Legal Benefits Disclosure Form

LEGAL BENEFITS DISCLOSURE FORM

This Legal Benefits Disclosure Form is made effective as of by and between Employer Name: with principal place of business at ("Employer"), and Employee Name: residing at ("Employee").

RECITALS

WHEREAS, Employer maintains or sponsors certain employee benefit programs, plans and services that provide legal, insurance, retirement or other employee-related benefits (collectively, "Benefits"); and

WHEREAS, Employee is or will be eligible to receive specified Benefits subject to the terms, conditions and limitations set forth in plan documents and this Disclosure; and

WHEREAS, Employer desires to set forth in writing the material terms, coverage limits, eligibility criteria and administrative procedures applicable to those Benefits as required by applicable law and good practice.

NOW THEREFORE, in consideration of the mutual covenants and agreements contained herein, the parties agree as follows:

1. DEFINITIONS

For purposes of this Form, the following definitions apply: "Benefits" means the programs and coverages identified in Section 2; "Plan Documents" means the written policies, summaries, insurance contracts, summary plan descriptions, and other controlling documents governing each Benefit; and "Eligible Employee" means an employee who satisfies eligibility conditions set forth in Section 3 and the applicable Plan Documents.

2. BENEFITS PROVIDED

Employer hereby discloses that, subject to Plan Documents and applicable eligibility rules, the Employer makes the following Benefits available to Eligible Employees. Check all benefits applicable and complete the corresponding description fields.

3. ELIGIBILITY AND ENROLLMENT

Eligibility for the Benefits set forth in Section 2 is subject to the Plan Documents. Employee eligibility commencement date: .

Employee contributions, if any, are described in the Plan Documents. Employee contribution amount (if applicable): $ per .

4. LEGAL SERVICES PLAN (IF APPLICABLE)

If the Legal Services Plan box in Section 2 is checked, the following terms apply to covered legal services: covered matter categories, hourly or flat fee caps, excluded matters, and any co-pay or deductible. Attorney selection, use of network counsel, and dispute resolution procedures are governed by the Plan Documents.

5. CLAIMS, APPEALS AND ADMINISTRATION

Claims for Benefits shall be submitted in accordance with the procedures specified in the Plan Documents. The Plan Documents include timeframes for initial determinations, appeals and external review where applicable. No oral statements by Employer or its agents modify the Plan Documents or this Disclosure.

6. CONFIDENTIALITY AND DATA USE

Employer and its administrators may use and disclose Employee personal information solely as necessary to administer the Benefits and as permitted by law. Personal medical information will be treated as confidential and disclosed only in accordance with applicable law and the Plan Documents.

7. TAX TREATMENT

Contributions, reimbursements or value of Benefits may have federal, state or local tax consequences. Employee acknowledges that Employer has not provided tax advice and that Employee should consult a tax advisor concerning the tax treatment of any Benefit.

8. TERM AND TERMINATION

The availability of Benefits is subject to Employer's discretion and the Plan Documents. Employer may amend, suspend or terminate any Benefit at any time in accordance with the Plan Documents and applicable law. Termination of employment may affect eligibility and continuation rights; such rights are governed by the Plan Documents.

9. NOTICES

Notices required under this Disclosure shall be given in writing to the addresses set forth below and shall be effective upon receipt.

10. AMENDMENT, WAIVER AND COUNTERPARTS

This Disclosure may be amended only by a written instrument signed by both parties. No failure or delay by either party to exercise any right under this Disclosure shall constitute a waiver of that right unless evidenced in writing and signed by the waiving party. This Disclosure may be executed in counterparts, each of which shall be an original and all of which together shall constitute one instrument.

11. GOVERNING LAW

This Disclosure shall be governed by and construed in accordance with the laws of the state identified below without regard to conflict of law principles.

12. ENTIRE AGREEMENT

This Disclosure, together with the Plan Documents referenced herein, constitutes the entire agreement between the parties with respect to the subject matter and supersedes all prior oral or written statements, representations or agreements relating to the Benefits.

13. SEVERABILITY

If any provision of this Disclosure is held invalid or unenforceable by a court of competent jurisdiction, the remainder of this Disclosure shall remain in full force and effect, and the invalid or unenforceable provision shall be reformed only to the extent necessary to make it valid and enforceable.

EMPLOYEE ACKNOWLEDGMENT

By signing below, Employee acknowledges receipt of this Legal Benefits Disclosure Form and any Summary Plan Descriptions or other materials provided contemporaneously, and understands that eligibility and coverage are governed by the Plan Documents and applicable law.

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