Checklist

 Read McDonald’s Short Term Disability Form Instructions/Checklist Instructions Instructions/General Information: The following are instructions and a checklist, which will guide you through the Short Term Disability (STD) Process. Read through the instructions to familiarize yourself with the entire process. Then go back and as you complete each required action, check the box on the left. Each box represents an action you need to take. IF YOU NEED ASSISTANCE Contact McDonald’s Service Center at 1-877-623-1955. For additional information regarding Leave of Absences, see McDonald’s Helping Balance Your Work and Life. Si usted tiene preguntas sobre este material, favor de llamar al centro de servicio de McDonald’s 1-877-623-1955. Read  A request for a Short Term Disability Leave of Absence may also qualify as a request for a Family and Medical Family Medical Leave, depending upon your eligibility. If you qualify for a Family and Medical Leave, the Family and Medical Leave Leave will run concurrently with Short Term Disability Leave. If you want to continue on a Family Leave of Information Absence following your Short Term Disability Leave, please discuss with your supervisor and if applicable call the Service Center to determine your eligibility and to request a formal Family and Medical Leave of Absence Package. In order for your request to be processed appropriately, it is important that you understand your rights and responsibilities. Refer to the enclosed “Family and Medical Leave Rights and Responsibilities” sheet, which contains information regarding your rights under the Family and Medical Leave Act of 1993.

 Notified To get your leave started: Supv.  Notify your supervisor and the Service Center of your need for a Short Term Disability Leave.  Notified  When you stop working, you must remind your supervisor to notify the Service Center of your last day the Service worked. The leave does not begin until your supervisor notifies us of your last day worked. Your pay will Center be stopped until we receive Short Term Disability approvals from our medical consultants. Check with  Supv. your supervisor to be sure that he/she has notified the Service Center. Called Service Center with last day worked SHORT TERM DISABILITY APPLICATION/EXTENSION FORM (Application)  To apply for a leave of absence under our Short Term Disability (STD) Program, you must complete the  Completed Short Term Disability Application / Extension Form included in this packet. & signed the top section of the  If your work location is in California, New York, New Jersey, Hawaii, or Rhode Island you must complete form the State Disability Insurance (SDI) forms in addition to McDonald’s forms.

 Completed  Check to see if you are eligible for Worker’s Compensation: Reminder for all Workers’ Compensation SDI Forms claims - your supervisor must call Gallagher Bassett to report the claim at 1-800-323-5650. Supervisor  State Disability Insurance (SDI) Information (for employees whose work location is CA, HI, RI, NY, NJ) called Gallagher California, Hawaii, Rhode Island, New York, and New Jersey are states that offer a State Disability Income Bassett program. Benefits that you are eligible for through your State Disability plan will be deducted from your McDonald’s Short-Term Disability benefits. When you receive your State Disability Explanation of Benefit Statement (EOB), send the EOB to the Service Center. We cannot process and release your McDonald’s  Sent EOB Short-Term Disability payment until we have received the EOB. Consequently, it is very important that you to Service apply for your State Disability benefits timely. The state will notify you of your benefit eligibility with a Center Determination Letter.

As a reminder, per the McDonald’s Policies and Programs Total Compensation Handbook, benefits that you receive from the state will be used to offset benefits paid to you from the McDonald’s Short Term Disability Program.

Worker’s Compensation: We cannot process and release your McDonald’s Short-Term Disability payment until we have received worker’s compensation start dates and weekly amounts. Consequently, it is  Workmen’s very important that your claim is called in timely. Comp amounts received Please contact the Service Center if you are not familiar with the process to apply for these benefits.

Package 3881 2/6/2007  Completed, To complete the Short Term Disability Form/Extension Form: Signed & Dated the Employee  After reading the Patient Authorization section, complete the Employee Information section, sign and date portion of the the form. form  Give the signed form to your physician and have them complete the Attending Physician Information. The  Gave form physician should retain a copy for their records and return the completed form to you. (This must be a to my Doctor McDonald’s accepted Licensed Healthcare Provider, we do not accept midwives; assistants; nurse  Reviewed practitioners; etc.).Refer to enclosed document called Definition of a Licensed Health Care Provider. If for you have any questions, please contact the Service Center at 1-877-623-1955. completeness & accuracy and  Mail or Fax the completed form to the McDonald’s Service Center. The address and fax number can be mailed or faxed found at the bottom of your Short Term Disability Application Form. Retain a copy of the form for your form to the records Service Center  Once your Short Term Disability application is thoroughly completed, we will forward your application to our medical consultants, a medical consulting group. They will review the form, contact your physician’s office, and recommend approval or denial of your application. To help expedite your leave you may choose to obtain a copy of your medical records and forward them along with your application. If the leave is approved, they will determine the appropriate leave length. McDonald’s reserves the right of  Received final approval on all Short Term Disability claims. Generally, the approval process will take seven to ten Approval/Denial business days to review your application, provided your physician responds in a timely manner. Letter  When the Service Center receives the approval or denial from our medical consultants, you will be notified with a letter.

Next Steps:

 If you need to continue your leave, complete another Short Term Disability Application/Extension Form following the instructions below to apply for extension of benefits.  You may be eligible for long term disability benefits if you are disabled for more than 180 days. Please contact the Service Center for additional information.  If you exhaust your Short Term Disability benefits and you are not medically able to return to work and are not eligible for long term disability, you will automatically be placed on a Medical Leave of Absence without Pay. This is also contingent upon verifying your continued disability. Request the Medical Leave without Pay Forms from the Service Center.  If you do not need to continue your leave, please go to the Return to Work form section.

SHORT TERM DISABILITY APPLICATION/EXTENSION FORM: (Extension)  If you are out on an approved Short Term Disability leave and are unable to return to work by the expected date, you must complete a Short Term Disability Application/Extension Form. An additional  Filled out copy of the Short Term Disability Application/Extension Form is available through the Service Center Extension Form Fax-Back system, which can be accessed by calling 1-877-623-1955. The Form # is 3889. If you have exhausted your Short Term Disability benefits and you are within the time frame your medical provider has certified you as disabled, you will automatically move to a Medical Leave without Pay. In either  Signed & event, continue with the instructions in this box. Dated the Form  After reading the Patient Authorization section, sign and date the form.  Gave form to my Doctor  Give the signed form to your physician and have them complete the Attending Physician Information. The  Reviewed physician should retain a copy for their records and return the completed form to you. (This must be a McDonald’s accepted Licensed Healthcare Provider, we do not accept midwives; assistants; nurse for practitioners; etc.) completeness & accuracy and  Mail or Fax the completed Short Term Disability Extension Form to the McDonald’s Service Center. The mailed or faxed form to the address and fax number can be found at the bottom of your Short Term Disability Application Form. Service Center Retain a copy of the form for your records.  Received  The request for an extension is also subject to approval by both our medical consultants and McDonald’s. Approval/Denial The approval process will take seven to ten business days to review your application, provided that your letter physician responds in a timely manner.

Package 3881 2/6/2007  When the Service Center receives the approval or denial from our medical consultant s, you will be notified with a letter.

Package 3881 2/6/2007  Filled out Form Next Step:  Signed & dated the form  Go to Return to Work.  Gave form to my Doctor RETURN TO WORK FORM: Gave form  If you have been out on a leave due to your own medical condition, you must have an authorized Return to to my Work Form before you will be allowed to come back to work. Supervisor  Reviewed  Complete the Employee Information portion of the McDonald’s Return to Work Form. for completeness &  After reading the Employee Authorization section, sign and date the form. accuracy and mailed or faxed  Give the signed form to your physician and have them complete the Attending Physician Information. The form to the physician should retain a copy for their records and return the completed form to you. (This must be a Service Center McDonald’s accepted Licensed Healthcare Provider, we do not accept midwives; assistants; nurse practitioners; etc.)  Supv. called Service  Provide this signed release form to your direct supervisor and mail or fax a copy to the Service Center. Center with You will not be allowed to return to active work until your supervisor receives a signed release. return to work date  It is your responsibility to remind your supervisor to notify the Service Center of your return to work date and any restriction information. Your pay may be impacted if your return to work date is not called in by your supervisor. You may wish to double check to insure this has occurred.

 Failure to provide the Company with a physician’s return to work release does not extend your medical leave of absence, and may be grounds for termination.

Package 3881 2/6/2007