© Copyright Envision Corporation. 2002. All rights reserved.

Protected by the copyright laws of the United States & Canada and by International treaties. IT IS
ILLEGAL AND STRICTLY PROHIBITED TO DISTRIBUTE, PUBLISH, OFFER FOR SALE, LICENSE OR SUBLICENSE, GIVE OR DISCLOSE TO ANY OTHER
PARTY, THIS PRODUCT IN HARD COPY OR DIGITAL FORM. ALL OFFENDERS WILL BE SUED IN A COURT OF LAW.

© SHORT-TERM DISABILITY PLAN

C
o
p 1. POLICY
y
r a) [COMPANY NAME] provides a Short-Term Disability Program available to eligible full-time regular
i employees as approved by [COMPANY NAME] designed to assist those regular employees
g unable to work due to extended illness or disability lasting up to [NUMBER] months.
h
t b) All regular employees with more than one year of continuous service based on date of
employment as a regular employee are eligible for consideration of Short-Term Disability benefits.
E
n c) This plan is to be integrated with [COMPANY NAME] Employees’ Long-Term Disability Plan,
v which provides benefit payments to regular employees with at least one year of service, after
i [NUMBER] months of total disability.
s
i d) Any illness or impairment of health verified by a certified doctor’s written statement, that requires
o an employee to be absent from work for [NUMEBER] or more continuous working days, qualifies
n the employee for consideration of benefits under the Short-Term Disability Program.

C e) Benefits are available only to an employee who is under a certified physician’s care. A doctor
o must certify the starting, continuing, and ending dates of the employee’s disability on Disability
r Certification Form. Payment of the employee’s Short-Term Disability benefits will be delayed or
p denied if we are unable to certify the initiation or continuing status of the disability period.
o
r f) Short-Term Disability benefits must be approved before benefits are paid. The fact that an
a employee presents a doctor’s certificate indicating an illness/disability does not in and of itself
t establish eligibility for Short-Term Disability benefits.
i
o g) [COMPANY NAME] retains and reserves the right to request additional information from the
n employee or the employee’s physician and/or to request the employee to obtain certification of
. the illness/disability from a physician of [COMPANY NAME]’s choice at [COMPANY NAME]’s
expense, prior to granting approval of Short-Term Disability benefits under this program.
2
0 h) Benefits under this program must be requested by the employee through [NAME OF PERSON
0 WHO RECEIVES REQUESTS] and approved by [NAME OF PERSON WHO APPROVES
2 REQUESTS].
.
i) [COMPANY NAME] may place employees on a medical leave of absence without pay if doubt
A exists as to the bona fide nature of the illness/disability or if additional medical information is
l required to substantiate the claim. When additional medical information is requested, employees
l remain on medical leave of absence without pay until the illness/disability is certified and an
effective date obtained based on the additional information from the employee’s physician or a
r physician of [COMPANY NAME]’s choice.
i
g j) Reconfirmation of disability or long-term illness by the patient’s physician will be required by
h [COMPANY NAME] every two weeks unless a physician is able to project at the outset a total
t period of disability. These re-certifications may be subject to review by a physician called in at the
s company option and expense.

r k) Short-Term disability benefits start on the date of the doctor’s certificate or the first day of the
e disability period as indicated by the effective date of the doctor’s certificate, whichever is earlier.
s l)
e
© Copyright Envision Corporation. 2002. All rights reserved. Protected by the copyright laws of the United States & Canada and by International treaties. IT IS
ILLEGAL AND STRICTLY PROHIBITED TO DISTRIBUTE, PUBLISH, OFFER FOR SALE, LICENSE OR SUBLICENSE, GIVE OR DISCLOSE TO ANY OTHER
PARTY, THIS PRODUCT IN HARD COPY OR DIGITAL FORM. ALL OFFENDERS WILL BE SUED IN A COURT OF LAW.

m) Maximum benefits under the Short-Term Disability Program are [NUMBER] working days at full
pay or a combination of full and half pay totaling [NUMBER] working days, after which time a
determination may be made regarding an employee’s eligibility for company-paid Long-Term
Disability benefits.

Short-Term Disability benefits are paid in accordance with the following schedule:

Length of Employment
as a Regular Employee Amount of Benefit
20 days at full pay followed by
1-2 years 20 days at half pay

30 days at full pay followed by

3 years 30 days at half pay

40 days at full pay followed

4 years by 40 days at half pay

50 days at full pay followed by

5 years 50 days at half pay

60 days at full pay followed by

6 years 60 days at half pay

70 days at full pay followed by

7 years 60 days at half pay

80 days at full pay followed by

8 years 50 days at half pay

90 days at full pay followed by

9 years 40 days at half pay

100 days at full pay followed by

10 years 30 days at half pay

110 days at full pay followed by

11 years 20 days at half pay

120 days at full pay followed by

12 years 10 days at half pay

13 years or more (Maximum benefit) [NUMBER] days at full pay

n) The basis for calculation of an account representative’s or other incentive compensation

employee’s benefits is either:

i) 80% of the total income of the prior 24 months divided by 52 bi-weekly periods (or, if newly
eligible, the prior 12 months divided by 26) to determine the average bi-weekly paycheck;
or

ii) 100% of the true total annual earnings divided by 26 to determine the bi-weekly paycheck,
whichever is greater. These employees will be paid Short-Term Disability benefits based
on the schedule in l) above. Commission payments cease while the incentive
compensation employee is paid Short-Term Disability benefits.
© Copyright Envision Corporation. 2002. All rights reserved. Protected by the copyright laws of the United States & Canada and by International treaties. IT IS
ILLEGAL AND STRICTLY PROHIBITED TO DISTRIBUTE, PUBLISH, OFFER FOR SALE, LICENSE OR SUBLICENSE, GIVE OR DISCLOSE TO ANY OTHER
PARTY, THIS PRODUCT IN HARD COPY OR DIGITAL FORM. ALL OFFENDERS WILL BE SUED IN A COURT OF LAW.

o) Regular employees are eligible for the different amounts as stated above according to length of
service on their anniversary date. If an anniversary date occurs while an employee is receiving
Short-Term Disability benefits, he/she will be eligible for the greater amount of coverage, as
outlined in the chart in l) above.

p) At the end of six months of continuous disability, an assessment will be made to see if the
employee qualifies for disability benefits under the [COMPANY NAME] Long-Term Disability Plan.
If at that time, the employee cannot be certified disabled by the Long-Term Disability Plan
Administrator, his or her employment may be terminated with the option for rehire when the
employee’s health allows. If it becomes clear that the employee’s return to work is imminent, after
paid Short-Term Disability benefits lapse, a leave of absence without pay may be authorized by
[Name of person or persons who authorizes leaves of absence].

q) [COMPANY NAME] bases disability payments on an incident of disability, rather than on a

calendar-year basis. A period of disability begun in one year could extend into the following year.

r) When the employee returns to work following a period of extended disability or illness and has
subsequent absences related to the original disability within [NUMBER] calendar days of the
return to work, those absences will be considered part of the original disability period.

s) Pregnancy is treated the same as is any other illness under the Short-Term Disability Program.
Commencement of short-Term disability benefits for a maternity leave must be based on actual
disability of the individual, not the mere fact of pregnancy.

t) If the request for Medical Leave is determined by [NAME OF PERSON WHO GRANTS LEAVE
REQUESTS] to be unwarranted, the employee will be notified of the denial of the request. If the
employee is not actively at work at this time, his/her failure to return immediately will be
considered a resignation.

u) If false claims for Short-Term Disability benefits are discovered at any time, or if an employee fails
to report to work on the first regularly scheduled workday following absence under the Short-Term
Disability Program, he/she will be subject to disciplinary action up to and including termination of
employment.

v) Employees receiving benefits under the [COMPANY NAME]’s Short-Term Disability Program will
be eligible to continue participation in the [COMPANY NAME] Comprehensive Health and Life
Insurance plans and continue to accrue service for purposes of the [NAME OF THE COMPANY
RETIREMENT PLAN, IF APPLICABLE] in accordance with plan provisions.

w) [ONLY IF APPLICABLE] In states where employees are required to maintain disability insurance,
[COMPANY NAME] will coordinate benefits available under this program with those available
under state-mandated programs.

x) Under no circumstances will the combined benefits from a State/Province Disability Plan or the
Short-Term Disability program exceed the salary of the employee.

y) The company may require periodic verification of an employee’s inability or ability to work
(including, for example, examination by a doctor designated by the company).

z) Company policy provides that an employee’s position may be filled while on a leave if this is
necessary in order to meet business requirements. If this occurs, upon conclusion of the medical
leave, every reasonable effort will be made to return the employee to the position formerly held or
to one of similar responsibility and salary level.

aa) Exceptions to this policy will be determined by [NAME OF PERSON DETERMINING BENEFITS
POLICIES].
© Copyright Envision Corporation. 2002. All rights reserved. Protected by the copyright laws of the United States & Canada and by International treaties. IT IS
ILLEGAL AND STRICTLY PROHIBITED TO DISTRIBUTE, PUBLISH, OFFER FOR SALE, LICENSE OR SUBLICENSE, GIVE OR DISCLOSE TO ANY OTHER
PARTY, THIS PRODUCT IN HARD COPY OR DIGITAL FORM. ALL OFFENDERS WILL BE SUED IN A COURT OF LAW.

2. RESPONSIBILITIES

a) The employee is responsible for completing his/her section of the Disability Certification Form and
for obtaining the necessary information from the attending physician or a physician of [COMPANY
NAME]’s choice, who must certify the nature, extent of illness or injury and projected duration of
the employee’s disability on the Disability Certification Form.

b) [NAME OF PERSON RESPONSIBLE FOR MONITORING DISABILITY-RELATED CLAIMS] is

responsible for monitoring an employee’s eligibility for the Short-Term Disability Program.

c) [NAME OF PERSON RESPONSIBLE FOR CALCULATING BENEFITS] is responsible for the

calculation of benefits under the Short-Term Disability program.

d) [NAME OF PERSON RESPONSIBLE FOR COORDINATING WORKERS’ COMP BENEFITS] is

responsible for coordinating the benefits under this program with benefits available under
Workers’ Compensation or State Disability Programs, where applicable.

e) [NAME OF PERSON RESPONSIBLE FOR STATUS-RELATED ISSUES] is responsible for

initiating the appropriate Personnel Status Change form for any employee who becomes eligible
for the Short-Term Disability Program and for obtaining approval of the change.

f) [NAME OF PERSON RESPONSIBLE FOR APPROVING PAYMENTS] is responsible for

approving payment of benefits under this policy.

g) [NAME OF PERSON RESPONSIBLE FOR OVERSEEING DISABILITY BENEFITS] is

responsible for monitoring the Short-Term Disability Program and for coordinating with physicians.

h) Employee is responsible for submitting copies of all check stubs and documentation of payments
of all State/Province Disability benefits to [NAME OF PERSON TO WHOM DOCUMENTS ARE
TO BE DELIVERED] within [NUMBER] days of receipt of last payment.

i) [NAME OF PERSON RESPONSIBLE FOR PAYMENTS] is responsible for the payment of Short-
Term Disability benefits.

3. PROCEDURES

Note: Your procedures may be much simpler. If so, modify the following to reflect your circumstances.

a) Employee obtains physician’s statement (Disability Certification Form), certifying nature, extent
and duration of illness/disability and forwards it to [PERSON TO WHOM THE STATEMENT
SHOULD BE DELIVERED].

b) [PERSON WHO REVIEWS THE DOCUMENTS] reviews documentation and [PERSON WHO
OVERSEES LEAVE POLICIES, IF DIFFERENT FROM REVIEWER] regarding leave period.
[PERSON WHO OVERSEES PAY AND BENEFITS] may request additional information or
request [COMPANY NAME]’s physician to confirm illness/disability before final approval.

c) [PERSON WHO OVERSEES PAY AND BENEFITS] initiates Status Change Form authorizing
Short-Term Disability benefits, obtains [NAME OF PERSON WHO MUST SIGN IT]’s signature on
it.

d) [PERSON WHO HANDLES PAYROLL] adjusts casual illness absence or vacation balance, if
necessary, and disburses a check consisting of full or partial pay for the portion of the certified
period of disability, during which the employee is entitled to benefits.
e) [ONLY IF APPLICABLE] In states where [COMPANY NAME] employees are required to maintain
© Copyright Envision Corporation. 2002. All rights reserved. Protected by the copyright laws of the United States & Canada and by International treaties. IT IS
ILLEGAL AND STRICTLY PROHIBITED TO DISTRIBUTE, PUBLISH, OFFER FOR SALE, LICENSE OR SUBLICENSE, GIVE OR DISCLOSE TO ANY OTHER
PARTY, THIS PRODUCT IN HARD COPY OR DIGITAL FORM. ALL OFFENDERS WILL BE SUED IN A COURT OF LAW.

disability insurance, [COMPANY NAME] will coordinate the benefits available under this plan with
those available under state-mandated programs, as well as with Workers’ Compensation.

f) [PERSON WHO HANDLES EMPLOYEE ISSUES] estimates the benefit amount employee is
expected to receive from State Disability (where applicable) during the period of an approved
medical leave.

g) [PERSON WHO HANDLES PAYROLL] will deduct the amount of the benefit from Short-Term
Disability benefits paid during the period of the leave.

h) [PERSON WHO HANDLES EMPLOYEE ISSUES] ends Short-Term Disability benefits when
employee’s illness/disability terminates.