lifebenefits Power of Attorney Notice Many times throughout the past several years, BP employees and retirees who can no longer handle their own affairs - either through travel or disability - have sought to have the BP Benefits Center recognize a relative or other agent to accomplish an important health and protection benefits task on their behalf. However, the staff at the BP Benefits Center has no idea if these persons have the actual legal authority to accomplish these tasks. Therefore, these requests must be rejected, to the irritation and dismay of the employee and/or retiree, let alone their agent. As well, BP receives hundreds of powers of attorney (POA) forms every year, many of which are outdated or are simply not legal. Review of these documents results in time consuming delays when required information is either missing or unreadable. To more efficiently assist employees, retirees and beneficiaries with their health and protection benefit matters, BP has developed a form POA, which follows. This POA is especially tailored for use by BP. If fully completed, signed and notarized, it will be ready for efficient review and approval by the BP Benefits Center. All forms create questions, and we are sure this is no different. Immediately following the form are a series of common Questions and Answers. Please review these, but if you have other questions, do not hesitate to contact the BP Benefits Center at 1-800-890-4100 or check BP s LifeBenefits website at http://hr.bpglobal.com/lifebenefits/sites/core/bp-lifebenefits/forms.aspx. Similarly, on occasion a relative or other agent may seek assistance at a time when the employee or retiree may no longer have the mental or physical capacity to execute the BP POA form. In such an instance, a durable power of attorney or guardianship may be submitted for review in lieu of the BP POA form. To assist you in completing the BP POA form or submitting a durable power of attorney or guardianship, we have included a checklist of the steps to take and documents/ information you ll need to provide to the BP Benefits Center (for health and protection POA forms) or BP (for durable POAs or guardianships). Thank you for your cooperation and assistance. delivered by H
BP BENEFITS CENTER POWER OF ATTORNEY FORM FOR H&P BENEFITS I,, (Principal Full Name, please print) Social Security Number: - -, date of birth (Month, Day, Year), hereby certify that I am a participant in one or more health or protection benefit plans (such as medical or life insurance) sponsored by BP Corporation North America Inc. ( BP ). I hereby state ( name of your Agent), whose date of birth is (Month, Day, Year), whose address is (Street Address) (City) (State, ZIP Code) (Phone Number) is my personal representative and Attorney-in-Fact ( Agent ) to act in my stead for all BP health and protection benefits in which I am a participant. Put an X on the line before each type of transaction that your Power of Attorney will handle on your behalf: For all of my BP Benefits Center Benefits, to direct the BP Benefits Center to act on my behalf on all matters related to administration of my BP Benefits Center Benefits, including but not limited to my enrollment or disenrollment and to select payment methods for contribution requirements due for the benefits I have elected. To change my address on file with the BP Benefits Center. To make inquiries or file claims and receive information from the BP Benefits Center on my behalf with respect to my BP Benefits Center health and protection benefits and to receive any statements, reports or information provided to me by the BP Benefits Center and to submit information required for administration of my BP Benefits Center Benefits.
Power of Attorney Notice Page 2 I AGREE to indemnify and hold harmless the BP parties (including BP, its affiliates, the plans it sponsors, Hewitt Associates LLC, and their employees, agents, delegates and successors) from any losses or damages, including without limitation, attorneys fees, resulting from the BP Benefits Center at Hewitt acting upon instruction, either oral or in writing, reasonably believed by the BP Benefits Center to have originated from my Attorney-in-Fact with respect to administration of my benefits under the BP Benefits Center Benefits; and I FURTHER AGREE that this authorization and indemnity shall not be affected by my subsequent disability, shall be a continuing one and shall remain in full force and effect until revoked by me by written notice delivered to the BP Benefits Center or until my death. I understand that all beneficiary designations for my benefits from a life insurance plan sponsored by BP must be made by me and that my Agent may not change my beneficiary designations on file or any deemed beneficiary as required by law, according to the terms of the applicable plan and as set forth in the BP Power of Attorney Guidelines as in effect and as may be amended from time to time. IN WITNESS WHEREOF, I have hereunto set my hand and seal this, (Month) (Year) day of (Day) Principal Name (Printed) Principal Signature Agent Name (Printed) Agent Signature
Power of Attorney Notice Page 3 STATE OF: COUNTY OF: (please print) (please print) On this day of,, before me personally (Day) (Month) (Year) appeared: (Principal Name, please print) to me known to be the individual described in and who executed the foregoing instrument and acknowledged that he or she executed the same. (Notary Public Signature) My Commission Expires: (Month Day, Year) (Notary Seal) Please mail or fax your completed POA to: Fax: 1-847-883-8280 Mail: BP Benefits Center 100 Half Day Road Lincolnshire, IL 60069-1429 NOTE: Please DO NOT send POAs via certified mail. Any documents sent via certified mail will not be processed and will be returned to the sender.
Power of Attorney Notice Page 4 QUESTIONS AND ANSWERS ABOUT THE BP POA FORM FOR HEALTH AND PROTECTION BENEFITS Q1: I already have a POA on file with the BP Benefits Center. Do I need to complete and file one using the new form? A1: No. Your current POA will remain in effect until revoked in writing or until your death. All new POAs submitted to BP can be on the new form. Q2: I don t have a POA on file with the BP Benefits Center. When should I submit one? Now or when I need a representative to assist me? A2: You or your representative should submit the POA only when you need your representative to begin assisting you. We do recommend, though, that you prepare for your future needs by preparing the BP POA form now and keeping it with your other important papers until it is needed. You should note, though, that if any of the information changes, you should prepare an updated POA so that only the representative you want to designate will be able to act on your behalf. Q3: What does the BP POA form permit my representative to do on my behalf? A3: The POA form permits you to make 3 separate choices: 1) full access to direct the BP Benefits Center on your behalf; 2) to make an address change on your behalf; or 3) to make inquiries or file claims and receive information on your behalf. You choose the level of access that you wish your representative to have. Q4: Can my representative change beneficiary designations that I have made based on this POA? A4: No. Use of the BP POA will not permit a representative to change any beneficiary designations that you have made for any of your benefits. To do that, your representative must have a valid court order compliant with the laws of the state in which you reside. Q5: If a guardian or conservator is appointed for me, will BP honor these court orders? A5: Yes. BP will honor guardianships and conservatorships that comply with applicable state laws. The BP Benefits Center will forward any such orders to BP for review. To expedite review of a guardianship, mail a complete copy of the guardianship order to the address listed in question 7 below. Include the following information: - A complete copy of the guardianship - Agent address - Agent telephone number - Last 4 digits of the Agent s Social Security number - The Agent s date of birth - Q6: How long will it take for the BP Benefits Center to process the BP POA form? A6: The BP Benefits Center will strive to complete its review and to notify you and your representative within 30 days of receipt. To expedite processing, please adhere to the following guidelines: Make sure the BP POA form is fully completed, signed, dated and notarized. Do not alter the form of the BP POA text or add/mark out text.
Power of Attorney Notice Page 5 Indicate the type of access you want your representative to have (full access, address change only or inquiry). If you check full access, you should not check the other types of access. Mail or fax your completed BP POA form to: Fax: 1-847-883-8280 Mail: BP Benefits Center 100 Half Day Road Lincolnshire, IL 60069-1429 NOTE: Please DO NOT send documents via certified mail. Q7. If an employee or retiree is incapacitated and unable to execute the BP POA form, will BP accept a durable financial or health care POA that is compliant with state law? A7. Yes. To make sure that a durable POA can be efficiently reviewed, please have your Agent provide the following information: - A complete copy of the durable Power of Attorney - Your treating physician statement of incapacity for the Principal - Agent address - Agent telephone number - Last 4 digits of the Agent s Social Security number - The Agent s date of birth Incomplete submissions will cause delay in processing your request. Mail your documents to: BP America P.O. Box 941644 Houston, Texas 77094-8644 NOTE: To expedite receipt, please DO NOT send documents via certified mail. BP will strive to complete its review and notify the BP Benefits Center as soon as administratively feasible. The BP Benefits Center will then notify your Agent of the review result and, if approved, provide a temporary user ID and pass code. Your Agent must then contact the BP Benefits Center through the toll free telephone system to establish his or her personal security information and conduct business on your behalf such as address updates or benefit inquiries. Q8. Is the BP POA compliant with all state laws? A8. It is impossible to tell. The BP POA form is meant to provide you with an administratively simple way to have your personal representative act on your behalf with regard to BP s health and protection benefits. The form is NOT intended to satisfy the laws of any state regarding what constitutes a compliant power of attorney. You are strongly advised to contact an attorney in your state with expertise in such matters if you wish to obtain a compliant power of attorney for either health care or financial purposes.
Power of Attorney Notice Page 6 My POA To-Do list Do this And check it ( ) off the list I. BP POA Form Select the person who will serve as your POA representative. Talk to this person about the responsibilities that he or she will have as your Agent. Review and complete the BP POA form. Sign the form before a notary public. Please ask the notary to include a notary stamp so that the BP Benefits Center will be able to see your notary is currently authorized. Mail or fax a copy of your signed and notarized POA form to the BP Benefits Center. The address and fax information is listed on page 3 of the POA form. Keep the executed original with your other important papers for safekeeping and give a photocopy of the executed form to your Agent. You and your Agent will each receive a letter notifying you that the POA has been placed on file. Your Agent will receive a temporary password to establish security with the BP Benefits Center. Your Agent should establish representation by calling the BP Benefits Center through the toll free telephone system to establish his or her personal security information and conduct business on your behalf such as address updates or benefit inquiries. FOR DURABLE POAs OR GUARDIANSHIPS ONLY II. Durable Power of Attorney or Guardianship Your Agent must mail a complete copy of the durable power of attorney or guardianship to the address listed in Q&A 7. Make sure he or she includes all of the information needed to process the request. See question 5 for guardianship requirements. You and your Agent or Guardian will each receive a letter notifying you about approval/status of the POA or guardianship order. Your Agent or Guardian will receive a temporary password to establish security with the BP Benefits Center once approved. Your Agent or Guardian should establish representation by calling the BP Benefits Center through the toll free telephone system to establish his or her personal security information and conduct business on your behalf such as address updates or benefit inquiries.