Patch Management, Inc. et al.

Employee Injury Benefit Plan

THIS PLAN INCLUDES BINDING

ARBITRATION

HIGHLIGHTS BROCHURE

August 1, 2021

This brochure provides a brief overview of the Patch Management, Inc. et al. Employee
Injury Benefit Plan (“Plan.”) For a more detailed description of the Plan, including
benefits, limitations and exclusions, please see the “Summary Plan Description” booklet
provided to you by the Company. The Official Plan Document is on file with the
Human Resource Department and is available to all employees.
Contents
Questions & Answers .................................................................................................................…1

When does the amended Plan take effect? .................................................................................1

How do I enroll in the Plan? ......................................................................................................1

Who pays for the Plan? ..............................................................................................................1

How do I make a claim for benefits? .........................................................................................1

What is covered? ........................................................................................................................1

What is not covered? ..................................................................................................................1

Is there a waiting period before my wage replacement benefits will begin? .............................2

What if I have a problem with benefit payments? .....................................................................2

Will my personal health information be protected? ...................................................................2

Plan Benefits ...................................................................................................................................3

Benefits offered under the Plan (Chart) .....................................................................................3

Reporting an Injury .......................................................................................................................4

Enrolling in the Plan ......................................................................................................................5

QUESTIONS & ANSWERS
When does the amended Plan take effect?

It becomes effective on August 1, 2021. On and after that date, all policies and procedures relating
to benefits for occupational injuries and illnesses that happen on the job will be administered
according to the Plan.

How do I enroll in the Plan?

To enroll you need to sign and date the Enrollment Agreement and Arbitration Form. The Plan is
available to all employees on active status.

Who pays for the Plan?

The Company pays 100% of the cost.

How do I make a claim for benefits?

You or a person acting on your behalf must report each incident (no matter how minor) that might
result in medical treatment or lost time. We will cover your reporting responsibilities later in this
booklet.

What is covered?

If you are injured or die in a job related accident or illness, the Company will provide you with medical,
lost wage, death and dismemberment benefits under the Plan.

What is not covered?

1. an injury that occurred while you were not eligible for benefits, and/or you were not in course
and scope of your job;
2. an injury or disease when the medical expense was not incurred within 30 days of the accident
or discovery of the disease;
3. an injury, illness or disease that did not hurt you physically;
4. an injury that was caused by airborne contaminants that did not result from a sudden and
accidental release;
5. a bacterial infection (except pyogenic infection occurring from an injury);
6. an incident that cannot be identified as caused by an occupational accident;
7. an injury that arises from an act of God;
8. when no treatment has been required for a period of sixty days;
9. a hernia, unless it is an inguinal hernia that appeared immediately following an occupational
accident and was not a Pre-Existing Condition;
10. any injury arising from a contract, the employment relationship, violation of any state, federal
or common law;

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Continued

11. care or treatment of alcoholism or drug abuse;

12. a treatment from a non approved provider;

Is there a waiting period before my wage replacement benefits will begin?

Wage replacement benefits are paid to employees who miss work due to an on-the-job injury. The
Plan will pay wage replacement starting on the 8th day you miss work.

What if I have a problem with benefit payments?

The Plan will be administered by professionals who are trained to deliver the benefits provided by the
Plan. They will work with you to resolve any problems that may develop. In the event you feel there
has been an improper delivery of benefits, the Plan has clearly defined appeal procedures. If the appeal
procedures do not resolve your problem with the claim administrator you can appeal their decision to
the Plan Committee. If the Plan Committee rules against you and you still believe you have a case for
benefits, your claim will be mediated. Lastly, if the issue is still unresolved, the claim will be arbitrated
to quickly and fairly resolve any disputes between you and the Plan or the Company.

Will my personal health information be protected?

The Plan Administrator has adopted procedures in compliance with “HIPPA Privacy Rules” in 45
CFR Part 160, 164, Subparts A and E to the extent that these rules apply to Medical Benefits provided
by the Plan.

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PLAN BENEFITS
The Company has provided this Plan for all associates. Generally benefits will be provided whether
the injury was caused by the Company or by you. The benefits available are: Medical Benefits,
Disability Benefits, and Death and Dismemberment Benefits.

The following chart summarizes the Benefits provided by the Plan. The Benefits scheduled are
subject to a single $1,000,000.00 individual and occurrence Plan maximum benefit of
$5,000,000.00.

BENEFITS OFFERED UNDER THE PLAN

BENEFITS
Medical Benefits
Pays for care from 100% of covered charges for 156 weeks up to a
approved doctors and hospitals maximum of $500,000.00.
if you’re injured at work
Disability Benefits
Pays your weekly income Pays 75% of your “Lost Wages” for up to 156
if you need time at home weeks. Pays up to $700.00 per week.
to recover from your injuries Pay starts on the 8th day.
Death Benefits
Provides payment to your Pays up to the lesser of $250,000.00 or 10 times
family if death occurs on the job annual pay.

Dismemberment Benefits
Provides a payment based on Pays up to $250,000.00.
the severity of the injury

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REPORTING AN INJURY
What should I do if I am injured on the job?

The Company has set up procedures to make sure you receive top quality treatment for your injuries
in an efficient, quick manner. By following these and other Plan benefit rules, your covered medical
bills will be paid and your income benefits will continue even if you need to stay at home to recover.
If you do not follow these procedures, your claim for benefits may be denied. For more detailed
information regarding these procedures, please refer to your Summary Plan Description booklet.

The following summarizes your responsibilities in the event of an on-the-job injury:

1. Report Your Injury Immediately

By no later than the end of your work shift, report your injury to your supervisor. Don’t
Wait! Your injury might get worse and we want to help you as soon as possible.

2. Fill Out an Employee Incident Report

By the end of your work shift, you must complete a written report that provides details of the
incident that resulted in your injury. You and the Company will then work together to
investigate your claim.

3. Use an Approved Doctor, Hospital or Clinic for Medical Treatment

In order to receive injury benefits, you must use medical providers and facilities that have been
approved by the Plan Administrator.

4. Take a Drug and Alcohol Screen

If you are injured on the job, you will be required to take a drug and alcohol test.

5. Follow the Doctor’s Orders

You must follow the approved physician’s instructions, and keep all scheduled appointments
with healthcare providers.

6. Keep the Company Informed

You must keep the Company informed regarding your health status and anticipated return-to-
work date.

7. Welcome Back!

We will look forward to welcoming you back as soon as the treating physician issues a medical
release stating that you are able to return to full or transitional duty.
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ENROLLING IN THE PLAN
The Plan is available to all employees of the Company.

This Plan only applies to injuries you may suffer while on active status and during the course and
scope of your employment with the Company.

Read the Arbitration Agreement, Summary Plan Description booklet and this Highlights Brochure.
You are eligible to receive the Plan benefits as of August 1, 2021, sign and date the Acknowledgement
of Arbitration and Enrollment Agreement, have it witnessed and return it to the Human Resources
representative today.

This Highlights Brochure is intended to provide a brief overview of the

Plan. It does not replace the Summary Plan Description or the official Plan
Document. The Summary Plan Description has been provided to you and additional copies are
available at each facility office. The official Plan document governs all benefit and administration
issues of the Plan.

Adopting Employers of the “Company”: Patch Management, Inc., Asian Endeavours, LLC,
Pizza Hut of Muleshoe, Inc., Caprock Pizza, Inc., Pizza Hut of Levelland, Inc., Tijuana Taco,
Inc.

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