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Maternity and AdoptionLeave Information

Updated August 2020

Notice of Eligibility - Family Medical Leave Act Rights & Responsibilities for Maternity Leave

Under the provisions of the Family Medical Leave Act (FMLA), an eligible employee is entitled to up to 12 weeks (60 work days) of unpaid leave in a 12-month period for the birth and first-year care of an employee’s child after birth, or placement for adoption or foster care. To be eligible for job-protected maternity leave under the FMLA, an employee must have been employed the Liberty School District for at least 12 months, and have worked at least 1,250 hours in the 12 months preceding the leave. You informed the District that you anticipate the need for FMLA for the birth of a child, or the placement of a child for adoption or foster care. Please complete the information below regarding your leave request: Employee Name: ________________________________ Employee Job Title: __________________________

Building/Department: _________________________ Anticipated Due Date: ___________________________

Anticipated Leave Start Date: ______________________ Anticipated Return Date: _____________________ This notice is to inform you that: 1. _____ You are eligible for FMLA leave.

_____ You are not eligible for FMLA leave, because

_____ a. You have not met the FMLA’s 12-month length of service requirement. As of the first date of requested leave, you will have worked approximately _____ months toward this requirement.

_____ b. You have not met the FMLA’s 1,250 hours-worked requirement. As of the first date of requested leave, you will have worked approximately _____ hours toward this requirement.

2. The leave you have requested will be counted against your annual FMLA leave entitlement. FMLA provides up to 12 weeks (60 work days) of job-protected leave in a 12-month period.

3. You will not be required to furnish medical certification of a pregnancy. Should you require medical leave prior to delivery for any pregnancy-related incapacity, please contact the Human Resources Department to discuss the documentation that must be provided by your physician.

4. You will be required to utilize accrued Paid Time Off (PTO) and/or Vacation during your FMLA leave. If you exhaust your accrued PTO or Vacation, your resulting absences will continue to be protected FMLA leave (up to the aggregate of 60 work days) but the absences will be unpaid.

5. Additional information regarding FMLA and District leave policy may be found in Board Policy GBBDA: Family and Medical Leave.

6. Additional information regarding employee rights and responsibilities under FMLA may be found in the FMLA Poster provided by the U.S. Department of Labor. The FMLA Poster is also included in the District maternity information packet.

By signing this notice, you acknowledge that: 7. You have read and understand the information outlined above.

8. Should there be a change in your Anticipated Leave Start Date or your Anticipated Return Date, you must notify the Human Resources Department and your Supervisor as soon as possible.

________________________________________________ ___________________________________ Employee’s Signature Date ________________________________________________ ___________________________________ Human Resources Administrator’s Signature Date

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Congratulations! On behalf of Liberty Public Schools we congratulate you on the upcoming addition to your family! Our Human Resources Department will provide you with the support necessary to make preparing for your maternity leave a smooth and stress-free process. Follow the steps below in preparation for your time off work. 1: Contact Melody Fritson in Human Resources at (816) 736-5303 or by email at melody.fritson@lps53.org to schedule an appointment to discuss maternity details and develop an anticipated leave calendar. 2: Complete the attached FMLA Notice of Eligibility form and bring it with you to your appointment. Your leave request will be reviewed and the Human Resources Department will evaluate your eligibility for leave under the Family Medical Leave Act (FMLA). Following your appointment with Ms. Fritson, you will receive a decision letter from Human Resources documenting the details of your leave request. 3: If your position requires a substitute, you may begin discussing possible long-term substitute candidates with your supervisor. In order to be eligible for a long-term substitute assignment, a sub must be an active employee of Kelly Educational Staffing, the District’s substitute employment service. Long-term substitute assignments are secured after the supervisor (not the employee) has offered the assignment, the substitute has accepted the assignment, and the supervisor has submitted the appropriate paperwork to the Human Resources Department. 4: Following the placement of your long-term substitute, you will have the opportunity to coordinate two (2) shadow days with your sub. Shadow days may take place prior to your leave start date, or following your return from leave. Please notify Melody Fritson in the Human Resources Department of your planned shadow dates so they can be appropriately recorded in Frontline. 5: Discuss with your building and supervisor who will contact your sub on the date your leave is to begin. On your first day off work for maternity leave, the building should notify Melody Fritson in the Human Resources Department in order for your leave to be entered in Frontline or NOVAtime.

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Frequently Asked Questions 1. What is FMLA?

FMLA stands for “Family Medical Leave Act.” FMLA is a federal job protection measure that entitles eligible employees to up to 12 weeks (60 work days) of unpaid leave in a 12-month period for the birth and first-year care of an employee’s child after birth or placement for adoption or foster care. To be eligible for FMLA leave, you must have worked for the District for 12 months, and must have worked a minimum of 1,250 hours in the 12 months immediately prior to your first date of leave. If you are eligible for job protection under FMLA, it will automatically be designated to your maternity leave. FMLA leave runs concurrently with your accrued Paid Time Off (PTO) or Vacation. Please view the FMLA Poster provided by the Department of Labor for more information regarding your rights and responsibilities under FMLA.

2. What if I am not eligible for FMLA?

According to Board Policies GCBDA and GDBDA: “Employees who are ineligible for FMLA may take up to eight weeks of leave for the birth, first-year care, adoption or foster care of a child.” Additionally, policy states “Pregnant employees who need more than eight weeks of leave for a pregnancy-related incapacity must provide certification of the medical necessity for such leave.”

3. Can I begin maternity leave prior to my baby’s birth?

A pregnant employee should continue in the performance of her work duties as long as she is able to do so and as long as her ability to perform her duties is not impaired, based on medical opinion. Maternity leave will begin on the first day a pregnant employee is absent from work for the delivery of a baby, or for a pregnancy-related incapacity that has been documented by the health care provider. Without a documented medical reason for absence, consecutive absences prior to the delivery of a newborn may be considered “excessive,” as outlined in Board Policy GBCBC.

4. Do holidays or non-work days count as part of maternity leave?

- Employees who are not eligible for FMLA will be granted up to eight weeks of leave, in which holidays and non-work days will be included.

- FMLA leave is calculated based on scheduled work days only. For employees who are eligible for FMLA, holidays and non-work days will not be considered part of the maternity leave.

5. What if there are inclement weather days while I am on maternity leave?

- If your work calendar requires that you report to work on inclement weather days, they will be considered part of your maternity leave. PTO, Vacation, or unpaid leave will be applied accordingly.

- If you are not eligible for FMLA, and your work calendar does not require that you report to work on inclement weather days, they will be considered part of your maternity leave. However, you will not be charged PTO or Vacation for these days.

- If you are eligible for FMLA, and your work calendar does not require that you report to work on snow days, they will not be considered part of your FMLA leave. Additionally, you will not be charged PTO or Vacation for these days.

6. What if I want to change my expected return-to-work date?

If you will not have exhausted all of your allowable time off, as calculated by the Human Resources Department, you are entitled to revise your return-to-work date. You will be responsible for contacting Human Resources to request a leave revision, as well as contacting your building supervisor to discuss any changes that need to take place as a result of your revised return date. Leave revisions must be requested at least 30 days prior to your original scheduled return-to-work date.

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7. My spouse also works for LPS. Can we both take FMLA leave? When spouses entitled to FMLA leave are both employed by the District and both wish to use FMLA leave for the same qualifying event, both employees will be limited to a combined total of 12 weeks of leave in a 12-month period. Example: If the child’s mother takes six weeks of FMLA leave for recovery from delivery and six weeks of FMLA leave in order to bond with the newborn, the child’s father would be entitled to up to six weeks of FMLA leave to also bond with the newborn.

8. Can I take more than 60 work days of leave?

FMLA entitles eligible employees to a maximum of 60 work days of leave. Any additional consecutive absences will not be protected under FMLA and may be considered “excessive” under Board Policy GBCBC. In addition, Board Policy also states that “Unless otherwise required by law, employees whose leave extends for longer than 60 work days will be required to pay their own premiums if they wish to continue coverage of any health benefits made available by the District.” If your leave extends longer than 60 consecutive work days, your benefits will cancel on the last day of the month following your 61st absence.

9. Will I have access to District applications during my leave?

The District encourages employees to avoid regular work duties during maternity leave. However, your LPS Gmail account will remain active in order for Human Resources to provide you with a minimal amount of leave-related communication via email. If you have a PowerSchool or Canvas account, your access will be disabled for the duration of your leave in order to assign access to your long-term sub. Please be prepared for gradebook access to be disabled on your first day of maternity leave.

10. I have an extra day/extra duty assignment. How does this impact my leave? - Employees whose positions require extra report days are expected to complete these additional work

days prior to, during, or following maternity leave. Please work with your supervisor or department director to develop a plan for flexing extra days, if necessary.

- Employees who have accepted an extra duty assignment are expected to fulfill the necessary responsibilities of the assignment in order to receive their extra duty stipend. Some extra duty assignments must be fulfilled on specific dates, while others allow for flexibility. If you are unable to fulfill your extra duty responsibility due to maternity leave, please notify Mandy Fangmann in the Human Resources Department at mandy.fangmann@lps53.org. Keep in mind that if you do not complete your extra duty assignment in its entirety, your stipend amount will be adjusted accordingly.

- In order to fulfill extra day/extra duty responsibilities during maternity leave, you will be required to present a work release note from your physician. This note may be delivered to the District Administration Center or faxed to Human Resources at (816) 736-5505.

11. How will I be paid during my leave?

The District will apply accrued PTO or Vacation to your time off work for maternity leave. You may also qualify for reduced-salary benefits from the District’s short-term disability provider. If you exhaust your accrued PTO or Vacation, or you are granted short-term disability benefits, your status will change to non-paid, resulting in necessary adjustments to your paychecks.

12. Can the District provide me with an estimate of my paycheck adjustments?

The District does not provide paycheck estimates to employees. Please utilize the pay adjustment calendar you will receive at your personal meeting with Human Resources to calculate the approximate impact your maternity leave will have on your pay.

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13. What is short-term disability? Short-term disability is a benefit made available by the District to employees who are regularly scheduled to work 30 hours or more per week. The District’s disability provider, The Standard Insurance Company, provides disabled employees with 66.67% of their basic weekly salary, up to $500 per calendar week, following a 14-day benefit waiting period. Disability payments usually end 6 weeks from the date of birth for vaginal delivery, or 8 weeks for cesarean delivery. Short-term disability does not apply to leaves for adoption or foster care.

14. Is short-term disability available during the summer?

The maximum disability benefit payment is not available during months in which you are not regularly scheduled to work. Therefore, 10-Month Employees will not receive short-term disability payments following the last scheduled work day of their work calendar.

15. Do I have to present a Doctor’s note before returning to work?

Yes. You will be required to present a work release note from your physician before returning from maternity leave. A release note is also required to attend Professional Development or Parent Teacher Conferences, complete extra duty/extra day responsibilities, or report for any other pre-approved work day during maternity leave. This note may be delivered to the District Administration Center or faxed to Human Resources at (816) 736-5505 and must be submitted before you return to work.

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Maternity Leave and Public School Retirement Unpaid time off work for maternity leave can impact your service credit in the Public School and Education Employee Retirement System of Missouri (PSRS, PSRSS, or PEERS). In order to accrue one (1) year of service credit in the Retirement System, you must earn at least 95% of your expected salary for the year. Any unpaid days, including days for which you receive short-term disability payments, will be deducted from your annual salary and, therefore, reduce the percent of salary earned for the year. [Example]

- LPS reports to PSRS that an employee’s annual salary will be $40,000. - Her daily rate is $215.05. - She accumulates 15 unpaid days during maternity leave and earns a total of $36,774.25 for the year. - To calculate the percent of salary earned, her end-of-year salary is divided by the salary reported at the

beginning of the year: 36,774.25 / 40,000 = 91.9% - The employee did not earn 95% of her salary for a full year of service credit.

Buy-Back Option Employees who do not earn 95% of their salary for the year have the opportunity to buy-back service credit that was not earned due to unpaid maternity leave. The buy-back is calculated based on the total number of unpaid days for the year and the applicable contribution rate for PSRS, PSRSS, or PEERS. Employees have two (2) years from the year of the maternity leave to buy-back up to 100% of their un-earned service credit. There are two advantages to purchasing the credit within this time frame:

- Calculations will be based on the salary and contribution rate used during the year of the leave - LPS will be responsible for the employer amount

At the conclusion of the school year, you may contact the Benefits Department at benefits@lps53.org to inquire about buying-back retirement service credit. The Benefits Department will provide you with the buy-back amount. If you decide to make the purchase, you must write a lump-sum check for the purchase amount to LPS. LPS will then take the necessary steps to complete the purchase with the Retirement System.

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Insurance Coverage for Newborn or Adoptee If you are eligible for LPS benefits and wish to add a child to your medical, dental, or vision insurance plan, you must contact the Benefits Department no later than 31 days following your child’s date of birth or date of placement for adoption or foster care. The Benefits department can be reached at (816) 736-5300 or benefits@lps53.org. Once enrolled, coverage begins on the date of the child’s birth or date of placement for adoption or foster care. Dependent insurance additions that are not requested in writing within 31 days of the qualifying event cannot be added to LPS insurance coverage until the next open enrollment period for the following calendar year. When contacting the Benefits Department to add a qualifying dependent to your insurance plan, please provide the following written information and documentation:

- Child’s name, date of birth, and social security number (if available) - Documentation verifying date of qualifying event (copy of hospital crib card, court document, etc.) - Desired insurance coverage change - Additional information as requested by the Benefits Department

Insurance Resources To view LPS insurance plan summaries, premium rates, and additional general benefit information, please view the Health & Wellness section of Inside HR on the LPS Website.

For questions regarding specific LPS health insurance coverage information, networks, deductibles, out-of-pocket cost estimates, or other policy information, please contact Blue Cross and Blue Shield of Kansas City (Blue KC) at (816) 395-2270. LPS does not advise or counsel employees on the personal or financial impact of insurance coverage decisions.

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Insurance Coverage Acknowledgement I fully acknowledge that: 1. By signing this document, I affirm that I have received and read the page entitled Insurance Coverage for

Newborn or Adoptee, provided to me by Liberty Public Schools.

2. By signing this document, I understand it is my responsibility to request an insurance addition through the Liberty Public Schools Benefits Department, as outlined on the page entitled Insurance Coverage for Newborn or Adoptee, should I desire to add my newborn or adoptee to my Liberty Public Schools medical, dental, or vision insurance plan(s).

3. By signing this document, I understand that the addition of my newborn or adoptee to my Liberty Public

Schools insurance plan must be made within 31 calendar days following the date of birth or date of placement for adoption or foster care, as described on the page entitled Insurance Coverage for Newborn or Adoptee. Failure to enroll my new dependent within 31 days of the qualifying event will mean my new dependent is not covered by a Liberty Public Schools insurance provider and cannot be enrolled until the next open enrollment period set forth by the District.

4. I further understand that it is not the responsibility of Liberty Public Schools to advise me of the personal,

financial, or other impact of my insurance coverage decision. I take full responsibility for researching the details of the coverage, network, deductible, out-of-pocket costs, and other policy information associated with the insurance plan of my choosing.

____________________________________________________ _____________________________________ Employee Signature Date

Please read, sign, date, and return this completed acknowledgement to the Human Resources Department, located at the LPS District Administration Center. This acknowledgement should be received by Human

Resources prior to the beginning of your maternity leave.

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Breaks for Nursing Mothers If you plan to express breastmilk following your return to work, you are encouraged to contact your supervisor to discuss how break arrangements might be made within your building or department. See the information below regarding the legal requirements for nursing mothers who wish to take breaks to express breastmilk during the work day. Exempt Employees

- The law does not require that the District provide a reasonable break time for employees to express milk during the work day if the employee is exempt from the regulations outlined in the Fair Labor Standards Act. However, exempt employees are encouraged to contact their supervisor to determine if a reasonable break time can be arranged. If possible, the District will provide a functional location, other than a bathroom, that is shielded from view and free from intrusion.

Non-Exempt Employees - In accordance with the Fair Labor Standards Act, the District will provide a reasonable break time for a

non-exempt employee to express milk for her nursing child for one year following the child's birth. The District will provide a functional location, other than a bathroom, that is shielded from view and free from intrusion. Breaks to express milk are considered compensatory if the break is fewer than 21 minutes. Employees must punch out for breaks lasting 21 minutes or more.

Breast Pump Benefit If you participate in LPS medical insurance through Blue Cross and Blue Shield of Kansas City, your health plan may include a covered breast pump benefit. If you have a breast pump benefit on your plan, Blue KC will cover the allowable charge for a manual or electric breast pump to meet the needs of you and your newborn. For more information regarding this benefit, please view the Breast Pump Coverage flyer located on Inside HR, or contact Blue Cross and Blue Shield of Kansas City (Blue KC) at (816) 395-2270.

Short-term disability benefits are available to eligible Liberty Public Schools (LPS) employees through The Standard Insurance Company. The purpose of short-term disability insurance is to provide employees with an opportunity to minimize the financial burdens that may result from an extended illness, pregnancy-related health condition, or non-work related accident or injury. Employees are not required to utilize short-term disability benefits.

If you choose to apply for short-term disability benefits, you and your physician must complete the attached Employee/Attending Physician’s Statement and Authorization to Obtain and Release Information. The completed claim components may be returned to Human Resources via fax to (816) 736-5505, or delivery to the DAC.

SHORT-TERM DISABILITY BENEFITS

DISABILITY BENEFIT OVERVIEW

Benefit Waiting Period: 14 calendar days from the date of disability

• Accrued PTO/vacation must be used during the waiting period. If PTO/vacation is exhausted, the wait is unpaid.

• Employees may choose to use additional accrued PTO/vacation before disability payments begin.

Accident or Illness Benefit Duration: 90 days from the date of disability

Maternity Benefit Duration: 6 weeks from the date of birth for vaginal delivery; 8 weeks for cesarean elivery • Benefit durations include the 14-day waiting period.

• Benefits are payable for employee disability only. Family members are not covered.

Benefit Eligibility: Active, benefit-eligible LPS employees working 30 hours or more per week

CLAIM SUBMISSION INSTRUCTIONS

• Employees receive disability payments directly from The Standard via weekly checks by mail.

Maximum Benefit Amount: 66 2/3% of employee’s basic weekly salary, up to $500 per calendar week

• Any days for which employees receive payments from The Standard will be unpaid by LPS.

If you wish to use accrued PTO/vacation beyond the 14-day benefit waiting period, you must notify LPS at the time of your disability claim submission by completing the form below. If you do not designate additional PTO/vacation usage, approved disability benefits will automatically become effective following the 14-day waiting period. Changes to PTO/vacation usage will not be permitted after your disability claim has been submitted to The Standard.

Employee Name: _________________________________________ Date: _____________________

“Following the 14-day benefit waiting period, I request to utilize ______ days of PTO and/or ______ days of vacation before receiving my disability payments. I understand that, should I be granted short-term disability benefits, my payments will not begin until the conclusion of the PTO/vacation usage I designated above.”

Please return this request to LPS Human Resources along with your disability claim, or notify Melody Fritson of your PTO/vacation request via email: melody.fritson@lps53.org.

-TheStandardGt Liberty Public School District No. 53 Disability Insurance

Claim Packet Instructions

Standard Insurance Company 800.368.2859 Tel 800.378.6053 Fax PO Box 2800 Portland OR 97208

Your Disability Benefit CJaim This packet contains the forms necessary to apply for disability benefits. It also addresses common questions about Disability claims. Please save this material for your future reference. For specific information about your Disability insurance coverage, refer to your group insurance certificate. The certificates are the ultimate authority for Disability claim decisions. If you need other information, please contact your employer's benefit administrator or call our customer service line at 800.368.2859.

How To Apply For Benefits

The Disability benefits application includes claim forms and an Authorization.

1. Complete and sign your part of the claim form (on page 2), and then have your treating physician complete their part of the claim form (the Attending Physician's Statement, also on page 2). If more than one physician is treating you for your disabling condition, each should complete a form. Additional forms are available from your employer's benefits administrator. Your physician may return the completed form to you for you to send to us with the other completed forms, or your physician may mail or fax the completed form to us directly, using the con tact information at the top of the form.

2. Read the Claim Form Fraud Notice on page 3, then provide it to your treating physician with the Attending Physician's Statement.

3. Sign and date the Authorization and send it, along with the completed claim forms, to The Standard at the above address. This authorization allows us to request further information about your claim, if necessary.

Once we receive your completed claim application, it will take approximately one week to make a claim decision. If we have not reached a decision within one week, you will be notified with the details.

Other Benefits That May Reduce Your Disability Benefits

Other benefits you receive, or may be eligible to receive, may reduce the amount of Disability benefits due you. Your coverage or group insurance certificate lists these benefits which may include, but are not limited to, sick leave, Workers' Compensation, State Disability, Social Security and Retirement.

To avoid a possible overpayment on your claim, which would need to be repaid to The Standard, please inform The Standard if you receive other benefits.

When You Return To Work

Your disability benefits usually stop when you return to work. Be sure that you notify The Standard immediately when you plan to return, or have returned to work to assure no overpayment occurs.

Sl 2047-162275-EE 1 of 5 (2/17)

Standard Insurance Company Liberty Public School District No. 53 800.368.2859 Tel 800.3'78.6053 Fax Disability Insurance PO Box 2800 Portland OR 9'7208 Employee/ Attending Physician's Statement

To Be Completed By Employee For a prompt review of your claim, AIL of this form must be tlwroufilily oumpleted by the appropriate persons. Full Name I EmpiO'Jer/Company Name Group Policy No.

Liberty Public School District No. 53 162275 Social Security No. I (honeN}. Birthdate Sex Birlhdate ol Youngest Chld

DMDF Address City State ZIP

1. Is your disability work related? DYes 0 No H yes, have you filed a Workers' Compensation claim? DYes D No

2. Last date at work before disability Date you returned or expect to return to work

3. Cause of Disability: D Accident D Illness D Pregnancy If accident or illness, please explain (include date and location, if applicable)

4. Please describe all work activity, Including self-employment, since the start of your disability. If none, initial here

Acknowledgement - I certify that the answers I have made to the above questions are complete and true to the best of my knowledge and belief. I acknowledge that I have read the fraud notice on page 3 of this form and will provide it to the physician completing the Attending Physician's Statement.

Signature Date

To Be Completed By The Attending Physician '1he following injormati.on is needed t» document the patient's inability t» work. '1he patient is responsible for obf4ining a romplet£ form without expense to The Smndard. Please romplet£ this form and mail ur fax itt» The SbmdiJrd using the contact informtJtima listed above.

1 Dl 1 I A. Diagnosis . agnos s JICDA Classification

B. Symptoms Height Weight B/P

2. Pregnancy (if applicable) A. Expected date of delivery I B. Actual date of delivery

D Vaginal D C-section

3. History and Treatment A. Date you recommended the patient stop work B. When did symptoms appear or accident happen?

C. Has the patient ever had the same or similar condition? DYes DNo If yes, when?

D. Is this condition related to the patient's employment? DYes D No I E. Did you complete a Workers' Compensation claim form? DYes D No F. Date of first visit for this condition I G. Frequency of subsequent visits: I H. Date of most recent visit

D Weekly D Monthly D Other

I. Describe planned course and duration of treatment

J. Hospitalization? I K. Date Admitted Date Discharged L. Surgery? I M. Date Surgery Completed/Scheduled

DYes D No DYes D No N. Reason/Surgery Type 0 . Surgery/Post-Surgery Complications?

DYes D No If yes, please describe

4. Level of Functional Impairment Please attach recent clulrt notes/pertinent records. A. Describe patient's physical and/or mental limitations and restrictions (functional capacity).

B. Factors Delaying Recovery (if applicable)

C. How long do you expect these limitations and restrictions to impair your patient?

0 Date D Unable to determine, follow up in weeks D Permanently

5. Physician Information Please type ur print. Name of physician completing this form Specialty Phone No.

( ) Address City I State I ZIP Fax No.

( ) Acknowledgement- I certify that the answers I have made to the above questions are complete and true to the best of my knowledge and belief. I acknowledge that I have read the fraud notice on page 3 of this form.

Signature Date

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Standard Insurance Company 800.1168.2859 Tel 800.378.60511 Fax PO Box 2800 Portland OR 97208

Some states require us to provide the following information to you:

ALABAMA, MARYLAND AND RHODE ISLAND RESIDENTS

Liberty Public School District No. 53 Disability Insurance

Claim Form Fraud Notices

Any person who !uwwingly or willfully presents a false or fraudulent claim for payment of a loss or benefit or who knowingly or willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.

CALIFORNIA RFSIDENTS

For your protection, California law requires the following to appear on this form: Any person who knowingly presents a false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison.

COLORADO RESIDENTS

It is unlawful to knowingly provide false, incomplete or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance, and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to the policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado division of insurance within the department of regulatory agencies.

DISTRICT OF COLUMBIA RESIDENTS

WARNING: It is a crime to provide false or misleading information to an insurer for the purpose of defrauding the insurer or any other person. Penalties include imprisonment and/ or fines. In addition, an insurer may deny insurance benefits, if false information materially related to a claim was provided by the applicant.

FLORIDA RESIDENTS

Any person who knowingly and with intent to injure, defraud or deceive an insurance company, files a statement of claim or an application containing false, incomplete or misleading information is guilty of a felony of the third degree

NEW JERSEY RESIDENTS

Any person who knowingly files a statement of claim containing any false or misleading information is subject to criminal and civil penalties.

NEW YORK RESIDENTS

Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim, containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime, and shall also be subject to civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation.

PENNSYLVANIA RESIDENTS

Any person who knowingly and ·with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties.

ALL OTHER RESIDENTS

Some states require us to inform you that any person who knowingly and with intent to injure, defraud or deceive an insurance company, or other person, files a statement containing false or misleading information concerning any fact material hereto commits a fraudulent insurance act which is subject to civil and/ or criminal penalties, depending upon the state. Such actions may be deemed a felony and substantial fines may be imposed.

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Liberty Public School District No. 53 Authorization to Obtain and Release Information

I AUTHORIZE THESE PERSONS having any records or knowledge of me or my health: • Any physician, medical practitioner or health care provider. • Any hospital, clinic, pharmacy or other medical or medically related facility or association. • Kaiser Permanente. • Any insurance company or annuity company. • Any empioyer, poiicyhoider or pian sponsor. • Any organization or entity administering a benefit or leave program (including statutory benefits) or an annuity program. • Any educational, vocational or rehabilitation counselor, organization or program. • Any consumer reporting agency, financial institution, accountant, or tax preparer. • Any government agency (for example, Social Security Administration, Public Retirement System, Railroad Retirement Board, Workers'

Compensation Board, etc.). TO GIVE THIS INFORMATION:

• Charts, notes, x-rays, operative reports, lab and medication records and all other medical information about me, including medical history, diagnosis, testing and test results. Prognosis and treatment of any physical or mental condition, including: • Any disorder of the immune system, including HIV, Acquired Immune Deficiency Syndrome (AIDS) or other related

syndromes or complexes. • Any communicable disease or disorder. • Any psychiatric or psychological condition, including test results, but excluding psychotherapy notes. Psychotherapy notes

do not include a summary of diagnosis, functional status, the treatment plan, symptoms, prognosis and progress to date. • Any condition, treatment, or therapy related to substance abuse, including alcohol and drugs.

and: • Any non-medical information requested about me, including such things as education, employment history, earnings or

finances, return to work accommodation discussions or evaluations and eligibility for other benefits or leave periods including but not limited to claims status, benefit amount, payments, settlement terms, effective and termination dates, plan or program contributions, etc.

TO STANDARD INSURANCE COMPANY, THE STANDARD LIFE INSURANCE COMPANY OF NEW YORK, THE STANDARD BENEFIT ADMINISTRATORS AND THEIR AUTHORIZED REPRESENTATIVES (referred to as "The Companies", individually and collectively), AND MY EMPLOYER'S ABSENCE MANAGEMENT PROGRAM ADMINISTRATOR ("Absence Manager").

• I acknowledge that any agreements I have made to restrict my protected health information do not apply to this authorization and I instruct the persons and organizations identified above to release and disclose my entire medical record without restriction.

• I understand that each of The Companies and Absence Manager will gather my information only if they are administering or deciding my disability or leave of absence claim(s), and will use the information to determine my eligibility or entitlement for benefits or leave of absence.

• I understand that I have the right to refuse to sign this authorization and a right to revoke this authorization at any time by sending a written statement to The Companies and Absence Manager, except to the extent the authorization has been relied upon to disclose requested records. A revocation of the authorization, or the failure to sign the authorization, may impair The Companies and Absence Manager's ability to evaluate or process my claim(s), and may be a basis for denying or closing my claim(s) for benefits or leave of absence.

• I understand that in the course of conducting its business The Companies and Absence Manager may disclose to other parties information about me. They may release information to a reinsurer, a plan administrator, plan sponsor, or any person performing business or legal services for them in connection with my claim (s). I understand that The Companies and Absence Manager will release information to my employer necessary for absence management, for return to work and accommodation discussions, and when performing administration of my employer's self-funded (and not insured) disability plans.

• I understand that The Companies and Absence Manager comply with state and federal laws and regulations enacted to protect my privacy. I also understand that the information disclosed to them pursuant to this authorization may be subject to redisclosure with my authorization or as otherwise permitted or required by law. Information retained and disclosed by The Companies and Absence Manager may not be protected under the Health Insurance Portability and Accountability Act [HIPAA].

• I understand and agree that this authorization as used to gather information shall remain in force from the date signed below: • For Standard Insurance Company, the duration of my claim(s) or 24 months, whichever occurs first. • For The Standard Life Insurance Company of New York, the duration of my claim(s) or 24 months, whichever occurs first. • For The Standard Benefit Administrators, the duration of my claim(s) administered by The Standard Benefit

Administrators or 24 months, whichever occurs first. • For Absence Manager, 24 months.

• I understand and agree that The Companies and Absence Manager may share information with each other regarding my disability and leave of absence claim(s). This authorization to share information shall remain valid for 12 months from the date signed below.

• I acknowledge that I have read this authorization and the New Mexico notice on page 5. A photocopy or facsimile of this authorization is as valid as the original and will be provided to me upon request.

Name (please print) ____________________________________________________________________________ ___

Signature of Claimant/Representative Date ___________________________ __

If signature is provided by legal representative (e.g., Attorney in Fact, guardian or conservator), please attach documentation of legal status.

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Liberty Public School District No. 53 Authorization to Obtain and Release Information

Standard Insurance Company is a licensed insurance company in all states except New York. The Standard Life Insurance Company of New York is an insurance company licensed only inN ew York. An absence manager may be hired by your employer and may be one of The Companies.

FOR RESIDENTS OF NEW MEXICO

The state of New Mexico requires Standard Insurance Company to provide you with the following information pursuant to its Domestic Abuse Insurance Protection Act.

The Authorization form allows Standard Insurance Company to obtain personal information as it determines your eligibility for insurance benefits. The information obtained from you and from other sources may include confidential abuse information. "Confidential abuse information" means information about acts of domestic abuse or abuse status, the work or horne address or telephone number of a victim of domestic abuse or the status of an applicant or insured as a family member, employer or associate of a victim of domestic abuse or a person with whom an applicant or insured is known to have a direct, close personal, family or abuse-related counseling relationship. With respect to confidential abuse information, you may revoke this authorization in writing, effective ten days after receipt by Standard Insurance Company, understanding that doing so may result in a claim being denied or may adversely affect a pending insurance action.

Standard Insurance Company is prohibited by law from using abuse status as a basis for denying, refusing to issue, renew or reissue or canceling or otherwise terminating a policy, restricting or excluding coverage or benefits of a policy or charging a higher premium for a policy.

Upon written request you have the right to review your confidential abuse information obtained by Standard Insurance Company. Within 30 business days of receiving the request, Standard Insurance Company will mail you a copy of the information pertaining to you. Mter you have reviewed the information, you may request that we correct, amend or delete any confidential abuse information which you believe is incorrect. Standard Insurance Company will carefully review your request and make changes when justified. If you would like more information about this right or our information practices, a full notice can be obtained by writing to us.

If you wish to be a protected person (a victim of domestic abuse who has notified Standard Insurance Company that you are or have been a victim of domestic abuse) and participate in Standard Insurance Company's location information confidentiality program, your request should be sent to Standard Insurance Company.

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