMENT, AND LOSS OF SIGHT BENEFITS

Accidental Death, Dismemberment and Loss of Sight benefits provide lump sum payment of benefits to a Participant for loss of limb or sight and to a Participant's Beneficiary for loss of life. Loss of sight must be entire and irrevocable and must occur while covered by the Fund. Benefits are payable only for losses caused solely by, and resulting within 90 days of, an accidental bodily Injury. The loss of life benefit is paid in addition to the Death benefit and only applies to Active Employee’s death.

i. Designated Beneficiary
In order to designate your Beneficiary, you must submit (on a form supplied by the Fund) a complete designation of Beneficiary form to the Fund Office. If you designate more than one Beneficiary, each surviving Beneficiary will receive an equal share of the death benefit unless you indicate otherwise on the form. You may change your Beneficiary at any time by submitting to the Fund Office a new Beneficiary form, which has been properly completed by you. No beneficiary designation will be effective until it is filed with the Fund Office. The appropriate form may be obtained by calling the Fund Office.

If your Beneficiary dies before you, or if you have not designated a Beneficiary, your death benefit will be paid to the surviving class of Beneficiary in the following order:

• Your surviving spouse
• Your surviving children, in equal shares
• Your surviving parents, in equal shares
• Your surviving brothers and sisters, in equal shares
• Your executors or administrators

If your Beneficiary is a minor, the benefit will be paid to his or her legally appointed guardian.

ii. Exclusions
These benefits do not apply to death, dismemberment or loss of sight due to:

• war or any act of war, whether war is declared or not, or any Injury received while in any armed service of a country which is at war or engaged in armed conflict;
• any intentionally self-inflicted Injury, suicide, or suicide attempt, whether sane or insane;
• any injury received as a result of doing any work for pay or profit;
• taking drugs, sedatives, narcotics, barbiturates, amphetamines or hallucinogens unless prescribed for or administered to you by a licensed Physician;
• an accident caused by your intoxication while operating a motor vehicle.

iii. How to Claim Death and Accidental Death and Dismemberment Benefits
In the event of the death of a Participant, the Fund office must be provided with an original death certificate. The Fund office will file the appropriate application for life insurance benefit with the life insurance company on behalf of the designated Beneficiary. If the death is accidental, the accidental death benefit will automatically be applied.

To apply for the Dismemberment Benefit, you must supply the Fund Office with the appropriate medical evidence. The Fund Office will make the appropriate application for benefits with the insurance company.