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					                            Domestic Partner

                            Coverage Summary
                            and Enrollment Kit

                             CRW Employees
                             Hourly & Salaried




Last revised: AP 01.30.08         1 of 9
Meeting the Needs of all Families
Carlson Restaurants Worldwide (CRW) is pleased to recognize the diversity of today’s families by offering coverage to the
domestic partners of our employees, as well as to the dependent children of the domestic partner. The following benefits
programs are available to those that qualify under our domestic partner program: Health, Dental, Vision, Elective Life Insurance,
Elective Accidental Death and Dismemberment Insurance, LifeWorks Employee Assistance Program, Adoption Assistance,
MetLife Auto and Home Insurance, Universal Life Insurance, Long-Term Care and Legal Solution Plan. This summary provides
information about eligibility, required documentation, enrollment and tax implications. Please review your official Summary Plan
Description for the complete details regarding each benefit program. Call HRSolutions at 1-877-462-6947 if you have questions
regarding coverage for Domestic Partners.

Eligibility
Your domestic partner and your domestic partner’s dependent children (collectively referred to as your “domestic partners”) are
eligible to enroll if you are a full-time employee, eligible for the benefit programs of CRW and you are employed in the United
States. You must be enrolled in a benefit program in order to enroll your domestic partners in that program.

    Domestic Partner: To be eligible for coverage as your dependent, a domestic partner must meet all of the following
     requirements:
      Have resided with you continuously for at least six months in a sole-partner relationship that is intended to be
        permanent
      Be jointly responsible with you for the household's financial obligations
      Be unmarried and not related to you by blood
      Be at least 18 years of age

    Children of Your Domestic Partner: To be eligible for coverage as your dependent, a domestic partner's child(ren) must
     be living with you and your domestic partner on a full-time basis in a permanent parent-child relationship and dependent
     upon you for support. In addition, the child must be the natural or legally-adopted child of your domestic partner. Eligible
     children must also meet one of the age requirements listed below:
      be unmarried and under age 19, or
      be unmarried over age 18 but under age 25, provided they attend an approved school full-time, are not employed full-
          time, and rely on you for financial support

If you have legally adopted your domestic partner’s child(ren), note that CRW already extends coverage to children who have
been legally adopted by an employee. Therefore, you can follow the standard procedures if you’d like to add coverage for your
legally adopted child.

When You Can Enroll a Domestic Partner
You can enroll your domestic partners in the health, dental and or vision programs at the following times:
 Within 30 days of your date of hire
 During the fall Annual Enrollment Period, or
 Within 30 days of a Qualified Change in Status:
        Becoming eligible for domestic partner status
        Your domestic partner’s child(ren) becoming eligible for “dependent status”
        Birth or adoption or placement for adoption of a child
        Death of a domestic partner
        A change in your or your domestic partner's employment status
        Change in your or your domestic partner's work schedule or location that alters eligibility
        You or your domestic partner become eligible for Medicare or Medicaid
        Loss of Creditable Coverage under another plan
        A change in programs, elections or cost of coverage through your domestic partner's plans

You, along with your domestic partner, can enroll in Elective Life during a Qualified Change in Status. If you decline coverage
upon initial eligibility, the only opportunity to add coverage will be during a Qualified Change in Status. Changes to coverage are
limited to once per calendar year. You and/or your domestic partner can enroll for MetLife Auto and Home Insurance or Long-
Term Care at any time. See your Summary Plan Description for details. Enrollment in the LifeWorks program is automatic, no
enrollment is required.

If you are enrolling or changing coverage due to a Qualified Change in Status, proof may be required. Refer to the list below for
more information of what types of proof you must send in for your change in status.


 Last revised: AP 01.30.08                                     2 of 9
 Qualified Change in Status                                                        Proof Required
 Marriage, divorce, legal separation or annulment                                  Marriage Certificate, Divorce Decree or court document indicating legal
                                                                                   separation
 Dependent either satisfies or ceases to satisfy eligibility requirements          Evidence of full-time student status or Marriage Certificate
 Change in employment status of an eligible dependent                              Letter from Employer; COBRA letter
 Change in work schedule for you or an eligible dependent, including a             Documentation from employer noting the change; only required if
 reduction in hours of employment, a switch between part- and full-time work,      dependent experiences the change
 commencement or return from leave of absence
 Election change for dependent during another employer’s election period           Documentation from employer noting change
 You or and eligible dependent becomes eligible/ineligible for Medicare or         Medicare/Medicaid letter
 Medicaid
 Loss of creditable coverage under another plan                                    HIPAA Certificate
 Dependent’s Death                                                                 Death Certificate/Copy of Obituary
 Change in benefit programs or elections through a dependent's employer or         ID card or letter from dependent’s employer indicating coverage under
 increase/decrease in cost of coverage through a dependent's employer              his/her plan and documentation from the employer noting change


How to Enroll a Domestic Partner
1.   Complete, sign and date the Domestic Partner Employee Benefit Enrollment/Change/Cancel Form.

2.   Enrolling Your Domestic Partner: Complete the Affidavit of Domestic Partnership. Be sure to have your signatures
     notarized.
      Attach the following proof of domestic partnership to your affidavit:
               Proof of Residence: Documentation showing that your domestic partner resides with you. "Resides with
                  you" means that you and your domestic partner will have shared the same residence continuously for at least
                  six months and intend to share a residence on a permanent basis. One of the following documents is
                  required:
                        Driver's license for both partners showing the same address (including street address, apartment
                            number, city and state)
                        Utility bill showing names of both partners at the same address
                        Mortgage document or lease showing both partners as parties to the transaction, or
                        Income tax returns for both partners showing the same address
               Proof of Financial Responsibility: Documentation that shows you share financial responsibility with a
                  domestic partner. "Jointly responsible for the household's financial obligations" means sharing the basic cost
                  of food and shelter continuously for at least six months. Partners need not contribute equally or jointly to
                  the cost of these expenses, as long as they agree that both are responsible for these and other fundamental
                  costs on the same basis as a marriage. One of the following documents will be required:
                        Statement from a joint bank account
                        Credit cards in both names with the same account number or a copy of a credit or charge card
                            statement of account: i.e. Master Card, Visa, Sears, etc., showing the domestic partner as a
                            supplemental card holder
                        Designation of each other as signatories for a safe deposit box
                        Wills naming each other as principal residual beneficiary
                        Copy of a mortgage agreement (if the mortgage agreement is used to prove joint financial
                            responsibility, a separate form of proof must be submitted to document residence)
                        Statement from a joint IRA, mutual fund or a copy of an annuity certificate held in both names, or
                        City (or municipality) domestic partner registration form

3. Enrolling the Child(ren) of Your Domestic Partner: Complete the Affidavit of Dependent Status. Be sure to have your
   signatures notarized.
     Attach the following proof of dependent status to the affidavit:
               Proof of Parenthood: Documentation that shows the child is the natural or legally-adopted child of your
                  domestic partner. One of the following documents will be required:
                        A birth certificate for the child showing your domestic partner as a parent, or
                        Official adoption document from the court, social services or adoption agency that indicates the date
                            of the child's placement in your domestic partner's home or the date he/she assumed financial
                            responsibility for the child

                     Proof of Residence: Documentation that shows the child resides with you and your domestic partner in a
                      parent-child relationship. One of the following documents will be required:
                           Day care or school records that show the same address where you reside, or
                           Medical records that show the same address where you reside
 Last revised: AP 01.30.08                                                3 of 9
4. Forward the complete packet of forms and attachments to HR Forms, P.O. Box 59159, Minneapolis, MN 55459-8264.

All of the documents listed above must be dated no later than six (6) months before the effective date of coverage. All
required documentation must be completed and submitted before coverage can take effect. For example, if you are submitting
your application for coverage on December 1, your Proof of Residence and Proof of Financial Responsibility must be dated prior
to June 1 of that year.

When You Can Cancel Coverage for a Domestic Partner
You can cancel Health, Dental or Vision coverage at the following times:

       During the fall Annual Enrollment Period (only after a two-year participation period for Vision coverage), or
       Within 30 days of a Change in Status event. See "When You Can Enroll a Domestic Partner" for a complete list of events
        that qualify as a Change in Status.

* If you wish to cancel coverage for a domestic partner during the plan year because a domestic partnership ends, you will be
required to complete and submit an Affidavit of Dissolution of Domestic Partnership within 30 days of the end of the
relationship, and provide documentation similar to the documentation of residence and financial interdependence described in the
enrollment section. Documentation must indicate that you and your former domestic partner no longer share the same residence
and are no longer jointly responsible for your household.

If you wish to cancel coverage for an opposite sex domestic partner because you are getting married, you must complete the
Domestic Partner Benefits Enrollment/Change/Cancel form and the Employee Benefits Change Cancellation Form within 30
days of your marriage to avoid the after-tax contribution and imputed income ramifications.

Keep in mind that the Vision Care Plan has a two-year participation requirement and coverage may only be cancelled during the
fall Annual Enrollment at the end of the two-year period.

Cost of Coverage and Tax Implications
Contributions for coverage of a domestic partner are the same as those for a spouse. Contributions for coverage for your
domestic partner's child(ren) are the same as those for any other child. The contribution amount is determined according to the
option and coverage level you elect. The portion of your contribution that is attributable to coverage of your domestic partner
and your domestic partner's child who has not been legally adopted by you must be paid for on an after-tax basis.

Domestic partners and children of your domestic partner that you have not legally adopted generally do not qualify as spouses or
dependents for income tax purposes under Sections 105 and 152 of the Internal Revenue Code. Therefore, you should be aware
of the following tax implications associated with covering a domestic partner or an eligible child you have not legally adopted.

The value of the Company-paid coverage that relates to your domestic partner and eligible child(ren) who have not been legally
adopted by you will generally be considered imputed income and will be taxable. For example, let's say you elect "you +
spouse/DP" Health Plan coverage. Let's also assume the Company pays $4,200 a year on behalf of you and your domestic
partner and that the portion attributable to providing coverage for "you only" is $2,100 with the remaining $2,100 covering your
domestic partner. The $2,100 attributable to your domestic partner's coverage is considered imputed income and is taxable to
you. This is important to note because, in this example, if you’re in the 15% tax bracket, that could mean additional taxes of $315
a year on the value of the $2,100 in domestic partner coverage. The following is an illustration of this example:

            Example:
            Total annual cost of coverage:                                 $4,200
            Portion attributable to your coverage:                          2,100  You pay no tax on this amount
            Portion attributable to your domestic partner's coverage:       2,100  Considered as imputed taxable income
            Tax you owe if you are in the 15% tax bracket                  $ 315  ($2,100 x 15% = $315)

You may wish to consult with a tax advisor concerning the taxation of your domestic partner coverage.




    Last revised: AP 01.30.08                                    4 of 9
                        AFFIDAVIT OF DOMESTIC PARTNERSHIP
We ________________________________________ and _____________________________________________________
            (Employee’s Name)                                                                 (Domestic Partner’s Name)
submit this Affidavit of Domestic Partnership to establish ourselves as Domestic Partners (as defined below) for the purpose of
enrolling for any benefits that CRW may extend to Domestic Partners. We are Domestic Partners and reside together at:
____________________________________________________________________________________________________
                  (Street)                                        (City)                      (State)                        (Zip)

We affirm that we meet the below listed requirements of Domestic Partnership:

        We will have resided together continuously for at least six months as of our effective date of coverage in a sole
         partnership relationship that we intend to be permanent.
        We are jointly responsible for the household’s financial obligations.
        We are unmarried and not related by blood.
        We are both at least 18 years of age.

We have attached the following documents as evidence of common residence and joint financial responsibility. These documents
are dated no later than six months before the effective date of coverage:

  Proof of Residence: Copy of mortgage document, lease or utility bill showing both names, or copies of drivers’ licenses or
   tax returns showing the same address.
AND
  Proof of Financial Responsibility: Copy of statement from joint bank account, credit cards with the same account
   number, designation of both as signatories for safe deposit box, or wills naming each other as primary residual beneficiary.

This Affidavit is a Company record, and, therefore, will be subject to Company policy, practice and periodic audits.

We acknowledge and affirm that:
 The execution of this document may have the unintentional consequence of creating property rights.
 We will inform CRW within 30 days of the termination of the Domestic Partnership by submitting a completed, signed and
    notarized Affidavit of Dissolution of Domestic Partnership.
 The information provided above is true and complete to the best of our knowledge.

____________________________________________                      ____________________________________________
Printed Name of Employee                                          Printed Name of Domestic Partner

____________________________________________                      ____________________________________________
Signature of Employee                                             Signature of Domestic Partner

____________________________________________                      ____________________________________________
Date                                                              Date

ACKNOWLEDGEMENT OF NOTARY PUBLIC

STATE OF ___________________
COUNTY OF _________________

Sworn to before me this _____ day of ____________, 20___.

____________________________________________
Signature of Notary Public
My Commission Expires ________________________

 Last revised: AP 01.30.08                                    5 of 9
                                AFFIDAVIT OF DEPENDENT STATUS
We, the undersigned, submit this Affidavit of Dependent Status to establish that the child(ren) listed below meet the qualifications for Dependent Status:

Name of Dependent            Dependent’s Social Security Number         Dependent's Date of Birth
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________

We affirm that this(these) child(ren) meet the following requirements for Dependent Status:

     Are unmarried and under age 19, or under age 25 if a full-time student
     Are the natural or adopted child(ren) of the undersigned Domestic Partner
     Have not been legally adopted by the undersigned Employee, and
     Reside with the undersigned Employee and Domestic Partner in a parent-child relationship

We have attached the following documents as evidence of dependent status. These documents are dated no later than six (6)
months before the effective date of coverage:

  Proof of Parenthood: Copy(ies) of birth certificate(s) showing the undersigned Domestic Partner as parent, or official
   adoption documentation from the court, social services or adoption agency that indicates the date(s) the child(ren) were
   placed in the Domestic Partner’s home or the date the Domestic Partner assumed financial responsibility for the child(ren).
AND
  Proof of Residence: Copy(ies) of documentation that reasonably shows that the child(ren) reside with the undersigned
   Domestic Partner and Employee in a parent-child relationships, such as day care, school or medical records showing the
   Domestic Partner and Employee residing at the same address.

This Affidavit is a Company record, and, therefore, will be subject to Company policy, practice and periodic audits.

I affirm that the information provided above is true and complete to the best of my knowledge.

____________________________________________                                 ____________________________________________
Printed Name of Employee                                                     Printed Name of Domestic Partner

____________________________________________                                 ____________________________________________
Signature of Employee                                                        Signature of Domestic Partner

____________________________________________      ____________________________________________
Date                                              Date
                           ______________________________________________

ACKNOWLEDGEMENT OF NOTARY PUBLIC
STATE OF ___________________
COUNTY OF _________________

Sworn to before me this _____ day of ____________, 20___.

____________________________________________
Signature of Notary Public
My Commission Expires ________________________



 Last revised: AP 01.30.08                                               6 of 9
       AFFIDAVIT OF DISSOLUTION OF DOMESTIC PARTNERSHIP
I, __________________________________________________________________________________________________
            (Employee’s Name)                                                         Employee Social Security Number
hereby affirm that my domestic partnership is hereby dissolved and that my former Domestic Partner and I no longer share a
common residence and are not dependent upon each other financially. The following information is true to the best of my
knowledge:

Date of termination of domestic partnership: ________________________________________________________________
Name of Former Domestic Partner: _______________________________________________________________________
Former Domestic Partner’s Social Security Number: __________________________________________________________
New address for former Domestic Partner: __________________________________________________________________
                                                            street
____________________________________________________________________________________________________
city                                                                              state                zip

As evidence of the dissolution of my domestic partnership, I have attached the following evidence:

       Proof of Residence
            Copy of mortgage document, lease or utility bill showing your Domestic Partner’s name has been removed as a
                responsible party
OR
      Proof of Financial Responsibility
            Copy of bank account or credit card statements showing your former Domestic Partner is no longer a signatory on
                the account
            Proof your former Domestic Partner’s name has been removed as a signatory for your safe deposit box, or
            Will or amendment to your will showing your former Domestic Partner has been removed as a beneficiary.

This Affidavit is a Company record, and, therefore, will be subject to Company policy, practice and periodic audits.

I affirm that the information provided above is true and complete to the best of my knowledge.

____________________________________________
Printed Name of Employee

____________________________________________
Signature of Employee

____________________________________________
Date


ACKNOWLEDGEMENT OF NOTARY PUBLIC
STATE OF ___________________
COUNTY OF _________________

Sworn to before me this _____ day of ____________, 20___.

____________________________________________
Signature of Notary Public
My Commission Expires ________________________




    Last revised: AP 01.30.08                                 7 of 9
                                                                              Domestic Partner Benefits Enrollment/Change/Cancellation Form
                                                                                                                                                                                                          TGIFridays
This form is to be used for Domestic Partners only. Use the Employee Benefits or Change/Cancel form to enroll or change employee coverage. Complete this form for each Domestic Partner and Child of your Domestic Partner
you wish to enroll. Attach a complete, signed and notarized Affidavit of Domestic Partnership to enroll your Domestic Partner and an Affidavit of Dependent Status to enroll the children of your Domestic Partner.
EMPLOYEE INFORMATION
Please print
Carlson ID                           Employee Name                                            Employee SSN                                 Phone                                 Email


Home Street Address                                                                           City                                         State                                 Zip



ENROLLMENT & CHANGE IN STATUS INFORMATION
See page 3 for list of qualified changes in status and to determine if proof is required. Change in status must have occurred within the past 30 calendar days.
New Employee                                    Existing Employee with a Change in Status                                                                                                   Existing Employee
You are enrolling your domestic partner         You or your domestic partner have experienced a change in status event within the past 30 days.                                             Annual Enrollment
within 30 days of your hire date                See page 3 of the domestic partnership kit for list of qualified changes in status and to determine if proof is required.
                                                                                                                                                                                               You are enrolling your
Date of hire:                                      Date of change-in-status event:                    Reason for change-in-status:                                                          domestic partner during
                                                                                                                                                                                            annual enrollment

ENROLLEES please print                                                                        CHANGE IN HEALTH CARE                                CHANGE IN DENTAL                          CHANGE IN VISION
                                                               Date of         Gender                                                              For DHMO indicate Provider ID (6          Two year participation rqd
Name                                        SSN
                                                               Birth           (M/F)                                                               digit office #)
Domestic Partner                                                                                 Platinum – Salaried only
                                                                                                 Gold – Salaried only                                 DPPO
                                                                                                 Silver –Salaried or Hourly
                                                                                                 Bronze – Salaried or Hourly
                                                                                                                                       Cancel         DHMO #                    Cancel           Enroll           Cancel
                                                                                                 Copper – Hourly only
Domestic Partner’s Child #1                                                                      Platinum – Salaried only
                                                                                                 Gold – Salaried only                                 DPPO
                                                                                                 Silver –Salaried or Hourly
                                                                                                 Bronze – Salaried or Hourly
                                                                                                                                       Cancel         DHMO #                    Cancel           Enroll           Cancel
                                                                                                 Copper – Hourly only
Domestic Partner’s Child #2                                                                      Platinum – Salaried only
                                                                                                 Gold – Salaried only                                 DPPO
                                                                                                 Silver –Salaried or Hourly
                                                                                                 Bronze – Salaried or Hourly           Cancel         DHMO #                    Cancel           Enroll           Cancel
                                                                                                 Copper – Hourly only
Domestic Partner’s Child #3                                                                      Platinum – Salaried only
                                                                                                 Gold – Salaried only                                 DPPO
                                                                                                 Silver –Salaried or Hourly
                                                                                                 Bronze – Salaried or Hourly           Cancel         DHMO #                    Cancel           Enroll           Cancel
                                                                                                 Copper – Hourly only
Domestic Partner’s Child #4                                                                      Platinum – Salaried only
                                                                                                 Gold – Salaried only                                 DPPO
                                                                                                 Silver –Salaried or Hourly
                                                                                                 Bronze – Salaried or Hourly
                                                                                                                                       Cancel         DHMO #                    Cancel           Enroll           Cancel
                                                                                                 Copper – Hourly only


EMPLOYEE AUTHORIZATION                                                                                                                     ROUTING INSTRUCTIONS
Where contributions are required under these plans, I authorize the deduction from my pay of the required amounts toward the cost of       Mail or fax the completed and signed form to HRSolutions
benefits for which I am now or may later become eligible. I understand payroll contributions for health, dental, vision, HCSA, DCSA        Mailing Address          Fax Number          Contact Information
and PTSA will be taken on a pre-tax basis. I have read and understand the HIPAA Privacy Notice.                                            Carlson HRSolutions      763-212-8206        www.myhr.carlson.com >
Employee Signature                                                Date                                                                     PO Box 1750                                  HRSolutions online
                                                                                                                                           Minneapolis, MN          HQ Mail Stop        hrsolutions@carlson.com
                                                                                                                                           55440-1750               8264                1-877-462-6947

Last revised: AP 01.30.08                                                                                           8 of 9
                                                                              Domestic Partner Benefits Enrollment/Change/Cancellation Form
                                                                                                                                                                                                          TGIFridays
This form is to be used for Domestic Partners only. Use the Employee Benefits or Change/Cancel form to enroll or change employee coverage. Complete this form for each Domestic Partner and Child of your Domestic Partner
you wish to enroll. Attach a complete, signed and notarized Affidavit of Domestic Partnership to enroll your Domestic Partner and an Affidavit of Dependent Status to enroll the children of your Domestic Partner.

EMPLOYEE INFORMATION
Carlson ID                           Employee Name                                            Employee SSN                               Phone                                   Email


Home Street Address                                                                           City                                       State                                   Zip




ENROLLMENT & CHANGE IN STATUS INFORMATION
See page 3 for list of qualified changes in status and to determine if proof is required. Change in status must have occurred within the past 30 calendar days.
New Employee                                    Existing Employee                                                                                                                        Existing Employee
You are enrolling your domestic partner         You or your domestic partner have experienced a change in status event within the past 30 days.                                          Annual Enrollment
within 30 days of your hire date                See page 3 of the domestic partnership kit for list of qualified changes in status and to determine if proof is required.
                                                                                                                                                                                            You are enrolling your
Date of hire:                                      Date of change-in-status event:                    Reason for change-in-status:                                                       domestic partner during annual
                                                                                                                                                                                         enrollment




CHANGE IN ELECTIVE LIFE
Salaried employees only; this benefit is not offered to hourly employees
Enrollment elections and amount of coverage for elective life apply to all of domestic partner’s children ages six months to 18 years. Coverage automatically ends on the child’s 19 th birthday.
Domestic Partner                                           Domestic Partner’s Dependent Children
Domestic Partners can enroll for up to half of the         All amounts include $2,500 of free coverage.
employee’s coverage, up to a maximum of $30,000.
                                                                     $5,000
   0.5x salary
                                                                     $7,500
   1.0x salary           Cancel                                                           Cancel
                                                                     $10,000
   1.5x salary
                                                                     $12,500




EMPLOYEE AUTHORIZATION                                                                                                                   ROUTING INSTRUCTIONS
Where contributions are required under these plans, I authorize the deduction from my pay of the required amounts toward the cost of     Mail or fax the completed and signed form to HRSolutions
benefits for which I am now or may later become eligible. I understand payroll contributions for health, dental, vision, HCSA, DCSA      Mailing Address          Fax Number          Contact Information
and PTSA will be taken on a pre-tax basis. I have read and understand the HIPAA Privacy Notice.                                          Carlson HRSolutions      763-212-8206        www.myhr.carlson.com >
Employee Signature                                                Date                                                                   PO Box 1750                                  HRSolutions online
                                                                                                                                         Minneapolis, MN          HQ Mail Stop        hrsolutions@carlson.com
                                                                                                                                         55440-1750               8264                1-877-462-6947




Last revised: AP 01.30.08                                                                                           9 of 9

				
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