You are eligible for the benefits described in this website if contributions are made on your behalf as a member of the Port Chester Teachers Association. Also, other personnel listed below are eligible for Fund benefits if contributions are made on their behalf:

You are eligible to receive benefits under the PORT CHESTER TEACHERS ASSOCIATION WELFARE TRUST FUND (Fund) on the first day of your employment if you are an employee of the Port Chester School District working part time (at least 20 hours per week) or a fulltime employee as so designated by the School District and for whom contributions are made to the Fund on your behalf by the Port Chester School District.

If you request family coverage, your eligible dependents will be covered as of the date your coverage begins. Your eligible dependents include:

Dependent children are your natural children, stepchildren, legally adopted children (including children in a waiting period prior to finalization of adoption) and any other children related to you by blood or marriage who are living in a regular parent-child relationship with you and are dependent upon you for support and maintenance.

If your dependent is eligible for benefits as a member, then he or she is only eligible for member benefits and not for benefits as your dependent.

When Are Your Dependents Eligible for Coverage?

If you acquire a new dependent child after you become covered and you wish to include the dependent in your coverage, you should notify the Fund Office. The Fund reserves the right to request necessary documentation to support your relationship to your dependent (e.g., birth certificates; proof of marriage; adoption decree; etc.).

A member's coverage will end on the last day of employment and when any of the following events occurs:

A dependent's coverage will end when the first of these events occurs:

Under certain circumstances when coverage for you or your dependents would otherwise end, they may be eligible to continue coverage under the Fund. See the COBRA section for details.

Note: Basic Health Insurance is provided by the School District - not the PCTA Welfare Trust Fund.

WHAT IS COORDINATION OF BENEFITS AND HOW DOES IT WORK?

When benefits would be payable under more than one group plan, benefit payments will be coordinated so that the total benefits paid under all Group Plans will not exceed 100% of the total amounts charged. If you and your spouse are both eligible for benefits as members of the Port Chester Teachers Association Welfare Trust Fund, your benefit payments will also be coordinated not to exceed 100% of the total amounts charged.

Claim Procedure Under the Coordination of Benefits Provision:

If you are a covered member of the Fund and are eligible for benefits from another group plan:

If your spouse has a claim and is eligible for benefits under another group plan:

If a claim is submitted for a child when one parent is a covered member of the Fund and the other parent is a covered member of another plan:

If the claim is submitted for a child whose parents are divorced when one parent is a covered member of the Fund and the other parent is a covered member of another plan:

CLAIMS INFORMATION

Filing Dental and Optical Claims

You must file claims to receive your Port Chester Teachers Association Welfare Trust Fund benefits. Claims forms are available from Administrative Services Only, Inc., and Form Downloads (Top of this Page).

All claims should be sent to:

• Administrative Services Only, Inc.
• P.O. Box 9018
• Lynbrook, N.Y. 11563-9018
• 1-800-537-1238
• www.asonet.com

Appeal Procedure

The benefits provided by this Fund may be changed by the Board of Trustees. The Board of Trustees adopts rules and regulations for the payment of benefits and all provisions of this website are subject to rules and regulations and to the Trust Indenture which established and governs the Fund operations.

All rules are uniformly applied by the Fund Office. The action of the Fund Office is subject to review only by the Board of Trustees. A covered member may request a review of action taken by the Fund Office by submitting an appeal, in writing, to the Board of Trustees within 60 days after the action of the Fund Office. Such appeal should be addressed to the Board of Trustees, Port Chester Teachers Association Welfare Trust Fund, c/o Jeffrey D Querfeld, 4 Fox Hill Road Valhalla, NY 10595. Phone (914) 815-8929.

In Addition

When any change occurs in your status - marriage, divorce, separation, birth or adoption of a child, death of an eligible dependent - or you wish to change the beneficiary of your Life Insurance/AD&D, please notify the Fund Office. It is important and to your advantage that you keep the Fund Office up-to-date on your current status.

The Trustees intend to continue the benefits described in this website indefinitely. However, the Trustees reserve the right to change or discontinue the type and amounts of benefits offered by the Fund and the eligibility rules for coverage.

Benefits provided through the Fund and eligibility rules for active, retired, or disabled participants:

What is Cobra?

COBRA continuation coverage is a continuation of Fund coverage when coverage would otherwise end because of a life event known as a "qualifying event." Specific qualifying events are listed later in this notice. COBRA continuation coverage must be offered to each person who is a "qualified beneficiary." A qualified beneficiary is someone who will lose coverage under the Fund because of a qualifying event. Depending on the type of qualifying event, employees, spouses of employees, and dependent children of employees may be qualified beneficiaries. Under the Fund, qualified beneficiaries who elect COBRA continuation coverage must pay for COBRA continuation coverage.

WHAT IS A QUALIFYING EVENT?

If you are an employee, you will become a qualified beneficiary if you will lose your coverage under the Fund because either one of the following qualifying events happens:

If your are the spouse of an employee, you will become a qualified beneficiary if you will lose your coverage under the Fund because of any of the following qualifying events happens:

Your dependent children will become qualified beneficiaries if they will lose coverage under the Fund because any of the following qualifying events happens:

Sometimes, filing a proceeding in bankruptcy under Title 11 of the United States Code can be a qualifying event. If a proceeding in bankruptcy is filed with respect to the school district ("Employer") and that bankruptcy results in the loss of coverage of any retired-employee covered under the Fund, the retired employee is a qualified beneficiary with respect to bankruptcy. The retired employee's spouse, surviving spouse, and dependent children will also be qualified beneficiaries if bankruptcy results in the loss of their coverage under the Fund.

Election Period

The fund will offer COBRA continuation coverage to qualified beneficiaries only after the Fund Administrator has been notified that a qualifying event has occurred. When the qualifying event is the end of employment or reduction of hours of employment, death of the employee, commencement of a proceeding of bankruptcy with respect to the employer, or enrollment in Medicare (Part A, Part B, or both), the employer must notify the Fund Administrator of the qualifying event within 30 days of any of these events.

For the other qualifying events (divorce or legal separation of the employee and spouse or a dependent child's losing eligibility for coverage as a dependent child), YOU must notify the Fund Administrator. The Fund requires you to notify the Fund Administrator within 60 days after the qualifying event occurs. You must send this notice to the Fund Administrator. In the event of death, a copy of the death certificate must be provided. In the event of enrollment in Medicare, you must send a copy of the Medicare card. In the event of divorce, you must send a copy of the divorce judgment. In the event of legal separation, you must send a copy of the Court Order of Separation.

Once the Fund Administrator receives the notice that a qualifying event has occurred, COBRA continuation coverage will be offered to each of the beneficiaries. For each qualified beneficiary who elects COBRA continuation coverage, COBRA continuation coverage will begin on the date of the qualifying event or on the date that Fund coverage would otherwise have been lost, if later.

Continuation Period

COBRA continuation coverage is temporary continuation coverage. When the qualifying event is the death of the employee, enrollment of the employee in Medicare (Part A, Part B, or both), your divorce or legal separation, or a dependent child losing eligibility as a dependent child, COBRA continuation coverage lasts for up to 36 months.

When a qualifying event is the end of employment, COBRA continuation coverage lasts up to 18 months. There are two ways in which this 18-month period of COBRA continuation coverage can be extended:

• Disability Extension of 18-month Period of Continuation Coverage
  If you or anyone in your family covered under the Fund is determined by the Social Security Administration to be disabled at any time during the first 60 days of COBRA continuation coverage, and you notify the Fund Administrator in a timely fashion, you and your entire family can receive up to an additional 11 months of COBRA continuation coverage, for a total of 29 months. You must make sure that the Fund Administrator is notified of the Social Security Administration's determination by sending a copy of the Determination letter within 60 days of the date of the determination and before the end of the 18-month period of COBRA continuation of coverage. This notice should be sent to the Fund Administrator.
• Second Qualifying Event Extension of 18-month Period of Continuation Coverage
  If your family experiences another qualifying event while receiving COBRA continuation coverage, the spouse and dependent children in your family can get additional months of COBRA continuation coverage, up to a maximum of 36 months. This extension is available to the spouse and dependent children if the former employee dies, enrolls in Medicare (Part A, Part B, or both), or gets divorced or legally separated. The extension is also available to a child when the child stops being eligible under the Fund as a dependent. In all these cases, you must make sure the Fund Administrator is notified of the second qualifying event within sixty days of the second qualifying event. This notice must be sent to the Fund Administrator. In the event of death, a copy of the death certificate must be provided. In the event of enrollment in Medicare, you must send a copy of the Medicare card. In the event of legal separation, you must send a copy of the Court Order of Separation.

TERMINATION OF COVERAGE

The continued coverage will cease on the first of the following dates:

HOW ARE COBRA RATES DETERMINED?

The law permits the Fund to charge any person who elects to continue coverage 102% of the full cost to the Plan. If the cost changes, the Fund will revise the charge you are required to pay, but no more than once every 12 months. In addition, if the benefits change for active employees your coverage will change as well.

If you have questions

If you have questions about your COBRA continuation coverage, you should contact the Fund Administrator or you may contact the nearest Regional or District Office of the U.S. Department of Labor's Employee Benefits Security Administration (EBSA). Addresses and phone numbers of Regional and District EBSA Offices are available through EBSA's website www.dol.gov/ebsa.

Keep Your Fund Informed of Address Changes

In order to protect your family's rights, you should keep the Fund Administrator informed of any changes in the addresses of family members. You should also keep a copy, for your records, of any notices you send to the Fund Administrator.

COVERED EXPENSES

Covered Expenses include charges made by a Dentist for the performance of Dental Services provided for in the Port Chester Teachers Association Welfare Trust Fund Schedule of Covered Expenses, when the Dental Service is performed by or under the direction of a Dentist, is essential dental care, and begins and is completed while the individual is covered for benefits.

HOW TO DECLINE DENTAL COVERAGE:

Dental benefits may be declined for yourself and/or any dependents at any time by completing a Declination of Coverage form, which may be obtained by contacting the Fund Administrator .

A Dental Service is deemed to start when the actual performance of the service starts except that:

MAXIMUM AMOUNT PAYABLE:

The maximum amount payable for Covered Dental Expenses in any calendar year is:

MAXIMUM LIFETIME ORTHODONTIC BENEFIT:

ANNUAL DEDUCTIBLE:

HOW BENEFITS ARE PAID:

PRE-TREATMENT REVIEW:

ALTERNATE BENEFITS PROVISION:

EXPENSES NOT COVERED:

Covered Expenses will not include, and no payment will be made for, expenses incurred for:

GENERAL LIMITATIONS:

No payment will be made for expenses incurred:

EXTENSION OF BENEFITS:

An expense incurred in connection with a dental service that is completed after a person's benefits cease will be deemed to be incurred while that person was eligible if:

How to decline coverage:

Schedule of Covered Procedures

	Reimbursement
Eye Examination	$55.00
Lenses and Frames
Single vision lenses and frames	$145.00
Bifocal lenses and frames	$170.00
Other lenses and frames	$195.00
Contact Lenses	$170.00
Frames	$100.00

Limitations

Eligibility

Enrollment

Appeals to the Board of Trustees

How to Use the Legal Services Plan

If you wish to make an appointment to consult a lawyer for benefits provided by the Port Chester Teachers Association Welfare Trust Fund, call Mirkin & Gordon at 914-997-1576.

The initial appointment with the attorney will be made through the Fund. Necessary forms and instructions for their use will be given to you by the attorney. You will be provided with an attorney from the panel law firm selected by the Fund. This firm will provide the covered member with the benefits of the Fund. Your relationship with this Law firm will be that of attorney and client. The attorney-client relationship will be exclusively between the covered member and the law firm. No member of the Fund, or any Trustee of the Fund can interfere in this relationship.

The Fund is designed to help pay for covered legal services. This Fund cannot pay for all legal costs incurred, but it will help meet a substantial amount of such costs. You should explore, with an attorney of the panel law firm, the cost involved for any problem for which you seek help so that you and the law firm will have a working concept of what services are covered as well as what you will have to pay yourself. Remember, however, that it is not always possible to estimate total costs. When, after general consultation with the panel law firm, you decide to retain the panel law firm, you will then be required to make initial payment as indicated in the plan of benefits.

As a covered member you are not compelled to use the plan provided by the Fund. You are free at any time to select an attorney of your own choosing and make payment of such an attorney for his services, but the Fund will not absorb or be responsible for any part of the fees or charges of attorneys other than those representing law firms on the panel of the Fund.

A covered member is also free at any time to discontinue the services of the panel law firm and, if he/she so desires, to secure the services of a non-panel attorney. However, in such an event the Fund will not be responsible for nor adsorb any part of the fees or charges of such other attorneys. In addition, the covered member continues to be obligated to the panel law firm for any cost already incurred above the scheduled amount.

The panel law firm may, under exceptional circumstances, at any time (as is customary in the case of the independent retention of private attorneys) not undertake, discontinue or withdraw from representation of any covered member with appropriate adjustment of fees. In such cases, the covered member is free to secure his/her own counsel; however, the Fund will neither absorb nor be responsible for any of the fees or charges of a non-panel attorney.

There is no subscription or registration fee to be paid by any covered member in order to entitle him/her to the benefits of the Fund, unless you choose to continue being eligible for these benefits upon retirement or when you commence a leave of absence (unpaid).

In instances where two covered members are involved in the same controversy or proceedings as adversaries, (and both members would have the right to the benefit under the rules of the Fund) each member will be provided access to an attorney, or provided with a stipend by the Fund at the discretion of the Board of Trustees.

The benefits of the Fund are divided into two major benefit categories: Representation in Civil Matters and Representation in General Legal Matters.

Counseling of Unemancipated Minors

Who is Eligible?

Upon application of the member/parent, your unemancipated* child, who is over 18 years of age and qualifies as an eligible dependent child (as defined by the rules of the Fund).

What is the Benefit?

The Fund provides coverage through the panel law firm for consultation and document review services to your unemancipated child on matters involving the following:

How is the Counseling of Unemancipated Children Benefit obtained?

To obtain the Counseling of Unemancipated Children Benefit, simply contact the Fund to request an appointment for your child. At the time of the appointment, your child and an attorney from the panel firm will complete the appropriate forms.

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* An unemancipated child is any dependent child (as defined by the rules of the Fund) who is over 18 years of age and fully dependent on you/the member for support.

Exclusions:

Excluded from the Counseling of Unemancipated Children Benefit is advice or consultation in any controversy, dispute or proceeding with the covered member/parent.

This section describes the Civil Matters of the Fund. These benefits are provided to all members. The following describes the benefits included within the Civil Matters category.

LEGAL DEFENSE BENEFIT

Who is Eligible?

Any covered member who is a defendant in a situation involving his/her rights in resisting a claim and has had a legal action started against him/her, which does not fall within any of the specified benefits listed in this section*, is covered by this benefit.

*Please note that special service benefits such as those involving divorce proceedings, separation proceedings, annulment proceedings, adoption proceedings, and homeowner proceedings, are covered by the schedules and contained under those specific headings in this section.

What is the Benefit?

The Fund provides coverage through the panel law firm for all necessary legal services arising from the defense of a lawsuit or proceedings commenced against a covered member in courts and administrative agencies. The following are only examples of some of the courts and agencies in which the Fund provides coverage under the Legal Defense Benefit:

Supreme, Surrogate's and District Courts of Westchester County; United States District Court for the Eastern and Southern Districts of New York; United States Customs Court, Supreme, Surrogate's and County Courts of New York, Brooklyn, Queens, Richmond, Bronx, Nassau, Rockland, Putnam, Dutchess and Suffolk Counties; Civil Courts of New York, Brooklyn, Queens, Richmond and Bronx Counties; District Court of Nassau County; Administrative Agencies and Bureaus.

This benefit provides, for example, the legal defense cost of a lawsuit alleging breach of contract or against lawsuits involving garnishment or medical expense claims. A covered employee's problem may be successfully resolved after consultation with a panel attorney or it may necessitate the steps leading to and including defense in a litigation or before an administrative agency.

The following schedule indicates the legal services available and the amount to be paid by the member at each circumstance:

Steps in the Legal Process Provider By the Panel Law Firm	Amount Paid By Member
A. Consultation:	None
B. Pre-litigation: for example,negotiation of settlement including the drafting of any necessary papers	$15.00
C. Litigation: for example, third party complaint, demand for Bill of Particulars, preparation of Jury Demand and Court Appearance, if necessary	$35.00

the Legal Defense Benefit is concluded at the consultation stage, there is no cost to the member. However, if the Legal Defense Benefit is concluded at the pre-litigation stage, the cost to the member is $15.00; if the benefit must enter the litigation stage, the cost to the member is an additional $35.00. Hence, the total cost to the member for a Legal Defense Benefit that reaches litigation is $50.00 ($15.00 + $35.00).

How is the Legal Defense Benefit Obtained?

To obtain the Legal Defense Benefit, simply contact the Fund to request an appointment. At the time of your appointment, you and your attorney from the panel law firm will complete the appropriate forms.

UNCONTESTED LEGAL SEPARATION BENEFIT

Who is Eligible?

Any covered member who desires to seek a separation from his/her spouse by means of a separation agreement mutually agreed upon by the parties or any relief through the court by instituting an action for an uncontested legal separation is covered by this benefit.

What is the Benefit?

There are two types of legal separation: uncontested and contested separation. The Fund provides coverage for all circumstances in the legal process in an uncontested separation.

For Uncontested Separation, coverage is provided through the panel law firm for all necessary legal services which the preparation and negotiation of a separation agreement may require. The separation agreement may be prepared and executed with a minimum of consultation, or it may necessitate extensive negotiation with opposing counsel and spouse.

The following schedule indicates the legal services available and the amount to be paid by the member in each circumstance:

Steps in the Legal Process Provider By the Panel Law Firm	Amount Paid By Member
A. Consultation:	None
B. Uncontested or cooperatively agreed separation with minimal negotiation:	$45.00
C. Settlement after extensive negotiation:	$75.00

The following schedule indicates the legal services available in an uncontested separation proceeding and the amount to be paid by the member in each circumstance:

Steps in the Legal Process Provider By the Panel Law Firm	Amount Paid By Member
A. Consultation:	None
B. Litigation: for example, conference, preparation of summons and Verified Complaint, preparation of Findings of Fact and Conclusions of Law.	$75.00

How is the Uncontested Legal Separation Benefit Obtained?

To obtain the Uncontested Legal Separation Benefit, simply contact the Fund to request an appointment. At the time of the appointment, you and your attorney from the panel law firm will complete the appropriate forms.

UNCONTESTED DIVORCE BENEFIT

Who is Eligible?

Any covered member who is a defendant or a plaintiff in an uncontested divorce proceeding is covered by this benefit.

What is the Benefit?

The Fund provides coverage through the panel law firm for all steps of the legal process in uncontested divorce proceedings.

The following schedule indicates the legal services available to be paid by the member in each circumstance.

Steps in the Legal Process Provider By the Panel Law Firm	Amount Paid By Member
A. Uncontested Divorce: Coverage includes the issuance of Summons and Complaint, Note of Issue, preparation of Finding Fact, Conclusion of Law, Judgement, Entry of Judgement and Finalization	$60.00

How is the Uncontested Divorce Benefit Obtained?

To obtain the Uncontested Divorce Benefit, simply contact the Fund to request an appointment. At the time of the appointment, you and your attorney from the panel law firm will complete the appropriate forms.

UNCONTESTED ANNULMENT BENEFIT

Who is Eligible?

Any covered member who is a defendant or a plaintiff in an uncontested annulment proceeding is covered by this benefit.

What is the Benefit?

The Fund provides coverage through the panel law firm for all steps in the legal process in uncontested annulment proceedings.

The following schedule indicates the legal services available and the amount to be paid by the member in each circumstance.

Steps in the Legal Process Provider By the Panel Law Firm	Amount Paid By Member
A. Uncontested Annulment: Coverage includes, Summons, Complaint, Not of Issue, Trial or Hearing, preparation of Findings of Fact, Conclusion of Law, Entry of Judgement and Finalization	$60.00

How is the Uncontested Annulment Benefit Obtained?

To obtain the Uncontested Annulment Benefit, simply contact the Fund to request an appointment. At the time of the appointment, you and your attorney from the panel law firm will complete the appropriate forms.

ADOPTION BENEFIT

Who is Eligible?

Any covered member who seeks representation in an adoption proceedings is covered by this benefit.

What is the Benefit?

The Legal Services Fund provides coverage through the panel law firm for representation in formal adoption proceedings. This benefit does not include payment of any fees or expenses to adoption agencies or any other agencies but is limited to those services normally rendered by an attorney to formalize an adoption. After all arrangements have been agreed upon, the panel attorney will prepare all petitions and allied papers and will appear in court with the parties in support of the adoption, if required.

The following schedule indicates the legal services available and the amount to be paid by the covered member in each circumstance.

Steps in the Legal Process Provider By the Panel Law Firm	Amount Paid By Member
A. Consultation:	None
B. Preparation of Documents and court appearances for adoption of child:	$65.00

How is the Adoption Benefit Obtained?

To obtain the Adoption Benefit, simply contact the Fund to request an appointment. At the time of the appointment, you and your attorney from the panel law firm will complete the appropriate forms. PERSONAL BANKRUPTCY BENEFIT

Who is Eligible?

Any covered member who seeks representation in a personal bankruptcy proceedings is covered by this benefit.

What is the Benefit?

The Fund provides coverage through the panel law firm for all necessary conferences and legal services in the preparation of a petition to file for personal bankruptcy. Such a petition and schedules to file for personal bankruptcy may be finalized with a minimum of consultation and negotiation or it may involve a number of exceedingly complex steps. In some situations it may require attendance at meetings with creditors and settlement agreements. The following schedule indicates the legal services available and the amount to be paid by the member in each circumstance.

Steps in the Legal Process Provider By the Panel Law Firm	Amount Paid By Member
A. Consultation:	None
B. Personal Bankruptcy (Simple):	$75.00
C. Complex Personal Bankruptcy:	$100.00

How is the Personal Bankruptcy Benefit Obtained?

To obtain the Personal Bankruptcy Benefit, simply contact the Fund to request an appointment. At the time of the appointment, you and your attorney from the panel law firm will complete the appropriate forms. CHANGE OF NAME BENEFIT

Who is Eligible? Any covered member who wishes to legally change his/her name is covered by this benefit.

What is the Benefit?

The Fund provides coverage through the panel law firm for legal advice and representation in the change of name procedure. Counsel will file all appropriate papers and represent the member in the change of name process. The following schedule indicates the legal services available and the amount to be paid by the member in each circumstance.

Steps in the Legal Process Provider By the Panel Law Firm	Amount Paid By Member
A. Consultation:	None
B. Actual change of name procedure:	$45.00

How is the Change of Name Benefit Obtained?

To obtain the Change of Name Benefit, simply contact the Fund to request an appointment. At the time of the appointment, you and your attorney from the panel law firm will complete the appropriate forms.

HOMEOWNER'S RIGHTS BENEFIT

Who is Eligible?

Any covered member who owns a private dwelling, condominium or co-operative as a primary residence or is in the process of purchasing or selling such a residence or refinancing of a mortgage on a primary residence* is covered by this benefit.

*This benefit does not include any aspects of residential problems that involve title searches or title insurance nor the costs of same.

What is the Benefit?

The Fund provides coverage through the panel law firm for two (2) components of the homeowner's rights benefit.

1. Coverage is provided for legal advice or representation for the same, or purchase of a private dwelling, condominium or co-operative in which the member primarily resides or plans to reside; or the purchase of unimproved property with the intention of building a home in which the member expects to reside primarily, or the refinancing of a mortgage on a primary residence.

The following schedule indicates the legal service available and the amount to be paid by the member in each circumstance.

Steps in the Legal Process Provider By the Panel Law Firm	Amount Paid By Member
A. Consultation:	None
B. Negotiation, advice, and representation in the sale or purchase of real estate to be used as a primary residence	$60.00

2. Coverage is provided for legal advice or representation in defense of a proceeding to foreclose a mortgage on a dwelling which the member owns and in which the member primarily resides. A mortgage foreclosure problem may be resolved after consultation with a panel attorney or it may require the contesting of any action to foreclose the mortgage in the appropriate court.

The following schedule indicates the legal services available and the amount to be paid by the member at each circumstance.

Steps in the Legal Process Provider By the Panel Law Firm	Amount Paid By Member
A. Consultation:	None
B. Pre-litigation: for example, negotiation of settlement as well as the drafting of any necessary papers	$15.00
C. Litigation: for example, Demand for Bill of Particulars, preparation of Jury Demand, Motions, and Court Appearances,if necessary	$125.00

How Is The Homeowner's Rights Benefit Obtained?

To obtain the Homeowner's Rights Benefit, simply contact the Fund to request an appointment. At the time of the appointment, you and your attorney from the panel law firm will complete the appropriate forms.

REPRESENTATION IN GENERAL LEGAL MATTERS

indicated before, the Legal Services' benefits are divided into two categories: Civil Matters and Representation in General Legal Matters. This section describes the General Legal Matters of the Fund. These benefits are provided to members in those instances where the member's legal problems do not fall within the benefits provided within the Representation in Civil Matters category.

The following section describes the benefits included within the General Legal Matters category.

GENERAL CONSULTATION BENEFIT

Who is Eligible?

Any member who wishes legal consultation is covered by this benefit.

What is the Benefit?

The Fund provides coverage through the panel law firm for a member to consult with an attorney concerning any legal questions whatsoever.*

The Fund makes this benefit available at no charge to the member.

How is the Consultation Benefit Obtained?

To obtain the General Consultation Benefit, simply contact the Fund to request an appointment. At the time of the appointment, you and your attorney from the panel law firm will complete the appropriate forms.

* The General Consultation Benefit does not include representation. If such representation involves a covered matter, the Fund will pay the cost of representation in accordance with its Benefit Schedule. Of course, if the matter is not covered, then any further legal costs must be borne directly by the member.

DOCUMENT REVIEW BENEFIT

Who is Eligible?

Any member who wishes to have a document reviewed by an attorney is covered by this benefit.

What is the Benefit?

The Fund provides coverage through the panel law firm for professional review and interpretation of all legal documents such as: guarantees, warranties, installment purchase agreements, loans, leases, insurance policies and court papers.*

covered member may use the Document Review Benefit as many times during the year as proves necessary.

*The Fund makes this benefit available at no charge to the member.

The following are not included in the Document Review Benefit:

Tax Returns and work that is being prepared by other attorneys at the time of the Document Review. E.g., prenuptial agreements.

How is the Document Review Benefit Obtained?

To obtain the Document Review Benefit, simply contact the Fund to request an appointment. At the time of the appointment, you and your attorney from the panel law firm will complete the appropriate forms.

WILL BENEFIT

Who is Eligible?

Any member and/or his or her spouse (if agreeable to the member) who wishes to execute a will or have one reviewed or updated is covered by this benefit.

What is the Benefit?

The Fund provides coverage through the panel law firm for the preparation and execution of a simple will (a will with no trust provisions) for the member and spouse (if agreeable to the member) under the supervision of an attorney. The Will Benefit may not be used more than once in every three (3) consecutive year period. The Fund makes this benefit available at no charge to the member and/or spouse.

How Is the Will Benefit Obtained?

To obtain the Will Benefit, simply contact the Fund to request an appointment. If both member and spouse desire a will, it is recommended that they make the appointment together. At the time of the appointment, you and your attorney from the panel law firm will complete the appropriate forms. A second appointment will be necessary for the execution (signing) of the completed will(s).

LIVING WILL/HEALTH CARE PROXY BENEFIT

Who is Eligible?

Any covered member and his/her spouse (if agreeable to the member) who wishes to establish a living will/health care proxy is covered by this benefit.

What is the Benefit?

The Fund provides coverage through the panel law firm to have a living will/health care proxy prepared and executed under the supervision of an attorney.

living will/health care proxy serves as a clear, documented expression of an individual's carefully considered intention to have life-sustaining procedures withheld or withdrawn in the event he/she were to suffer from a catastrophic illness, disease or injury from which there is little likelihood that he/she would recover to enjoy a meaningful quality of life.

The Fund makes this benefit available at no charge to the member or spouse.

How Is the Living/Health Care Proxy Benefit Obtained?

To obtain the Living Will/Health Care Proxy Benefit, simply contact the Fund to request an appointment. If both husband and wife desire a living will/health care proxy, it is recommended that they make the appointment together. At the time of the appointment, you and your attorney from the panel law firm will complete the appropriate forms.

PERSONAL INJURY (NEGLIGENCE) BENEFIT

Who is Eligible?

member and/or all members of his/her immediate family who has suffered a personal injury as a result of negligence is covered by this benefit.

What is the Benefit?

The Fund provides coverage through the panel law firm for all legal services, through trial if necessary, in connection with the prosecution of a claim for personal injury as a consequences of negligence in cases which legal counsel believes are worth of prosecution.

The member will be represented on the basis of a contingent fee of 33-1/3% of the net sum recovered.

What Does "Contingent Fee" Mean?

It means that the fee is contingent upon successful recovery, whether by suit, settlement or otherwise. Thus, if there is no recovery, there is no fee. Conversely, the more that is recovered, the greater the fee - all dependent upon a successful conclusion of the matter. For example, assuming there is a net recovery as in the following cases, the legal fees would be as follows:

Steps in the Legal Process Provider By the Panel Law Firm	Amount Paid By Member
A net recovery of:
$50,000.00	$16,666.66
$25,000.00	$ 8,333.00

is customary, whether the litigation is successful or not, you are required to reimburse the firm for all disbursements, charges and other expenses, such as: medical and police reports, investigations, witness fees, ect. Also, as is customary, in computing this contingent fee, liens in favor of hospitals, doctors, ect. or other statutory liens upon recovery, are not to be deducted. Such amounts would be paid out of the injured party's share of the recovery.

How Is the Personal Injury (Negligence) Benefit Obtained?

To obtain the benefit, simply contact the Fund to request an appointment. At the time of the appointment, you and your attorney from the panel law firm will complete the appropriate forms.

ARRAIGNMENT ASSISTANCE TELEPHONE CONSULTATION BENEFIT

Who is Eligible?

Any covered member or eligible covered dependent who is a defendant in a criminal proceeding in Putnam, Westchester, Dutchess, Rockland Counties or the boroughs of New York City, is covered by this benefit.

What is the Benefit?

The Fund provides coverage through the panel law firm for necessary legal assistance arising from an arrest which may lead to immediate imprisonment.

This benefit provides, for example, a telephone consultation with an attorney, where the member and/or dependent is charged as the defendant in a criminal matter. It is important to note, however, that this benefit DOES NOT cover the costs of legal assistance beyond the arraignment stage. Thus, if the member/defendant is interested in obtaining legal services beyond the arraignment stage, he/she must make the necessary arrangements directly with the panel law firm or retain another attorney of his/her choice.

The following schedule indicates the legal services available and the amount to be paid by the member in each circumstance.

Steps in the Legal Process Provider By the Panel Law Firm	Amount Paid By Member
A. Telephone Consultation:	None

How Is the Arraignment Assistance Telephone Consultation Benefit Obtained?

The Fund has arranged for the Arraignment Assistance Telephone Consultation Benefit to be provided on an emergency twenty-four (24) hour basis via our ARRAIGNMENT HOTLINE TELEPHONE NUMBER. CALL: 914-997-1576.

CONSUMER PROTECTION BENEFIT

Who is Eligible?

Any member who seeks representation in a consumer protection issue is covered by this benefit.

What is the Benefit?

The Fund provides coverage through the panel law firm for a broad range of legal services which might be needed to institute and pursue action against fraudulent practices by merchants, department stores, home repair contractors, public utilities, automobile dealers, appliance dealers, ect. Utilization of this benefit is limited to two (2) matters per member per year, and the matter must involve a purchase costing $250 or more.

The following schedule indicates the legal services available and the amount to be paid by the member in each circumstance.

Steps in the Legal Process Provider By the Panel Law Firm	Amount Paid By Member
A. Consultation:	None
B. Representation by written communication	None
C. Litigation in Small Claims Court	$50.00
D. Litigation in court other than small claims court	$100.00*
E. Representation with appropriate Federal Agencies (e.g., F.T.C.)	$100.00

*If a lawsuit involves a consumer purchase of $5,000 or more, e.g. a "lemon car", then the cost to the member for litigation or representation shall be $250.00

NOTE: Some legal services not provided under this benefit include, but are not limited to, suits for Punitive Damages, Class Actions and Commercial Enterprises.

How Is The Consumer Protection Benefit Obtained?

To obtain the Consumer Protection Benefit, simply contact the Fund to request an appointment. At the time of the appointment, you and your attorney from the panel law firm will complete the appropriate forms.

PLANNING FOR THE ELDERLY BENEFIT

Who is Eligible?

Any covered member and his/her spouse who is responsible for elderly parents is covered by this benefit.

What is the Benefit?

The Fund provides coverage through the panel law firm for legal consultations on matters involving the placement of elderly parent(s) in nursing home(s), available Medicare entitlements and health planning for the elderly. This benefit includes the preparation of Power(s) of Attorney.

The Fund makes this benefit available at no charge to members and/or spouses.

How Is the Planning for the Elderly Benefit Obtained?

To Obtain the Planning for the Elderly Benefit simply contact the Fund to request an appointment. At the time of the appointment, you and your attorney from the panel law firm will complete the appropriate forms.

ESTATE PROBATE AND ADMINISTRATION BENEFIT

Who is Eligible?

Any member; member's eligible dependent who is named Executor in a Will; an Executor named in a Will by a covered member for whom the Executor is not an eligible dependent; and/or if there is no Will, a member or an eligible dependent who would qualify under intestacy laws, to serve as Administrator of the estate is covered by the benefit.

What Is the Benefit?

The Fund provides all legal services which may be required in connection with the handling of an estate from its inception (the Probate of a Will or Petition for Letters of Administration where there is no Will), through all phases of estate administration including tax proceedings and "winding up" of the estate (through accounting and distribution).*

With respect to the estate of a deceased member, these services are provided to the surviving spouse or eligible dependent child or children in those instances where a spouse or eligible dependent child(ren) would be entitled to the appointed Executor or Administrator.

*PLEASE NOTE: This benefit does not provide legal services of an adversarial nature, e.g. to contest an existing Will or provision therein.

The following schedule indicates the possible legal services available and the amount to be paid by the member in each circumstance.

Steps in the Legal Process Provider By the Panel Law Firm	Amount Paid By Member
A. Consultation:	None
B. Small Estate Proceedings	$150.00
C. Estates other than Small Estate Proceedings	$250.00 plus 3% of the gross estate for estate tax purposes in excess of $10,000 and up to $500,000, and 2.5% of the gross estate for estate tax purposes in excess of $500,000.

How Is the estate Probate and Administration Benefit Obtained?

To obtain the Estate Probate and Administration Benefit, simply contact the Fund to request an appointment. At the time of the appointment, you and your attorney from the panel law firm will complete the appropriate forms.

GENERAL EXCLUSIONS FROM ALL BENEFITS OF THE LEGAL SERVICES PLAN OF BENEFITS

All legal services provided by the Fund have been specifically stated and described. Any legal service that has not been so described can be considered excluded from the Fund Plan of Benefits.

However, in order to guide the member in his/her utilization of the Fund benefit package, this section lists specifically, but without limitation, particular exclusions from the Plan of Benefits:

The Fund will not pay:

IF YOU HAVE ANY QUESTIONS WITH REGARD TO COVERAGE, BENEFITS OR EXCLUSIONS, PLEASE CONTACT THE FUND OFFICE

LIFE INSURANCE, ACCIDENTAL DEATH AND DISMEMBERMENT (AD&D) INSURANCE

INTRODUCTION

Your Life and AD&D Insurance benefits are provided under a policy of insurance issued to The Port Chester Teachers Association Welfare Trust Fund by The First Reliance Standard Life Insurance Company. The benefits available under this policy are described in the following section. In this section, the terms "we", "our" and "us" refer to First Reliance Standard Life Insurance Company.

The group insurance policy specifies the exact benefit provided, and the language of the insurance policy will govern in the event of any inconsistency between it and the language of this booklet.

You may see a copy of the group policy at the Port Chester Teachers Association Welfare Trust Fund office.

SCHEDULE OF BENEFITS -

FIRST RELIANCE STANDARD LIFE INSURANCE COMPANY Policy #GL 145089

LIFE INSURANCE, ACCIDENTAL DEATH AND DISMEMBERMENT (AD&D)

ELIGIBLE CLASS(ES):

All permanent, active, full-time Superintendent of Schools, Assistant Superintendent of Schools, Superintendent of Buildings and Grounds, School Business Administrators, Teachers, Teacher Assistants, Confidential Secretaries, District Clerk, Directors, and Retired members receiving a New York State Retirement Benefit.

HOURLY REQUIREMENTS FOR FULL-TIME EMPLOYEES

at least 20 hours per week (except District Clerk - no hourly requirement).

WAITING PERIOD

Date of employment.

BASIS OF INSURANCE

NON-CONTRIBUTORY

Class	Amount of Life Insurance*	Full Amount of AD&D Insurance*
Eligible Employees	$100,000	$100,000

* For Active Employees, on or after your 65th birthday, the insurance company decreases the amount of your insurance. Based on age, the insurance company pays a percentage of the amount otherwise payable to you.

* For members who retire on 1/1/2009 or later, the benefits will be reduced by 35% at age 65, then reduced by another 35% at age 70 and finally reduced to $2,500 at age 75. AD&D terminates at retirement.

EMPLOYEE'S INSURANCE

Definitions

employee - an active employee in an eligible class who the employer employs and pays and who works a sufficient amount of hours to fulfill the hourly requirement as stated above. For Life Insurance only, also included are former active employees who satisfy the definition of retiree as stated above.

employee's insurance - the coverage of an insured employee under the Group Policy, according to the Schedule of Benefits. It does not include any dependents' insurance

Participating Employer - The Port Chester School District.

Policy Holder - The Port Chester Teachers Association Welfare Trust Fund.

we, us, our - The First Reliance Standard Life Insurance Company at its Home Office.

you, your - an employee insured for employee's insurance under the Group Policy.

How does an employee become insured?

To become insured, all of the following conditions must be met:

The employee must:

• be eligible for the insurance.
• be actively at work.
• give us proof of good health we accept, without expense to us, if the employee applies more than 31 days after becoming eligible.
• give us proof of good health we accept, without expense to us, if the employee applies after converting any part of this insurance under its Conversion Right.

When is any employee eligible for insurance?

The employee is eligible on the later of the following dates:

• The Group Policy's Effective Date, July 1, 1994.
• The Plan Effective Date.
• The date the employee completes the waiting period with the Policyholder.

When does employee's insurance start?

The employee's insurance starts on the latest of the following dates:

• The date the employee becomes eligible.
• The date the employee returns to active work if the employee is not actively at work on the date insurance would otherwise start. Exception: The employee's insurance starts on a non-working day if the employee was actively at work on the employee's last scheduled working day before the non-working day.
• The date the employee applies for the insurance, if the employee has to pay any part of the cost.
• The date we approve the employee's proof of good health, if we require proof.

When is a change in the amount of your insurance effective?

If a change in your insurance class or earnings results in a change in the amount of your insurance

The amount of your insurance increases on -

• The date your class or earnings change, if you are actively at work on that date,
• The date you return to active work, if you are not actively at work on the date your class or earnings change, or
• The non-working day on which your class or earnings change if you were actively at work on your last scheduled working day before the non-working day.

The amount of your insurance decreases on the date of change in class or earnings.

When does your insurance stop?

Your insurance stops on the earliest of the following dates:

• The date you are no longer actively at work for the Employer.
• The date you are no longer eligible for insurance under the Group Policy.
• The date the Group Policy terminates.
• The date the Fund stops participating in the trust.
• The date the Trust Agreement establishing the First Reliance Standard Life Insurance Company Trust terminates.
• The end of the period for which you paid premiums, if you do not make a required premium contribution when due.
• For AD&D Insurance, the date your Life Insurance stops. AD&D Insurance stops at the beginning of the period in which you are eligible to convert your Life Insurance.

We stop providing a specific benefit under your insurance on the date that benefit stops being provided under the Group Policy.

Under what conditions may your insurance be continued?

Your insurance may be continued depending on the reason it will otherwise stop.

LIFE INSURANCE

What is the Life Insurance Benefit?

We pay a death benefit to your beneficiary if we receive written proof that you died while this insurance is in force.

The death benefit is the Amount of Life Insurance for your class shown on the Schedule of Benefits in effect on the date of death.

We pay the death benefit for all causes of death.

Beneficiary

The beneficiary is named to receive the proceeds to be paid at the time of your death. You may name one or more beneficiaries. You cannot name the Employer or Policyholder as beneficiary.

You may name, add, or change beneficiaries by written request as described below. You may also choose to name a beneficiary that you cannot change without his or her consent. This is an irrevocable beneficiary.

How do you name, add, or change beneficiaries?

You can name, add, or change beneficiaries by written request if all of these are true:

• Your coverage is in force.
• We have written consent of all irrevocable beneficiaries.
• You have not assigned the ownership of your insurance. The rights of an assignee are described under the Assignment Section.

All requests are subject to our approval. A change will take effect as of the date it is signed but will not affect any payment we make or action we take before receiving your notice.

To whom do we pay proceeds?

We pay proceeds to the beneficiary. If there is more than one beneficiary, each receives an equal share, unless you have requested another method in writing.

If there is no eligible beneficiary or you did not name one, we pay proceeds to the persons listed below in order:

• 1) Your spouse.
• 2) Your children.
• 3) Your parents.
• 4) Your estate.

Settlement Options

Settlement Options are alternative ways of paying the proceeds under the Group Policy. Proceeds are the amount of each benefit we pay when the insured person dies.

To find out more about the settlement options available or how to choose or cancel an option, please contact the Policyholder or Employer.

AD&D INSURANCE

What is the Accidental Death and Dismemberment (AD&D) Insurance Benefit?

We pay AD&D benefits if you lose your life, limb, or sight due to accidental injury.

Under what conditions do we pay benefits?

We pay benefits if all of the following are true:

• You are covered for AD&D Insurance on the date of the accident.
• Loss occurs within 365 days of the accident.
• The cause of the loss is not excluded.

How much will we pay?

We pay the benefit shown on the Table of AD&D Benefits if you suffer any of the losses listed.

The Full Amount of AD&D Insurance is shown in the Schedule of Benefits. We pay only one Full Amount in total while the Group Policy is in effect. If you have a loss for which we pay 1/2 the Full Amount, we pay no more than 1/2 the Full Amount for the next loss. After we have paid one Full Amount, no further benefits are payable under this AD&D Insurance.

Table of AD&D Benefits

For loss of:	The benefit is:
Life	Full Amount
Both hands	Full Amount
Both feet	Full Amount
Sight of both eyes	Full Amount
1 hand and 1 foot	Full Amount
1 hand and sight of 1 eye	Full Amount
1 foot and sight of 1 eye	Full Amount
1 hand	1/2 Full Amount
1 foot	1/2 Full Amount
Sight of 1 eye	1/2 Full Amount

Loss of hands or feet means loss by being permanently, physically severed at or above the wrist or ankle. Loss of sight means total and permanent loss of sight. We do not pay a benefit of loss of use of the hand or foot.

To whom do we pay benefits?

We pay death benefits to your beneficiary. We pay any other benefits to you.

When don't we pay benefits?

We do not pay benefits for loss directly or indirectly caused by any of these:

• Suicide or intentionally self-inflicted injury.
• >Physical or mental illness.
• Bacterial infection or poisoning. Exception: Infection from a cut or wound caused by an accident is covered.
• Injury suffered while in the military service for any country.
• Injury which occurs during a felony or other illegal act you commit or try to commit.
• An act of war.
• Participation in a riot, rebellion, or insurrection.

INTOXICANTS AND NARCOTICS:

We will not pay benefits for any loss sustained or contracted in consequence of your being intoxicated or under the influence of any narcotic unless administered on the advice of a physician.

WAIVER OF LIFE AND AD&D INSURANCE PREMIUM

DISABILITY BENEFIT

waived premium - a premium that is due which we do not require the Policyholder to pay.

What is the Waiver of Life and AD&D Insurance Premium Disability Benefit?

We waive each Life and AD&D Insurance premium that becomes due for you under the Group Policy while you are totally disabled under the conditions listed below. When we waive a premium, the Amount of Life and AD&D Insurance equals the amount that would have been provided if you had not become totally disabled. That amount will reduce according to the Schedule of Benefits in effect on the date total disability begins.

We waive premiums for your Life and AD&D Insurance only, not for any other insurance the Group Policy provides.

Under what conditions do we waive premiums?

In order to waive any premium, we require written notice of claim and proof of total disability. All of the following conditions must also be met:

• Total disability must begin before your 60th birthday.
• You must be totally disabled for 9 months in a row.
• You are insured for the Waiver of Life and AD&D Insurance Premium Disability Benefit on the date you become totally disabled.
• You continue to be totally disabled.
• Your insurance is in force when you suffer the sickness or accidental injury causing the total disability.
• All premiums are paid up to the date total disability begins.

We need written notice of claim before we waive any premium. We must receive this notice

• while you are living,
• while you are totally disabled, and
• within one year of the date total disability begins. If you cannot give us notice within one year, your claim is still valid if you show that you gave us notice as soon as reasonably possible.

We need proof of your total disability before we waive any premiums. We may require you to have a physical exam by doctors we choose. We can only require one exam a year after premiums have been waived for 2 full years. We pay for all exams we require.

When do we start waiving premiums?

When we approve your proof of total disability, we start waiving premiums as of the date you became totally disabled. We refund any premium paid for a period during which you were totally disabled to the Policyholder. It is the Policyholder's responsibility to refund to you any part of the premium you paid.

When do we stop waiving premiums?

We stop waiving premiums on the earlier of the following:

The date:

• you are no longer totally disabled.
• you do not give us the proof of total disability when we ask.
• for AD&D Insurance, the date you attain age 65.
• for AD&D Insurance, the date you retire.

Will your Life and AD&D Insurance stay in force when we stop waiving premiums?

If we stop waiving your premiums, your Life and AD&D Insurance will stay in force only if all of the following are true:

• The Life and AD&D Insurance provided by the Group Policy is still in force.
• You are eligible for employee's insurance under the Group Policy.
• You begin making premium payments equal to those of people of the same age and class insured under the Group Policy.
• The Policyholder resumes payment of your Life and AD&D Insurance Premiums.

The Amount of Life Insurance that stays in force will be the amount shown on the Schedule of Benefits in effect on the date the Policyholder resumes payment of your premiums.

If you buy an individual policy under the Conversion Right of the Group Policy during the first year of your disability, we will cancel the individual policy as of its issue date if within 12 months of the date you become totally disabled you file a claim under this Waiver of Life and AD&D Insurance Premium Disability Benefit and we approve it, and ask us to cancel your individual policy.

When we cancel your individual policy, we

• refund all premiums paid for the individual policy,
• restore your Life Insurance under the Group Policy, and
• retain the beneficiary named under the individual policy as beneficiary under the Group Policy, unless you ask us to change the beneficiary in writing.

CONVERSION RIGHT

What is the conversion right?

You can convert this insurance to a new individual life insurance policy if any part of your Life Insurance under this Group Policy stops.

Under what conditions can you convert?

You can convert if your Life Insurance stops for one of the following reasons:

• You are no longer actively at work.
• You are no longer eligible for employee's insurance.
• Your Amount of Life Insurance is reduced.
• We stop waiving premiums under the Waiver of Life and AD&D Insurance Premium Disability Benefit and your Group Life Insurance stops.
• The Group Policy is changed or canceled.

How do you convert?

You convert this insurance by applying for the individual policy within 31 days after any part of your Group Insurance stops.

If you wish to buy an individual life insurance policy under this conversion right, tell us or the Policyholder. We will give you a conversion form to complete and return.

You must begin paying for the individual policy within 31 days after any part of your Group Life Insurance stops.

What individual policies are available?

You may choose your individual life insurance from any nonparticipating plan we offer, except term insurance. The new policy must provide for a level amount of insurance and have premiums at least equal to those of our whole life plan that has the lowest premium. You may choose to convert to a term life insurance policy for a period of one year before choosing one of the other plans offered.

Your new insurance will not include additional benefits such as

• disability benefits.
• accidental death and dismemberment benefits.

What amount of insurance can be converted?

The amount of insurance that can be converted depends on the reasons your Life Insurance under the Group Policy stopped;

• If your Life Insurance is changed or canceled because the Group Policy is changed or canceled, the amount of life insurance under the individual policy will be the Amount of Life Insurance which stops, minus, any amount of group life insurance you may become eligible for within 31 days after your Life Insurance under the Group Policy stops.
• If this insurance stops for any listed reasons other than a change or cancellation of the Group Policy, the amount of life insurance under your individual policy can be any amount up to the Amount of Life Insurance that stopped.

When is the new policy effective?

The new policy takes effect 31 days after the part of your Group Life Insurance being converted stops.

If you die before the effective date of the individual policy, the death benefit will be the maximum amount of insurance you were eligible to convert. We will pay this amount whether or not you have applied or paid premium for the individual policy. We will return any premium paid for the individual policy to your beneficiary named under the Group Policy.

How much will the individual insurance cost?

We base premiums for the new policy on the plan chosen and your age on the date of conversion.

Submitting a Claim

What must you do to receive benefits?

• You send notice of claim
• You or someone on your behalf must send us written notice of the accidental injury, sickness, death or dismemberment on which your claim will be based. The notice must meet all of these conditions:

  It must:

  • include enough information to identify you, like your name and address and the Group Policy number (GL 145089).
  • be sent to First Reliance Standard Life Insurance Company, 590 Madison Avenue, 29th Floor, New York, N.Y. 10022.
  • be sent within 20 days after the date the sickness begins or the accidental injury, death or dismemberment happens - or as soon as reasonably possible.

We send proof of loss claim forms

We or our authorized agent will send proof of loss claim forms to you or to the Policyholder to give to you. We will send the forms within 15 days after we receive your notice of claim.

You send proof of loss

You or someone on your behalf must return the completed proof of loss forms to us within 90 days after the date of the loss.

Even if you do not receive the forms, written proof of loss must be sent to us within 90 days after the date of the loss. Written proof of loss includes details about how the sickness, accidental injury, death or dismemberment happened. It also includes copies of itemized doctor, hospital and prescription drug bills or receipts.

You must send proof as soon as reasonably possible.

CLAIMS APPEAL PROCEDURE

When a claim for payment is denied, the claimant has the right to file an appeal within 60 days of the notice of denial. This must be done in writing, including the claimant's comments and the issue to be determined and sent to First Reliance Standard Life Insurance Company.

Life Insurance Assignment

You can change the owner of your Life Insurance under the Group Policy by sending us written notice. This change is called an absolute assignment. You cannot make an absolute assignment to the Policyholder or the Participating Employer. You transfer all your rights and duties as owner to the new owner. The new owner can then make any change the Group Policy allows.

• An absolute assignment request does not change the insurance or the beneficiary,
• applies only if we receive your notice,
• takes effect from the date signed, and
• does not affect any payment we make or action we take before receiving your notice.

collateral assignment is not allowed.

We assume no responsibility as to the validity of any assignment. You are responsible to see that the assignment is legal in your state and that it accomplishes the goals you intend.

Legal Action

Legal action may not be taken to receive benefits until 60 days after the date proof of loss is submitted according to the requirements of the Group Policy. Legal action must be taken within 2 years after the date proof of loss must be submitted.

If the Policyholder's state requires longer time limits than these, we will comply with the state's time limits.

Exam Autopsy

When reasonably necessary, we may have you examined while a claim is pending under the Group Policy. We pay for the exam.

Where not forbidden by law, we may have an autopsy made if you die.

Incontestability

Your insurance has a contestable period starting with the effective date of your insurance and continuing for 2 years while you are living. During that 2 years, we can contest the validity of your insurance because of inaccurate or false information received relating to your proof of good health. Only statements that are in writing and signed by you can be used to contest your insurance.

DEFINITIONS

Unless specifically stated elsewhere, the following terms have a special meaning in your certificate. Other parts of the certificate contain definitions specific to that section.

• accident - an unexpected, external, violent, and sudden event.
• active work, actively at work - the employee is present at work with the intent and ability or working the scheduled hours and doing the normal duties of his or her job on that day.
• country - any government or group of countries.
• Group Policy - the written group insurance contract between us and the Policyholder.
• military service - service in any army, navy, air force, marines, coast guard, or any branch of the military.
• non-working day - a day on which the employee is not regularly scheduled to work, including scheduled time off for the following:
  • Vacations.
  • Personal holidays.
  • Weekends and holidays.
  • Approved leave of absence for non-medical reasons.
• non-working day does not include scheduled time off for the following:
  • Medical leave of absence.
  • Temporary layoff.
  • The Employer suspending its operations,
  • in total or part.
  • Strike.
• total disability, totally disabled - your inability, because of sickness or accidental injury to work at any job for pay or profit.
• war - any armed conflict, whether declared as war or not, involving a country.
• written, in writing - signed and dated and received at our Home Office in a form we accept.

PRIVACY OF PROTECTED HEALTH INFORMATION UNDER the HEALTH INSURANCE PORTABILITY and ACCOUNTABILITY ACT ("HIPAA")

Effective Date: September 23, 2013

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

If you have any questions about this notice, please contact Fund Administrator.

OUR OBLIGATIONS:

We are required by law to: Maintain the privacy of protected health information Give you this notice of our legal duties and privacy practices regarding health information about you Follow the terms of our notice that is currently in effect

HOW WE MAY USE AND DISCLOSE HEALTH INFORMATION:

The following describes the ways we may use and disclose health information that identifies you (“Health Information”). Except for the purposes described below, we will use and disclose Health Information only with your written permission. You may revoke such permission at any time by writing to our practice Privacy Officer. For Treatment. We may use and disclose Health Information for your treatment and to provide you with treatment-related health care services. For example, we may disclose Health Information to doctors, nurses, technicians, or other personnel, including people outside our office, who are involved in your medical care and need the information to provide you with medical care. For Payment. We may use and disclose Health Information so that we or others may bill and receive payment from you, an insurance company or a third party for the treatment and services you received. For example, we may give your health plan information about you so that they will pay for your treatment. For Health Care Operations. We may use and disclose Health Information for health care operations purposes. These uses and disclosures are necessary to make sure that all of our patients receive quality care and to operate and manage our office. For example, we may use and disclose information to make sure the obstetrical or gynecological care you receive is of the highest quality. We also may share information with other entities that have a relationship with you (for example, your health plan) for their health care operation activities. Appointment Reminders, Treatment Alternatives and Health Related Benefits and Services. We may use and disclose Health Information to contact you to remind you that you have an appointment with us. We also may use and disclose Health Information to tell you about treatment alternatives or health-related benefits and services that may be of interest to you. Individuals Involved in Your Care or Payment for Your Care. When appropriate, we may share Health Information with a person who is involved in your medical care or payment for your care, such as your family or a close friend. We also may notify your family about your location or general condition or disclose such information to an entity assisting in a disaster relief effort. Research. Under certain circumstances, we may use and disclose Health Information for research. For example, a research project may involve comparing the health of patients who received one treatment to those who received another, for the same condition. Before we use or disclose Health Information for research, the project will go through a special approval process. Even without special approval, we may permit researchers to look at records to help them identify patients who may be included in their research project or for other similar purposes, as long as they do not remove or take a copy of any Health Information.

SPECIAL SITUATIONS:

Required by Law. We will disclose Health Information when required to do so by international, federal, state or local law.

To Avert a Serious Threat to Health or Safety. We may use and disclose Health Information when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person. Disclosures, however, will be made only to someone who may be able to help prevent the threat.

Business Associates. We may disclose Health Information to our business associates that perform functions on our behalf or provide us with services if the information is necessary for such functions or services. For example, we may use another company to perform billing services on our behalf. All of our business associates are obligated to protect the privacy of your information and are not allowed to use or disclose any information other than as specified in our contract.

Organ and Tissue Donation. If you are an organ donor, we may use or release Health Information to organizations that handle organ procurement or other entities engaged in procurement, banking or transportation of organs, eyes or tissues to facilitate organ, eye or tissue donation and transplantation.

Military and Veterans. If you are a member of the armed forces, we may release Health Information as required by military command authorities. We also may release Health Information to the appropriate foreign military authority if you are a member of a foreign military.

Workers’ Compensation. We may release Health Information for workers’ compensation or similar programs. These programs provide benefits for work-related injuries or illness.

Public Health Risks. We may disclose Health Information for public health activities. These activities generally include disclosures to prevent or control disease, injury or disability; report births and deaths; report child abuse or neglect; report reactions to medications or problems with products; notify people of recalls of products they may be using; a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition; and the appropriate government authority if we believe a patient has been the victim of abuse, neglect or domestic violence. We will only make this disclosure if you agree or when required or authorized by law.

Health Oversight Activities. We may disclose Health Information to a health oversight agency for activities authorized by law. These oversight activities include, for example, audits, investigations, inspections, and licensure. These activities are necessary for the government to monitor the health care system, government programs, and compliance with civil rights laws.

Data Breach Notification Purposes. We may use or disclose your Protected Health Information to provide legally required notices of unauthorized access to or disclosure of your health information.

Lawsuits and Disputes. If you are involved in a lawsuit or a dispute, we may disclose Health Information in response to a court or administrative order. We also may disclose Health Information in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain an order protecting the information requested.

Law Enforcement. We may release Health Information if asked by a law enforcement official if the information is: (1) in response to a court order, subpoena, warrant, summons or similar process; (2) limited information to identify or locate a suspect, fugitive, material witness, or missing person; (3) about the victim of a crime even if, under certain very limited circumstances, we are unable to obtain the person’s agreement; (4) about a death we believe may be the result of criminal conduct; (5) about criminal conduct on our premises; and (6) in an emergency to report a crime, the location of the crime or victims, or the identity, description or location of the person who committed the crime.

Coroners, Medical Examiners and Funeral Directors. We may release Health Information to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or determine the cause of death. We also may release Health Information to funeral directors as necessary for their duties.

National Security and Intelligence Activities. We may release Health Information to authorized federal officials for intelligence, counter-intelligence, and other national security activities authorized by law.

Protective Services for the President and Others. We may disclose Health Information to authorized federal officials so they may provide protection to the President, other authorized persons or foreign heads of state or to conduct special investigations.

Inmates or Individuals in Custody. If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may release Health Information to the correctional institution or law enforcement official. This release would be if necessary: (1) for the institution to provide you with health care; (2) to protect your health and safety or the health and safety of others; or (3) the safety and security of the correctional institution.

USES AND DISCLOSURES THAT REQUIRE US TO GIVE YOU AN OPPORTUNITY TO OBJECT AND OPT OUT

Individuals Involved in Your Care or Payment for Your Care. Unless you object, we may disclose to a member of your family, a relative, a close friend or any other person you identify, your Protected Health Information that directly relates to that person’s involvement in your health care. If you are unable to agree or object to such a disclosure, we may disclose such information as necessary if we determine that it is in your best interest based on our professional judgment.

Disaster Relief. We may disclose your Protected Health Information to disaster relief organizations that seek your Protected Health Information to coordinate your care, or notify family and friends of your location or condition in a disaster. We will provide you with an opportunity to agree or object to such a disclosure whenever we practically can do so.

YOUR WRITTEN AUTHORIZATION IS REQUIRED FOR OTHER USES AND DISCLOSURES

The following uses and disclosures of your Protected Health Information will be made only with your written authorization:

1. Uses and disclosures of Protected Health Information for marketing purposes; and

2. Disclosures that constitute a sale of your Protected Health Information

Other uses and disclosures of Protected Health Information not covered by this Notice or the laws that apply to us will be made only with your written authorization. If you do give us an authorization, you may revoke it at any time by submitting a written revocation to our Privacy Officer and we will no longer disclose Protected Health Information under the authorization. But disclosure that we made in reliance on your authorization before you revoked it will not be affected by the revocation.

YOUR RIGHTS:

You have the following rights regarding Health Information we have about you:

Right to Inspect and Copy. You have a right to inspect and copy Health Information that may be used to make decisions about your care or payment for your care. This includes medical and billing records, other than psychotherapy notes. To inspect and copy this Health Information, you must make your request, in writing, to Fund Administrator. We have up to 30 days to make your Protected Health Information available to you and we may charge you a reasonable fee for the costs of copying, mailing or other supplies associated with your request. We may not charge you a fee if you need the information for a claim for benefits under the Social Security Act or any other state of federal needs-based benefit program. We may deny your request in certain limited circumstances. If we do deny your request, you have the right to have the denial reviewed by a licensed healthcare professional who was not directly involved in the denial of your request, and we will comply with the outcome of the review.

Right to an Electronic Copy of Electronic Medical Records. If your Protected Health Information is maintained in an electronic format (known as an electronic medical record or an electronic health record), you have the right to request that an electronic copy of your record be given to you or transmitted to another individual or entity. We will make every effort to provide access to your Protected Health Information in the form or format you request, if it is readily producible in such form or format. If the Protected Health Information is not readily producible in the form or format you request your record will be provided in either our standard electronic format or if you do not want this form or format, a readable hard copy form. We may charge you a reasonable, cost-based fee for the labor associated with transmitting the electronic medical record.

Right to Get Notice of a Breach. You have the right to be notified upon a breach of any of your unsecured Protected Health Information.

Right to Amend. If you feel that Health Information we have is incorrect or incomplete, you may ask us to amend the information. You have the right to request an amendment for as long as the information is kept by or for our office. To request an amendment, you must make your request, in writing, to Fund Administrator.

Right to an Accounting of Disclosures. You have the right to request a list of certain disclosures we made of Health Information for purposes other than treatment, payment and health care operations or for which you provided written authorization. To request an accounting of disclosures, you must make your request, in writing, to Fund Administrator.

Right to Request Restrictions. You have the right to request a restriction or limitation on the Health Information we use or disclose for treatment, payment, or health care operations. You also have the right to request a limit on the Health Information we disclose to someone involved in your care or the payment for your care, like a family member or friend. For example, you could ask that we not share information about a particular diagnosis or treatment with your spouse. To request a restriction, you must make your request, in writing, to Fund Administrator. We are not required to agree to your request unless you are asking us to restrict the use and disclosure of your Protected Health Information to a health plan for payment or health care operation purposes and such information you wish to restrict pertains solely to a health care item or service for which you have paid us “out-of-pocket” in full. If we agree, we will comply with your request unless the information is needed to provide you with emergency treatment.

Out-of-Pocket-Payments. If you paid out-of-pocket (or in other words, you have requested that we not bill your health plan) in full for a specific item or service, you have the right to ask that your Protected Health Information with respect to that item or service not be disclosed to a health plan for purposes of payment or health care operations, and we will honor that request.

Right to Request Confidential Communications. You have the right to request that we communicate with you about medical matters in a certain way or at a certain location. For example, you can ask that we only contact you by mail or at work. To request confidential communications, you must make your request, in writing, to Fund Administrator. Your request must specify how or where you wish to be contacted. We will accommodate reasonable requests.

Right to a Paper Copy of This Notice. You have the right to a paper copy of this notice. You may ask us to give you a copy of this notice at any time. Even if you have agreed to receive this notice electronically, you are still entitled to a paper copy of this notice. You may obtain a copy of this notice at our web site, www.pctabenefits.com. To obtain a paper copy of this notice, contact Fund Administrator.

CHANGES TO THIS NOTICE:

We reserve the right to change this notice and make the new notice apply to Health Information we already have as well as any information we receive in the future. We will post a copy of the current notice on the website, www.pctabenefits.com. The notice will contain the effective date on the first page, in the top right-hand corner.

COMPLAINTS:

If you believe your privacy rights have been violated, you may file a complaint with our office or with the Secretary of the Department of Health and Human Services. To file a complaint with our office, contact Fund Administrator, (914) 815-8929. All complaints must be made in writing. You will not be penalized for filing a complaint.

Services Provided to Each Member:

1. Free financial consultation each year*:

Consultations will be held at School locations. Members can receive up to six hours of time, in person or over the phone or in combination. For more information or to schedule an appointment call 1-888-949-1925.

2. Unlimited access to Stacey Braun's proprietary website:

This password protected website is a useful financial tool intended to address many of your financial concerns. The website contains financial narratives, market data, quotes, charts, portfolio tracking, financial news, financial glossary, financial calculators, links to other useful financial sites and the email helpdesk. To access the site use "money" as your password and "portchester" as the username.

3. Unlimited use of Stacey Braun's email helpdesk:

To provide answers to basic financial questions, you have access to qualified professionals via Stacey Braun's email helpdesk.

4. Periodic financial education seminars:

Stacey Braun will hold periodic financial education seminars for Members at Port Chester facilities.

Topics for consultations and/or seminars include, but are not limited to:

Pre & Post Retirement Planning, Refinancing, Mortgages, Debt Management, Budgeting, Divorce, Investments (403B, Pension Advice), Mutual Fund Questions, Asset Allocation, Establishing Risk Tolerance, Taxes, Inheritance Issues, Gifting, Estate Planning, Savings, Cash Flow, General Education, Elder Care, Social Security, Education Funding (i.e. 529 plans), Second Opinions & Life, Disability and Long-Term Care Insurance

*Spouse's may attend consultations with the Member. Written summaries of consultations containing recommendations are available to members upon request.

Stacey Braun Associates, Inc.
377 Broadway
New York, NY 10013
1-888-949-1925