2016 Benefit Guide - City of Celina by Higginbotham Public Sector

CITY OF CELINA

BENEFIT GUIDE EFFECTIVE: 10/01/2016 - 9/30/2017 www.mybenefitshub.com/cityofcelina

Table of Contents

Benefit Contact Information How to Enroll Annual Benefit Enrollment 1. Annual Enrollment 2. Eligibility Requirements 3. Helpful Definitions 4. Section 125 Cafeteria Plan Guidelines UnitedHealthcare Medical APL MEDlinkÂ® NBS Health Savings Account (HSA) NBS Health Reimbursement Arrangement (HRA) MDLIVE Telehealth First Continental Life Dental Superior Vision Cigna Short Term Disability Cigna Long Term Disability APL Cancer APL Accident Texas Life Permanent Life 5Star Life and AD&D 5Star Critical Illness

3 4-5 6-9 6 7 8 9 10-13 14-21 22-23 24-25 26-27 28-31 32-33 34-37 38-41 42-45 46-49 50-51 52-55 56-59

FLIP TO... PG. 4 HOW TO ENROLL

PG. 8 HELPFUL DEFINITIONS

PG. 10 YOUR BENEFITS PACKAGE

Benefit Contact Information

Benefit Contact Information BENEFIT ADMINISTRATORS

DENTAL

INDIVIDUAL LIFE

Financial Benefit Services (800) 583-6908 www.mybenefitshub.com/cityofcelina

High Plan ID#-MA1890-D Low Plan ID#-MB1890-D First Continental Life (877) 493-6282 www.fcldental.com

Texas Life Insurance (800) 283-9233 www.texaslife.com

MEDICAL/PHARMACY

VISION

LIFE AND AD&D

UnitedHealthcare (866) 633-2446 www.myuhc.com

Superior Vision (866) 265-0517 www.superiorvision.com

5Star Life Insurance Company (800) 776-2322 www.5starlifeinsurance.com

MEDLINK

DISABILITY

CRITICAL ILLNESS

American Public Life (800) 256-8606 www.ampublic.com

Cigna (800) 244-6224 www.cigna.com

5Star Life Insurance Company (800) 776-2322 www.5starlifeinsurance.com

HSA/HRA

CANCER

COBRA MEDICAL, DENTAL, VISION

National Benefit Services (800) 274-0503 www.nbsbenefits.com

American Public Life (800) 256-8606 www.ampublic.com

National Benefit Services (800) 274-0503 www.nbsbenefits.com

TELEHEALTH

ACCIDENT

MDLIVE (888) 365-1663 www.consultmdlive.com

American Public Life (800) 256-8606 www.ampublic.com

How to Enroll On Your Device Enrolling in your benefits just got a lot easier! Text “cityofcelina” to 313131 to receive everything you

TEXT

need to complete your enrollment.

“cityofcelina”

Avoid typing long URLs and scan

directly to your benefits website,

313131

to access plan information, benefit guide, benefit videos, and more!

TRY ME

SCAN:

On Your Computer Access THEbenefitsHUB from your

Our online benefit enrollment

computer, tablet or smartphone!

platform provides a simple and easy to navigate process. Enroll at your own pace, whether at home or at work. www.mybenefitshub.com/ cityofcelina delivers important benefit information with 24/7 access, as well as detailed plan information, rates and product videos.

! 4

Open Enrollment Tip For your User ID: If you have less than six (6) characters in your last name, use your full last name, followed by the first letter of your first name, followed by the last four (4) digits of your Social Security Number.

Go to:

Click Login

Enter Username & Password

www.mybenefitshub.com/cityofcelina

All login credentials have been RESET to the default described below:

Username:

Sample Username

lincola1234 Sample Password

The first six (6) characters of your last name, followed by the first letter of your first name, followed by the last four (4) digits of your Social Security Number.

lincoln1234

If you have six (6) or less characters in your last name,

If you have trouble

use your full last name, followed by the first letter of

logging in, click on the

your first name, followed by the last four (4) digits of

“Login Help Video”

your Social Security Number.

for assistance.

Default Password: Last Name* (lowercase, excluding punctuation) followed by the last four (4) digits of your Social Security Number.

Click on “Enrollment Instructions” for more information about how to enroll. 5

Annual Benefit Enrollment

SUMMARY PAGES

Annual Enrollment During your annual enrollment period, you have the opportunity

Where can I find forms?

to review, change or continue benefit elections each year.

For benefit summaries and claim forms, go to your benefit

Changes are not permitted during the plan year (outside of

website: www.mybenefitshub.com/cityofcelina. Click on the

annual enrollment) unless a Section 125 qualifying event occurs.

benefit plan you need information on (i.e., Dental) and you can find the forms you need under the Benefits and Forms



Changes, additions or drops may be made only during the

section.

annual enrollment period without a qualifying event. How can I find a Network Provider?

 Employees must review their personal information and verify that dependents they wish to provide coverage for are

For benefit summaries and claim forms, go to your benefit website: www.mybenefitshub.com/cityofcelina. Click on the

included in the dependent profile. Additionally, you must

benefit plan you need information on (i.e., Dental) and you

notify your employer of any discrepancy in personal and/or

can find provider search links under the Quick Links section.

benefit information. When will I receive ID cards?



Employees must confirm on each benefit screen (medical, dental, vision, etc.) that each dependent to be covered is selected in order to be included in the coverage for that particular benefit.

If the insurance carrier provides ID cards, you can expect to receive those 3-4 weeks after your effective date. For most dental and vision plans, you can login to the carrier website and print a temporary ID card or simply give your provider the insurance company’s phone number and they can call and verify your coverage if you do not have an ID card at that

New Hire Enrollment All new hire enrollment elections must be completed in the online enrollment system within the first 31 days of benefit eligibility employment. Failure to complete elections during this timeframe will result in the forfeiture of coverage.

Q&A Who do I contact with Questions? For supplemental benefit questions, you can contact your Benefits/HR department or you can call Financial Benefit Services

at 866-914-5202 for assistance.

time. If you do not receive your ID card, you can call the carrier’s customer service number to request another card. If the insurance carrier provides ID cards, but there are no changes to the plan, you typically will not receive a new ID card each year.

SUMMARY PAGES

Employee Eligibility Requirements

Dependent Eligibility Requirements

Supplemental Benefits: Eligible employees must work 32 or more

Dependent Eligibility: You can cover eligible dependent

regularly scheduled hours each work week.

children under a benefit that offers dependent coverage, provided you participate in the same benefit, through the

Eligible employees must be actively at work on the plan effective

maximum age listed below. Dependents cannot be double

date for new benefits to be effective, meaning you are physically

covered by married spouses within the City of Celina or as

capable of performing the functions of your job on the first day of

both employees and dependents.

work concurrent with the plan effective date. For example, if your 2016 benefits become effective on October 1, 2016, you must be actively-at-work on October 1, 2016 to be eligible for your new benefits.

PLAN

CARRIER

MAXIMUM AGE

Medical

UnitedHealthcare

MEDlink®

American Public Life

Telehealth

MDLIVE

Dental

First Continental Life

Vision

Superior Vision

Cancer

American Public Life

Accident

American Public Life

Voluntary Life and AD&D

5Star

Critical Illness

5Star

If your dependent is disabled, coverage may be able to continue past the maximum age under certain plans. If you have a disabled dependent who is reaching an ineligible age, you must provide a physician’s statement confirming your dependent’s disability. Contact your HR/Benefit Administrator to request a continuation of coverage.

Helpful Definitions

SUMMARY PAGES

Actively at Work

Guaranteed Coverage

You are performing your regular occupation for the employer

The amount of coverage you can elect without answering any

on a full-time basis, either at one of the employer’s usual

medical questions or taking a health exam. Guaranteed

places of business or at some location to which the employer’s

coverage is only available during initial eligibility period.

business requires you to travel. If you will not be actively at

Actively-at-work and/or pre-existing condition exclusion

work beginning 10/1/2016 please notify your benefits

provisions do apply, as applicable by carrier.

administrator.

Annual Enrollment The period during which existing employees are given the

In-Network Doctors, hospitals, optometrists, dentists and other providers who have contracted with the plan as a network provider.

opportunity to enroll in or change their current elections.

Annual Deductible The amount you pay each plan year before the plan begins to

Out of Pocket Maximum The most an eligible or insured person can pay in co-insurance for covered expenses.

pay covered expenses.

Calendar Year

Plan Year October 1st through September 30th.

January 1st through December 31st.

Co-insurance

Pre-Existing Conditions Applies to any illness, injury or condition for which the

After any applicable deductible, your share of the cost of a

participant has been under the care of a health care provider,

covered health care service, calculated as a percentage (for

taken prescriptions drugs or is under a health care provider’s

example, 20%) of the allowed amount for the service.

orders to take drugs, or received medical care or services (including diagnostic and/or consultation services).

EPO (Exclusive Provider Organization) This type of plan does not pay benefits when you go outside of the designated network, except in the case of a true emergency.

SUMMARY PAGES

Section 125 Cafeteria Plan Guidelines A Cafeteria plan enables you to save money by using pre-tax dollars to pay for eligible group insurance premiums sponsored and offered by your employer. Enrollment is automatic unless you decline this benefit. Elections made during annual enrollment will become effective on the plan effective date and will remain in effect during the entire plan year.

Changes in benefit elections can occur only if you experience a qualifying event. You must present proof of a qualifying event to your Benefit Office within 30 days of your qualifying event and meet with your Benefit/HR Office to complete and sign the necessary paperwork in order to make a benefit election change. Benefit changes must be consistent with the qualifying event.

CHANGES IN STATUS (CIS):

QUALIFYING EVENTS

Marital Status

A change in marital status includes marriage, death of a spouse, divorce or annulment (legal separation is not recognized in all states).

Change in Number of Tax Dependents

A change in number of dependents includes the following: birth, adoption and placement for adoption. You can add existing dependents not previously enrolled whenever a dependent gains eligibility as a result of a valid change in status event.

Change in Status of Employment Affecting Coverage Eligibility

Change in employment status of the employee, or a spouse or dependent of the employee, that affects the individual's eligibility under an employer's plan includes commencement or termination of employment.

An event that causes an employee's dependent to satisfy or cease to satisfy coverage requirements Gain/Loss of Dependents' under an employer's plan may include change in age, student, marital, employment or tax dependent Eligibility Status status. If a judgment, decree, or order from a divorce, annulment or change in legal custody requires that you provide accident or health coverage for your dependent child (including a foster child who is your dependent), you may change your election to provide coverage for the dependent child. If the order Judgment/Decree/Order requires that another individual (including your spouse and former spouse) covers the dependent child and provides coverage under that individual's plan, you may change your election to revoke coverage only for that dependent child and only if the other individual actually provides the coverage. Eligibility for Government Programs

Gain or loss of Medicare/Medicaid coverage may trigger a permitted election change.

UNITEDHEALTHCARE

Medical

YOUR BENEFITS PACKAGE

About this Benefit Major medical insurance is a type of health care coverage that provides benefits for a broad range of medical expenses that may be incurred either on an inpatient or outpatient basis.

DID YOU KNOW?

More than 70% of adults across the United States are already being diagnosed with a chronic disease.

This is a general overview of your plan benefits. If the terms of this outline differ from your policy, the policy will govern. Additional plan details on covered expenses, limitations and exclusions are included in the summary plan description located on the City of Celina Benefits Website: www.mybenefitshub.com/cityofcelina

Medical This is a summary of what the plan does and does not cover. This summary can also help you understand your share of the costs. Itâ&#x20AC;&#x2122;s always best to review your Certificate of Coverage (COC) and check your coverage before getting any health services, when possible.

Medical Plan Options

Product

Prescription Drug Plan* Co-payment Your cost for an office visit

Specialist Co-payment Your cost for a specialist office visit

Deductible Your cost before the plan starts to pay

Co-insurance Your cost share after the deductible

Out-of-Pocket Limit Your co-pays, co-insurance and deductibles (including pharmacy) count towards meeting the out-of-pocket limit

HSA (Health Savings Account)

HRA (Health Reimbursement Arrangement)

PCP** (Primary Care Provider)

Rates Employee Employee + Spouse Employee + Child(ren) Employee + Family

Plan AG-YA

Plan AG-YU

Plan AG-2J

Plan AG-3J

Choice Insurance

Navigate HMO

Choice + Insurance

Choice Insurance

Plan 02V-HSA

Plan 032

Plan 052

None

$25

None

Individual - $25 Family - $50

Individual - $2,600 Family - $5,000

Individual - $2,600 Family - $5,200

Individual - $1,500 Family - $3,000

Individual - $1,000 Family - $2,000

20%

Individual - $6,350 Family - $12,700

Individual - $5,000 Family - $10,000

Individual - $4,000 Family - $8,000

Yes

$403.17 $886.98 $745.86 $1,229.67

$385.47 $848.03 $713.12 $1,175.66

$539.61 $1,187.14 $998.27 $1,645.82

$491.78 $1,081.91 $909.79 $1,499.93

*Refer to the Prescription Drug tables on the next page for more details about each plan.

**A plan with a Primary Care Provider (PCP) - Select your personal PCP from the plan network. Each enrolled person must select a PCP. Your PCP must be in an area where you (the subscriber) lives. Your PCP will be your first point of contact when you need care. You need to get online referrals from your PCP to see a network specialist. 11

Medical Prescription Drug Plan 02V (Medical Plan AG-YU)

Prescription Drug Plan 02V (Medical Plan AG-YA)

Retail Up to 31-day supply

Mail Order* Up to 90-day supply

Retail Up to 31-day supply

Mail Order* Up to 90-day supply

Network

Tier 1

$10

$25

Tier 1

$10

$25

Tier 2

$35

$87.50

Tier 2

$35

$87.50

Tier 3

$60

$150

Tier 3

$60

$150

Prescription Drug Plan 032 (Medical Plan AG-2J)

Prescription Drug Plan 052 (Medical Plan AG-3J)

Retail Up to 31-day supply

Mail Order* Up to 90-day supply

Retail Up to 31-day supply

Mail Order* Up to 90-day supply

Network

Tier 1

$15

$37.50

Tier 1

$15

$37.50

Tier 1 Specialty

$15

Not Covered**

Tier 1 Specialty

$15

Not Covered**

Tier 2

$35

$87.50

Tier 2

$40

$100

Tier 2 Specialty

$100

Not Covered**

Tier 2 Specialty

$100

Not Covered**

Tier 3

$60

$150

Tier 3

$75

$187.50

Tier 3 Specialty

$300

Not Covered**

Tier 3 Specialty

$300

Not Covered**

*Only certain Prescription Drug Products are available through mail order; please visit www.myuhc.com or call Customer Care at the telephone number on the back of your ID card for more information. **Maximum Network Coverage for Specialty Prescription Drug Products dispensed through Designated Pharmacy. See Designated Pharmacies section of your Outpatient Prescription Drug Rider.

Medical

AMERICAN PUBLIC LIFE YOUR BENEFITS PACKAGE

MEDlinkÂŽ IV

About this Benefit MEDlinkÂŽ is designed to help supplement your Employer's major medical plan. This plan provides supplemental coverage to help offset out-of-pocket costs that you may experience due to deductibles, co-payments and coinsurance of your medical plan.

DID YOU KNOW?

33% of total healthcare costs are paid out-of-pocket.

MEDlink® IV Enhanced

Limited Benefit Group Medical Expense Supplemental Insurance City of Celina

THE POLICY UNDER WHICH THIS CERTIFICATE IS ISSUED IS NOT A POLICY OF WORKERS’ COMPENSATION INSURANCE. THE EMPLOYER DOES NOT BECOME A SUBSCRIBER TO THE WORKERS’ COMPENSATION SYSTEM BY PURCHASING THE POLICY AND IF THE EMPLOYER IS A NON-SUBSCRIBER, THE EMPLOYEE LOSES THOSE BENEFITS WHICH WOULD OTHERWISE ACCRUE UNDER THE WORKERS’ COMPENSATION LAWS. THE EMPLOYER MUST COMPLY WITH THE WORKERS’ COMPENSATION LAW AS IT PERTAINS TO NON-SUBSCRIBERS AND THE REQUIRED NOTIFICATIONS THAT MUST BE FILED AND POSTED.

ENHANCED PLAN SUMMARY OF BENEFITS*

Base Policy

Option 1

Maximum In-Hospital Benefits

$1,500 per Covered Person per Confinement

In-Hospital Ambulance Benefit

Up to $350 per trip for ground transportation or up to $1,000 per trip for air transportation where a Covered Person is Confined as an Inpatient. Limited to one trip per day.

In-Hospital Deductible

$0 per Covered Person per Confinement

Outpatient Benefit Rider Maximum Outpatient Benefits

$500 per Covered Person per Occurrence for Covered Outpatient Services

Outpatient Ambulance Benefit

Up to $350 per trip for ground transportation or up to $1,000 per trip for air transportation where a Covered Person resides less than 18 hours. Limited to one trip per day.

Outpatient Deductible

$0 per Covered Person Per Occurrence

Covered Outpatient Services Hospital Emergency Room

Payable up to the Maximum Outpatient Benefit, subject to the Outpatient Benefit Deductible, as shown above.

Urgent Care Facility

Maximum of three Urgent Care visits per Covered Person per Calendar Year. Maximum of six Urgent Care visits per Calendar Year for all Covered Persons combined. Payable up to the Maximum Outpatient Benefit, subject to the Outpatient Benefit Deductible, as shown above.

Outpatient Surgery

Outpatient Surgery in Hospital Outpatient Facility or Freestanding Outpatient Surgery Center. Payable up to the Maximum Outpatient Benefit, subject to the Outpatient Benefit Deductible, as shown above.

Diagnostic Testing

Diagnostic Testing in a Hospital Outpatient Facility or MRI Facility. Payable up to the Maximum Outpatient Benefit, subject to the Outpatient Benefit Deductible, as shown above.

Outpatient Treatment for a Serious Mental Illness in a Hospital Outpatient Facility

Maximum of 60 days of treatment per Covered Person per Calendar Year. Payable up to the Maximum Outpatient Benefit, subject to the Outpatient Benefit Deductible, as shown above.

Benefit Rider Physician Outpatient Treatment Benefit Rider

$25 per visit; Maximum of four visits per Covered Person per Calendar Year and eight visits per Calendar Year for all Covered Persons combined for treatment in a: Hospital Outpatient Facility s s Freestanding Emergency Care Clinic s Urgent Care Facility/Clinic s Physician Office

Total Monthly Premiums by Plan* Ages 18-54 Ages 55+

Employee

Employee & Spouse

Employee & Child

Employee & Family

$29.44

$68.16

$53.59

$92.20

$42.14

$97.36

$75.18

$130.30

*Total premium includes the Plan selected and any applicable rider premium. Premiums are subject to increase with notice. The premium and amount of benefits vary dependent upon the Plan selected at time of application.

APSB-22354(TX) MGM/FBS City of Celina

MEDlink® IV Enhanced

Limited Benefit Group Medical Expense Supplemental Insurance

Important Policy Provisions Eligibility

You are eligible to be covered under this Policy/Certificate if you are Actively At Work, qualify for coverage as defined in the Master Application, are covered under your Employer’s Medical Plan and are under age 70 (if you work for an employer employing less than 20 employees). Your Eligible Dependents, as defined in the Policy/Certificate, are eligible for coverage if they are covered under the Employer’s Medical Plan. You must apply for insurance during the Initial Enrollment period or on the date the person first becomes eligible for coverage. If you do not apply during the Initial Enrollment period or on the date you become eligible for coverage, you may be subject to additional underwriting by APL. Evidence of coverage under your Employer’s Medical Plan is required.

When Coverage Begins

Coverage will begin on the requested Certificate Effective Date or the Certificate Effective Date assigned by us, upon approval of your application, if our underwriting rules are met, the premium has been paid and all persons to be insured are covered under your Employer’s Medical Plan and you are Actively At Work on the Certificate Effective Date. If you are not Actively At Work on the Certificate Effective Date due to disability, Injury, Sickness, temporary layoff, leave of absence or Family and Medical Leave of Absence, coverage begins on the date you return to Actively At Work.

Limitations & Exclusions No benefits will be payable for expenses incurred during any period the Covered Person does not have coverage under your Employer’s Medical Plan, except as provided in the Absence of the Insured’s Employer’s Medical Plan provision, described in the Policy. A hospital is not an institution, or part thereof, used as: a place for rehabilitation, a place for rest or for the aged, a nursing or convalescent home, a long term nursing unit or geriatrics ward, or an extended care facility for the care of convalescent, rehabilitative or ambulatory patients.

Pre-Existing Condition Limitation

No benefits are payable during the Pre-Existing Condition Exclusion Period following the Covered Person’s Effective Date for any loss resulting from a Pre-Existing Condition. The Pre-Existing Condition Limitation will apply only if the Covered Person is subject to a Pre-Existing Condition Limitation under the Employer’s Medical Plan. Therefore, any Pre-Existing Condition Limitation applied to the Major Medical plan would, in effect, limit coverage under this plan.

Exclusions

No benefits are payable for any loss resulting from or caused, whether directly or indirectly, by: s war or any act of war, whether declared or undeclared, or active service in the armed forces; (This exclusion includes Accident sustained or Sickness contracted while in the service of any military, naval or air force of any country engaged in war. If coverage is suspended for any Covered Person during a period of military service, APL will refund the pro-rata portion of any premium paid for any such Covered Person upon receipt of your written request) s an intentionally self-inflicted Injury or Sickness; s suicide or attempted suicide, while sane or insane; s rest care or rehabilitative care and treatment; s outpatient routine newborn care; s voluntary abortion except, with respect to you or your covered Eligible Dependent spouse: s where you or your Dependent spouse’s life would be endangered if the fetus were carried to term; or s where medical complications have arisen from abortion; s pregnancy of an Eligible Dependent child;

16APSB-22354(TX) MGM/FBS City of Celina

s participating in a riot, insurrection, rebellion, civil commotion, civil disobedience or unlawful assembly; (This does not include a loss which occurs while acting in a lawful manner within the scope of authority.) s committing, or attempting to commit, an illegal act that is defined as a felony; (Felony is as defined by the law of the jurisdiction in which the act takes place.) s participation in a contest of speed in power driven vehicles, parachuting or hang gliding; s air travel, except: s as a fare-paying passenger on a commercial airline on a regularly scheduled route; or s as a passenger for transportation only and not as a pilot or crew member; s being intoxicated or under the influence of any narcotic unless administered by a Physician or taken according to the Physician’s instructions; (Intoxication means that which is determined and defined by the laws and jurisdiction of the geographical area in which the event that caused the loss occurred.) s alcoholism or drug addiction; s sex changes; s experimental treatment, drugs or surgery; s Accident or Sickness arising out of, and in the course of, any occupation for compensation, wage or profit; (This does not apply to those sole proprietors or partners not covered by Workers’ Compensation.) s dental or vision services, including treatment, surgery, extractions or x-rays, unless: s resulting from an Accident occurring while the Covered Person’s coverage is in force and if performed within 12 months of the date of such Accident; or s due to congenital disease or anomaly of a covered newborn child. s routine examinations, such as health exams, periodic check-ups or routine physicals, except when part of Inpatient routine newborn care; s elective cosmetic surgery; s drugs (prescription and non-prescription for use outside of a covered facility as defined in this Policy/Certificate or any attached rider); s sterilization and reversal of sterilization; s an expense that does not meet the definition of Covered Charges; s an expense or service that exceeds any of the Maximum Benefits, as shown in the Schedule of Benefits; or s any expense for which benefits are not payable under your Other Medical Plan.

Premium Changes

The premium rates may be changed by APL at the first anniversary date of this Policy or any premium due date thereafter. No such increase in rates will be made unless 60 days prior notice is given to the Policyholder. Premiums will not increase during the initial 12 months of coverage.

Optionally Renewable

This Policy is renewable at the option of APL. The Policyholder or APL may terminate this Policy on any premium due date after the first anniversary following the Policy Effective Date, subject to 60 days written notice.

Termination of Certificate

Your insurance coverage under this Certificate and any attached riders will end on the earliest of these dates: s the date the Policy terminates; s the end of the grace period if the premium remains unpaid; s the date you no longer qualify as an Insured; s the date you attain age 70 (if you work for an employer employing less than 20 employees); s the date your coverage under your Employer’s Medical Plan ends; or s the date of your death.

MEDlink® IV Enhanced

Limited Benefit Group Medical Expense Supplemental Insurance

Limitations & Exclusions continued Termination of Coverage

Your insurance coverage under this Certificate and any attached riders for a Covered Person will end as follows: s the date the Policy terminates; s the date the Certificate terminates; s the end of the Certificate Month in which APL receives a written request from you to terminate the Covered Person’s coverage; s the date a Covered Person no longer qualifies as an Insured or Eligible Dependent; or s the date of the Covered Person’s death. APL may end the coverage of any Covered Person who submits a fraudulent claim.

Cobra Continuation of Coverage

This plan may be continued in accordance with the Consolidated Omnibus Reconciliation Act of 1986.

2305 Lakeland Drive | Flowood, MS 39232 ampublic.com | 800.256.8606 Underwritten by American Public Life Insurance Company. This is a brief description of the coverage. For complete benefits, limitations, exclusions and other provisions, please refer to the certificate/policy and riders. This coverage does not replace Workers’ Compensation Insurance. This product is inappropriate for people who are eligible for Medicaid coverage. | This policy is considered an employee welfare benefit plan established and/or maintained by an association or employer intended to be covered by ERISA, and will be administered and enforced under ERISA. Group policies issued to governmental entities and municipalities may be exempt from ERISA guidelines. | Policy Form MEDlink® Series | Texas | Limited Benefit Group Medical Expense Supplemental Insurance | (10/14) | City of Celina

APSB-22354(TX) MGM/FBS City of Celina 17

MEDlink® IV Enhanced

Limited Benefit Group Medical Expense Supplemental Insurance City of Celina

ENHANCED PLAN SUMMARY OF BENEFITS*

Base Policy

Option 2

Maximum In-Hospital Benefits

$2,500 per Covered Person per Confinement

In-Hospital Ambulance Benefit

Up to $350 per trip for ground transportation or up to $1,000 per trip for air transportation where a Covered Person is Confined as an Inpatient. Limited to one trip per day.

In-Hospital Deductible

$0 per Covered Person per Confinement

Outpatient Benefit Rider Maximum Outpatient Benefits

$500 per Covered Person per Occurrence for Covered Outpatient Services

Outpatient Ambulance Benefit

Up to $350 per trip for ground transportation or up to $1,000 per trip for air transportation where a Covered Person resides less than 18 hours. Limited to one trip per day.

Outpatient Deductible

$0 per Covered Person Per Occurrence

Covered Outpatient Services Hospital Emergency Room

Payable up to the Maximum Outpatient Benefit, subject to the Outpatient Benefit Deductible, as shown above.

Urgent Care Facility

Outpatient Surgery

Diagnostic Testing

Diagnostic Testing in a Hospital Outpatient Facility or MRI Facility. Payable up to the Maximum Outpatient Benefit, subject to the Outpatient Benefit Deductible, as shown above.

Outpatient Treatment for a Serious Mental Illness in a Hospital Outpatient Facility

Maximum of 60 days of treatment per Covered Person per Calendar Year. Payable up to the Maximum Outpatient Benefit, subject to the Outpatient Benefit Deductible, as shown above.

Total Monthly Premiums by Plan* Employee

Employee & Spouse

Employee & Child

Employee & Family

Ages 18-54

$34.73

$80.30

$62.57

$108.05

Ages 55+

$50.06

$115.58

$88.64

$154.06

18APSB-22354(TX) MGM/FBS City of Celina

MEDlink® IV Enhanced

Limited Benefit Group Medical Expense Supplemental Insurance

Important Policy Provisions Eligibility

When Coverage Begins

Pre-Existing Condition Limitation

Exclusions

APSB-22354(TX) MGM/FBS City of Celina

Premium Changes

Optionally Renewable

Termination of Certificate

MEDlink® IV Enhanced

Limited Benefit Group Medical Expense Supplemental Insurance

Limitations & Exclusions continued Termination of Coverage

Cobra Continuation of Coverage

This plan may be continued in accordance with the Consolidated Omnibus Reconciliation Act of 1986.

APSB-22354(TX) MGM/FBS City of Celina 20

MEDlinkÂŽ IV Enhanced

NBS

HSA (Health Savings Account)

YOUR BENEFITS PACKAGE

About this Benefit A Health Savings Account is a tax-advantaged medical savings account available to employees who are enrolled in a high-deductible health plan. The funds contributed to the account are not subject to federal income tax at the time of deposit. Unlike a flexible spending account (FSA), funds roll over and accumulate year to year if not spent.

DID YOU KNOW? The interest earned in an HSA is tax free.

Money withdrawn for medical spending never falls under taxable income.

HSA (Health Savings Account) You can use your Health Savings Account (HSA) to pay for a wide range of IRS-qualified medical expenses for yourself, your spouse or tax dependents. An IRS-qualified medical expense is defined as an expense that pays for healthcare services, equipment, or medications. Funds used to pay for IRS-qualified medical expenses are always tax-free.

What is an HSA? 

 



A tax-advantaged savings account that you use to pay for eligible medical expenses as well as deductible, co-insurance, prescriptions, vision and dental care. Allows you to save while reducing your taxable income. Unused funds that will roll over year to year. There’s no “use it or lose it” penalty. Potential to build more savings through investing. If you maintain a minimum balance of $2,000, your additional funds may be invested in mutual funds yielding tax‐free earnings. A way to accumulate additional retirement savings. After age 65, funds can be withdrawn for any purpose without penalty.

Participant Account Web Access www.nbsbenefits.com A Health Savings Account (HSA) works with a high deductible health plan (HDHP) and lets you set aside a portion of your paycheck ‐ before taxes– into an account to help you pay for medical expenses before you reach your deductible or that you aren’t covered by your plan. It can also help you pay for future medical expenses.

A Health Savings Account (HSA):  

Grows with you. If you maintain a balance of $2,000, your additional funds may be invested in mutual funds yielding tax‐free earnings. Helps you plan for the future. Until you turn 65, withdrawals used for eligible expenses are tax free. After you turn 65, or if you become disabled, your HSA account becomes similar to a regular IRA. Withdrawals you use for noneligible expenses will be taxed at your regular income tax rate but won’t incur additional penalties.

Using Funds

For a list of sample expenses, please refer to the City of Celina benefit website at www.mybenefitshub.com/cityofcelina

Pre-paid Debit Card: You may use the card to pay merchants or service providers that accept Master Card credit cards, so there is no need to pay cash up front and wait for reimbursements.

NBS Contact Information

2016 Annual HSA Contribution Limits Individual: $3,350 Family: $6,750 Catch-Up Contributions: Account holders over the age of 55 who have not yet enrolled in Medicare are eligible to make an additional $1,000 “catch‐up” contribution to their HSA.

P.O. Box 6980 West Jordan, UT 84084 Phone‐800‐274‐0503 Fax‐800‐478‐1528 Email: service@nbsbenefits.com

Will my HSA Funds be up fronted to me? Like a savings account, you can only withdrawal what you’ve contributed to the account. Funds are not up fronted. Are there any monthly fees? There is a $2.00 administrative fee that will be deducted from your HSA account on a monthly basis.

NBS

HRA (Health Reimbursement Arrangement)

YOUR BENEFITS PACKAGE

About this Benefit A Heath Reimbursement Arrangement (HRA) is an employer-sponsored plan that can be used to reimburse a portion of you and your eligible family member's out-of-pocket medical expenses, such as deductibles, coinsurance and pharmacy expenses. It is not an insurance plan, but a reimbursement plan funded entirely by your employer and reimbursement amounts are determined by your employer.

DID YOU KNOW?

Nearly 1 in 4 people in the United States taking prescription drugs report difficulty affording them.

HRA (Health Reimbursement Arrangement) General Plan Information Plan Name: City of Celina Address: 142 North Ohio Celina, TX 75009 Telephone: (972) 382-2692 Tax I.D. Number: 75-6000481 Plan Effective Date: 10/1—9/30 Coverage Period End: Sept. 30th Plan Administrator: National Benefit Services Company Contact: (800) 274-0503

Expenses are considered “incurred” when the service is performed, not necessarily when it is paid for. You can get a claim form at www.nbsbenefits.com for reimbursement. Any monies left at the end of the Coverage Period will be rolled to the next plan year as long as you are actively employed by the City of Celina. You must submit claims no later than 30 days after the end of the Coverage Period.

Family and Medical Leave Act Notwithstanding anything in the Plan to the contrary, in the event any benefit under this Plan becomes subject to the requirements of the Family and Medical Leave Act of 1993 and regulations thereunder, this Plan shall be operated in accordance with proposed Regulation 1.125-3.

Qualified Expenses

Additional Plan Information

The plan allows you to be reimbursed for certain out of pocket medical, dental and vision expenses which are incurred by you and your dependents. These would include drugs obtained through a prescription. The expenses, which qualify, are those permitted by Section 213 of the Internal Revenue Code. A list of some of the expenses that qualify is available from the Administrator.

As a participant in the Plan, you are entitled to certain rights and protections under the Employee Retirements Income Security Act of 1974 (ERISA). Please refer to your Summary Plan Description for more information on your ERISA rights. Terminated Employees have 30 Days after their date of termination to submit receipts for services prior to their termination date.

Eligibility If you work 32 hours or more each week for the company, you will be eligible to join the Plan as of your date of employment and upon enrollment in our group medical plan. You will enter the Plan on the first day of the month following 90 days.

Benefit The maximum Employer contribution allowed each month is $496.80 per Participant.

Benefits Payment During the course of the Coverage Period, you may submit requests for reimbursement of expenses you have incurred. However, you must make your requests for reimbursements no later than 30 days after the end of the Coverage Period. The Administrator will provide you with acceptable forms for submitting these requests for reimbursement. In addition, you must submit to the Administrator proof of the expenses you have incurred and that they have not been paid by any other health plan coverage. If the request qualifies as a benefit or expense that the Plan has agreed to pay, you will receive a reimbursement payment soon thereafter. Remember, reimbursements made from the Plan are generally not subject to federal income tax or withholding. Nor are they subject to Social Security taxes.

MDLIVE YOUR BENEFITS PACKAGE

Telehealth

About this Benefit Telehealth provides 24/7/365 access to boardcertified doctors via telephone consultations that can diagnose, recommend treatment and prescribe medication. Whether you are at home, traveling or at work, Telehealth makes care more convenient and accessible for non-emergency care when your primary care physician is not available.

DID YOU KNOW?

75%

of all doctor, urgent care, and ER visits could be handled safely and effectively via telehealth.

Telehealth When should I use MDLIVE?

 If you’re considering the ER or urgent care for a non-emergency medical issue  Your primary care physician is not available  At home, traveling, or at work  24/7/365, even holidays!

What can be treated?         

Allergies Asthma Bronchitis Cold and Flu Ear Infections Joint Aches and Pain Respiratory Infection Sinus Problems And More!

Pediatric Care related to:       

Cold & Flu Constipation Ear Infection Fever Nausea & Vomiting Pink Eye And More!

Are children eligible? Yes. MDLIVE has local pediatricians on-call 24/7/365. Please note, a parent or guardian must be present during any interactions involving minors. We ask parents to establish a child record under their account. Parents must be present on each call for children 18 or younger.

How much does it cost? $10 Covers you, your spouse, and children up to age 26, with unlimited phone consultations.

Download the App Doctor visits are easier and more convenient with the MDLIVE App. Be prepared. Download today. www.mdlive.com/getapp     

Access to a doctor anywhere: at home, at work, or on the go Choose doctors from one of the nation's largest telehealth networks Available 24/7 by video or phone Private, secure and confidential visits Connect instantly with MDLIVE Assist

Who are our doctors? MDLIVE has the nation’s largest network of telehealth doctors. On average, our doctors have 15 years of experience practicing medicine and are licensed in the state where patients are located. Their specialties include primary care, pediatrics, emergency medicine and family medicine. Our doctors are committed to providing convenient, quality care and are always ready to take your call.

Scan with your smartphone to get the app.

Call us at (888) 365-1663 or visit us at www.consultmdlive.com

Disclaimers: MDLIVE does not replace the primary care physician. MDLIVE operates subject to state regulation and may not be available in certain states. MDLIVE does not guarantee that a prescription will be written. MDLIVE does not prescribe DEA controlled substances, non-therapeutic drugs and certain other drugs which may be harmful because of their potential for abuse. MDLIVE physicians reserve the right to deny care for potential misuse of services. For complete terms of use visit www.mdlive.com/pages/terms.html 010113

FIRST CONTINENTAL LIFE

Dental

YOUR BENEFITS PACKAGE

About this Benefit Dental insurance is a coverage that helps defray the costs of dental care. It insures against the expense of routine care, treatment and dental disease.

DID YOU KNOW?

Good dental care may improve your overall health. Also Women with gum disease may be at greater risk of giving birth to a preterm or low birth weight baby.

Dental Passive PPO Dental Plan (100/80/50) City of Celina MB1890-D Annual Benefit - Per Person

$750

Percentage of Covered Benefits Per Policy Year Calendar Year Deductible - Per Person This deductible applies to Type II and III services. Dependent children covered to age 26

TYPE I: 100% TYPE II: 80% TYPE III: 50% $50/$150

Payment is based upon allowable charges in the area in which service is rendered. Services provided at a no-contracting provider are paid at the 90th percentile

Percentage of Covered Benefits Per Policy Year TYPE I (PREVENTIVE SERVICES) Including:  No waiting period  Routine Exams  Prophylaxis (cleanings-one per 6 months)  Emergency exams for dental pain (minor procedures)  Fluoride treatments for dependent children under age 19

100%

(one per 12 months)  Bitewing X-rays (once per 6 months)  Sealants for children ages 6-15 (one per tooth)  Periapical X-rays  Space maintainers  Full mouth or panorex X-rays (one per 36 months)

TYPE II (BASIC SERVICES) Including:  No waiting period  Simple restorative services (fillings)  Simple extractions  Palliative treatment for dental pain, local anesthesia

80%

TYPE III (MAJOR SERVICES) Including:  No waiting period  Major restorative services (crowns and inlays)  Prosthetics (bridges, dentures)  Replacement of prosthodontics, dentures, crowns and inlays  Denture relines  Implants and related services  Endodontics/root canal therapy  Periodontics  Complex Oral Surgery  General anesthesia (for services dentally necessary)

50%

Monthly Rates Employee Only Employee and Spouse Employee and Child(ren) Employee and Family

$23.08 $45.62 $50.90 $76.02 29

Dental Passive PPO Dental Plan (100/80/50) City of Celina MA1890-D Annual Benefit - Per Person Percentage of Covered Benefits Per Policy Year Calendar Year Deductible - Per Person This deductible applies to Type II and III services. Dependent children covered to age 26

$1,500 TYPE I: 100% TYPE II: 80% TYPE III: 50% $50/$150

Payment is based upon allowable charges in the area in which service is rendered. Services provided at a no-contracting provider are paid at the 90th percentile

100%

TYPE II (BASIC SERVICES) Including:  No waiting period  Simple restorative services (fillings)  Simple extractions  Palliative treatment for dental pain, local anesthesia  Endodontics/root canal therapy  Periodontics  Complex Oral Surgery  General anesthesia (for services dentally necessary) TYPE III (MAJOR SERVICES) Including:  No waiting period  Major restorative services (crowns and inlays)  Prosthetics (bridges, dentures)  Replacement of prosthodontics, dentures, crowns and inlays  Denture relines  Implants and related services ORTHODONTIC SERVICES  No waiting period  No Deductible  $1,000 lifetime maximum benefit  Children under 19 only

80%

50%

Monthly Rates Employee Only Employee and Spouse Employee and Child(ren) Employee and Family 30

$29.78 $59.02 $64.96 $97.56

Dental Limitations and Exclusions Covered Expenses Will Not Include and No Benefits Will be Payable: 1. For any treatment which is for cosmetic purposes or to correct congenital malformations, except for medically necessary care and treatment of congenital cleft lip and palate. 2. To replace any prosthetic appliance, crown, inlay or onlay restoration, or fixed bridge within five years of the date of the last placement of these items, unless required because of an accidental bodily injury sustained while the Insured is covered. Replacement is not covered if the item can be repaired. 3. For initial placement of any prosthetic appliance or fixed bridge unless such placement is needed because of the extraction of natural teeth during the same period of continuous coverage. But the extraction of a third molar (wisdom tooth) will not qualify the item for payment. Any such appliance or fixed bridge must include the replacement of the extracted tooth or teeth. Coverage does not include the part of the cost that applies specifically to replacement of teeth extracted prior to the period of coverage. 4. For addition of teeth to an existing prosthetic appliance or fixed bridge unless for replacement of natural teeth extracted during the same period of continuous coverage. 5. For any expense incurred or procedure begun before the Insured’s current period of continuous coverage. 6. For any expense incurred or procedure begun after the Insured’s insurance under this section terminates, except for a prosthetic appliance, fixed bridge, crown, or inlay or onlay restoration for which both (a) the procedure begins before insurance ends and (b) the item’s final placement is within 90 days after insurance ends. 7. To duplicate appliances or replace lost or stolen appliances. 8. For appliances, restorations or procedures to: a. alter vertical dimension; b. restore or maintain occlusion; c. splint or replace tooth structure lost as a result of abrasion or attrition; or d. treat jaw fractures or disturbances of the Temporomandibular joint. 9. For education or training in, and supplies used for, dietary or nutritional counseling, personal oral hygiene or dental plaque control. 10. For broken appointments or the completion of claim forms. 11. For orthodontia service or for any services associated with orthodontic therapy when this optional coverage is not elected and the premium is not paid. 12. For sealants which are: a. not applied to a permanent molar; b. applied before age 6 or after attaining age 16; or c. reapplied to a molar within three years from the date of a previous sealant application. 13. For subgingival curettage or root planing (procedure numbers 4220 and 4341) unless the presence of periodontal disease is confirmed by both x-rays and pocket depth summaries of each tooth involved. 14. Because of an Insured’s injury arising out of, or in the course of, work for wage or profit. 15. For an Insured’s sickness, injury or condition for which he or she is eligible for benefits under any Workers Compensation Act or similar laws. 16. For charges for which the Insured is not liable or which would not have been made had no insurance been in force.

17. For services which are not recommended by a dentist, not required for necessary care and treatment, or do not have a reasonably favorable prognosis. 18. Because of war or any act of war, declared or not, or while on fulltime active duty in the armed forces of any country. 19. To an Insured if payment is not legal where the Insured is living when expenses are incurred. 20. For any services related to: equilibration, bite registration or bite analysis. 21. For crowns for the purpose of periodontal splinting. 22. For charges for: any implants; overdentures; precision or semiprecision attachments and associated endodontic treatment; other customized attachments; or specialized prosthodontic techniques or characterizations. 23. For charges for myofunctional therapy, orthognathic surgery or athletic mouthguards. 24. For procedures for which benefits are payable under the employer’s medical expense benefits plan for employees and their dependents. 25. Services or supplies provided by a family member or a member of the Insured’s household.

Note: This is a general outline of covered benefits and does not include all the benefits, limitations and exclusions of the policy. See your certificate for details. Predetermination of Benefits: As a service to protect the Insured, First Continental Life & Accident Insurance Co. will provide predetermination of benefits for recommended treatment plans that exceed $300. This predetermination of benefits explains which of the recommended procedures will be covered and at what amount. This benefit helps Insured's better understand their coverage. The Insured should submit the treatment plan to First Continental Life & Accident Insurance Co. for review and predetermination of benefits before the service begins. TAKEOVER BENEFITS Takeover means that you are given credit for waiting periods for like coverage's accumulated under your existing plan. No credit is given for deductibles satisfied under your existing plan. 1. In order to provide Takeover Benefits your employer’s current dental plan must have been in effect continuously for at least 12 months prior to the effective date of this plan. 2. All employees insured on the effective date with continuous coverage from the prior group dental contract are eligible for Takeover Benefits. Waiting periods will be reduced by the amount of time insured under the prior plan. 3. A minimum of five (5) enrolled members are needed for an employer to be eligible for Takeover Benefits. 4. Takeover Benefits must be requested and are subject to the approval of First Continental Life & Accident Insurance Co.

Submission of Claims: First Continental Life & Accident Insurance Co. ATTN: Claims Department 101 Parklane Blvd., Suite 301 Sugar Land, TX. 77478 Verification of Claims: 281-313-7170 (local) 1-877-493-6282 (toll free) 31

SUPERIOR VISION YOUR BENEFITS PACKAGE

Vision

About this Benefit Vision insurance provides coverage for routine eye examinations and may cover all or part of the costs associated with contact lenses, eyeglasses and vision correction, depending on the plan.

DID YOU KNOW?

75% of U.S. residents between age 25 and 64 require some sort of vision correction.

Vision Benefits Exam Frames Contact Lenses1

In-Network

Out-of-Network

Covered in full $100 retail allowance $175 retail allowance

Up to $35 retail Up to $55 retail Up to $65 retail

Covered in full

Up to $150 retail

Medically Necessary Contact Lenses Lasik Vision Correction

$8.30 $14.11 $14.49 $22.40

Co-Pays

$200 allowance2 Exam Materials

Lenses (standard) per pair Single Vision Bifocal Trifocal Scratch coating Progressive Lenticular

Monthly Premiums EE Only EE + Spouse EE + Child(ren) EE + Family

Covered in full Covered in full Covered in full Covered in full Covered in full Covered in full

Up to $25 retail Up to $40 retail Up to $45 retail Up to $25 retail Up to $75 retail Up to $80 retail

$10 $25

Services/Frequency Exam Frame Lenses Contact Lenses

12 months 12 months 12 months 12 months

(Based on date of service)

Co-pays apply to in-network benefits; co-pays for out-of-network visits are deducted from reimbursements. 1

Contact lenses and related professional services (fitting, evaluation and followup) are covered in lieu of eyeglass lenses and frames benefit. 2 Lasik Vision Correction is in lieu of eyewear benefit, subject to routine regulatory filings and certain exclusions and limitations

Discount Features Non-Covered Eyewear Discount: Members may also receive a discount of 20% from a participating provider’s usual and customary fees for eyewear purchases which exceed the benefit coverage (except disposable contact lenses, for which no discount applies). This includes eyeglass frames which exceed the selected benefit coverage, specialty lenses (i.e. progressives) and lens “extras” such as tints and coatings. Eyewear purchased from a Walmart Vision Center does not qualify for this additional discount because of Walmart’s “Always Low Prices” policy.

SuperiorVision.com Customer Service 800.507.3800

The Plan discount features are not insurance. All allowances are retail; the member is responsible for paying the provider directly for all non-covered items and/or any amount over the allowances, minus available discounts. These are not covered by the plan. Discounts are subject to change without notice. Disclaimer: All final determinations of benefits, administrative duties, and definitions are governed by the Certificate of Insurance for your vision plan. Please check with your Human Resources department if you have any questions 33

CIGNA

Short Term Disability

YOUR BENEFITS PACKAGE

About this Benefit Disability insurance protects one of your most valuable assets, your ability to earn a living. This insurance will replace a portion of your income in the event that you become physically unable to work. Short term disability coverage provides benefits when you are unable to work for a short period of time due to a covered sickness or injury.

DID YOU KNOW?

60% of Americans do not have a â&#x20AC;&#x153;rainy dayâ&#x20AC;? fund to cover three months of unanticipated financial emergencies.

Short Term Disability

Short Term Disability (STD) Insurance Coverage - paid by you Eligibility Eligibility Waiting Period

Active, full-time Employees of the Employer regularly working a minimum of 32 hours per week. First of the month following 90 days. Benefit Amount

Up to 60% of your weekly covered earnings

Maximum

$1,000 per week

Weekly Benefit

Elimination Period Benefit Duration

You must be disabled for 14 days from accident and 14 days from sickness. Once you qualify for benefits under this plan, you continue to receive them until the end of the 26 week benefit period, or until you no longer qualify for benefits, whichever occurs first.

Definition of Disability

Cost

Disability means that, solely because of a covered injury or sickness, you are unable to perform the material duties of your regular occupation and/or you are unable to earn 80% or more of your covered earnings from working in your regular occupation. We will require proof of earnings and continued disability.

The cost of this insurance program is paid by you. The cost per $10 of weekly covered benefit is shown below. Costs are subject to change.

Covered Earnings Covered earnings means your wages or salary, not including extra compensation, bonuses, commissions and overtime.

Earnings While Disabled Benefits will be reduced for any week that benefits plus income from employment exceeds 100% of weekly covered earnings.

Pre-existing Conditions Benefits are not payable for medical conditions for which you incurred expenses, took prescription drugs, received medical treatment, care or services (including diagnostic measures,) during the 3 months just prior to the most recent effective date of insurance. Benefits are not payable for any disability resulting from a pre-existing condition unless the disability occurs after you have been insured under this plan for at least 12 months after your most recent effective date of insurance.

Age <20 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-84 85-89 90-94 95-99

Rate per $10 of Weekly Covered Benefit $0.3600 $0.3600 $0.3600 $0.3600 $0.3600 $0.3600 $0.3600 $0.4180 $0.5200 $0.6250 $0.6860 $0.6860 $0.6860 $0.6860 $0.6860 $0.6860 $0.6860

Short Term Disability Additional Plan Details & Features Termination of Disability Benefits Your benefits will terminate on the earliest of any of the following dates: the date the insurance company determines you are no longer disabled; the date you earn from any occupation more than the percentage of covered earnings as defined in your definition of disability; the date the maximum benefit period ends; the date you cease to get appropriate care; the date you die; the date you refuse to participate without good cause in all required phases of the rehabilitation plan; the date you fail to cooperate with us in the administration of the claim. Benefits may be resumed if you begin to cooperate in the rehabilitation plan within 30 days of the date benefits terminated.

Effects of Other Income Benefits The disability benefit provided by this plan is a total benefit; that is, it will be reduced by any disability benefits payable on behalf of you or your dependents, or a qualified third party on behalf of you or your dependents, whether or not you are actually receiving them. Other income sources that may reduce your benefits under this plan include:  Any Social Security disability or retirement benefits you or any third party receive (or are assumed to receive) on your own behalf; or which your dependents receive (or are assumed to receive) because of your entitlement to such benefits.  Benefits payable by a Canadian and/or Quebec provincial pension plan.  Amounts payable under the Railroad Retirement Act.  Amounts payable under local, state, provincial or federal government disability or retirement plan or law as it pertains to the employer.  Employer-paid portion of company retirement plan benefits.  Amounts payable by company sponsored sick leave or salary continuation plan.  Amounts payable by any franchise or group insurance or similar plan.  Benefits payable under work-loss provisions of any mandatory “no fault” auto insurance.  Any amounts paid on account of loss of earnings or earning capacity through settlement, judgment, arbitration or otherwise, where a third party may be liable, regardless of whether liability is determined.



Amounts payable under any workers’ compensation (including temporary or permanent disability benefits), occupational disease, and unemployment compensation. This includes damages, compromises or settlements paid in place of such benefits, whether or not liability is admitted.

Income sources that WILL NOT reduce your benefits under this plan are:  Benefits paid by personal, individual disability income policies.  Individual deferred compensation agreements.  Employee savings plans, including thrift plans, stock options or stock bonuses.  Individual retirement funds, such as IRA or 401(k) plans.  Profit-sharing, investment or other retirement or savings plans maintained in addition to an employer-sponsored pension plan.

Exclusions This plan does not pay benefits for a disability which results, directly or indirectly, from any of the following: Suicide, attempted suicide, or whenever you injure yourself on purpose; war or any act of war, whether or not declared; active participation in a riot; commission of a felony; the revocation, restriction or non-renewal of your license, permit or certification necessary for you to perform the duties of your occupation, unless solely due to injury or sickness otherwise covered by the policy. In addition, we will not pay disability benefits for any period of disability during which you are incarcerated in a penal or corrections institution for any reason.

Plan Termination Coverage terminates if the group policy is terminated, if you cease to be in active service, if you are no longer a member of an eligible class of employees, the day after the last date for which premium has been paid by you or the employer, or the date you become eligible for a plan of benefits intended to replace this coverage. If you are disabled and receiving benefits under this plan, your benefits and coverage will continue until the expiration of your benefit period, or until you no longer qualify for benefits under the plan, whichever comes first.

Short Term Disability When Coverage Takes Effect Your coverage takes effect on the later of the program’s effective date, the date you become eligible, the date we receive your completed enrollment form, or the date you authorize any necessary payroll deductions. If you have to submit evidence of good health, your coverage takes effect on the date we agree, in writing, to cover you. If you’re not actively at work on the date your coverage would otherwise take effect, you’ll be covered on the date you return to work.

This information is a brief description of the important features of the plan. It is not a contract. Terms and conditions of insurance are set forth in Group Policy No. VDT 601596. Please refer to your Certificate of Insurance or Summary Plan Description for more detailed information. Coverage is underwritten by Life Insurance Company of North America, a Cigna company. “Cigna” and the Tree of Life logo are registered service marks of Cigna Intellectual Property, Inc. © Cigna 2015

CIGNA YOUR BENEFITS PACKAGE

Long Term Disability

About this Benefit Disability insurance protects one of your most valuable assets, your paycheck. This insurance will replace a portion of your income in the event that you become physically unable to work due to sickness or injury for an extended period of time.

DID YOU KNOW?

Just over 1 in 4 of today's 20 year -olds will become disabled before they retire.

34.6 months is the duration of the average disability claim.

Long Term Disability

Long Term Disability (LTD) Insurance Coverage - paid by your employer Eligibility Eligibility Waiting Period

Active, full-time Employees of the Employer regularly working a minimum of 32 hours per week.

First of the month following 90 days.

Benefit Amount

Up to 60% of your monthly covered earnings

Maximum

$10,000 per month

Monthly Benefit

Benefit Period

You must be continuously disabled for 180 days before benefits may be payable.

Important Definitions and Features Definition of Disability

Covered Earnings

Disability means that, solely because of a covered injury or sickness, you are unable to perform the material duties of your regular occupation and you are unable to earn 80% or more of your indexed earnings from working in your regular occupation. After benefits have been payable for 24 months, you are considered disabled if solely due to your injury or sickness, you are unable to perform the material duties of any occupation for which you are (or may reasonably become) qualified by education, training or experience, and you are unable to earn 60% or more of your indexed earnings. We will require proof of earnings and continued disability.

Covered earnings means your wages or salary, not including extra compensation, bonuses, commissions and overtime.

Benefit Duration Once you qualify for benefits under this plan, you continue to receive them until the end of the benefit period shown below, or until you no longer qualify for benefits, whichever occurs first. Your benefit period begins on the first day after you complete your elimination period. Should you remain disabled, your benefits continue according to the following schedule, depending on your age at the time you become disabled.

Age at Disability Duration of Payments

62 or Younger

69+

Number of Months Benefits Paid

To age 65 or the date the 42nd monthly benefit is payable, if later

Long Term Disability Effects of Other Income Benefits The disability benefit provided by this plan is a total benefit; that is, it will be reduced by any disability benefits payable on behalf of you or your dependents, or a qualified third party on behalf of you or your dependents, whether or not you are actually receiving them. Other income sources that may reduce your benefits under this plan include:  Any Social Security disability or retirement benefits you or any third party receive (or are assumed to receive) on your own behalf; or which your dependents receive (or are assumed to receive) because of your entitlement to such benefits.  Benefits payable by a Canadian and/or Quebec provincial pension plan.  Amounts payable under the Railroad Retirement Act.  Amounts payable under local, state, provincial or federal government disability or retirement plan or law as it pertains to the employer.  Employer-paid portion of company retirement plan benefits.  Amounts payable by company sponsored sick leave or salary continuation plan.  Amounts payable by any franchise or group insurance or similar plan.  Benefits payable under work-loss provisions of any mandatory “no fault” auto insurance.  Any amounts paid on account of loss of earnings or earning capacity through settlement, judgment, arbitration or otherwise, where a third party may be liable, regardless of whether liability is determined.  Amounts payable under any workers’ compensation (including temporary or permanent disability benefits), occupational disease, and unemployment compensation. This includes damages, compromises or settlements paid in place of such benefits, whether or not liability is admitted. Income sources that WILL NOT reduce your benefits under this plan are:  Benefits paid by personal, individual disability income policies.  Individual deferred compensation agreements.  Employee savings plans, including thrift plans, stock options or stock bonuses.  Individual retirement funds, such as IRA or 401(k) plans.  Profit-sharing, investment or other retirement or savings plans maintained in addition to an employer-sponsored pension plan.

Additional Plan Details & Features Earnings While Disabled During the first 24 months that benefits are payable, benefits will be reduced if benefits plus income from employment exceeds 100% of pre-disability covered earnings. After that, benefits will be reduced by 50% of earnings from employment.

Pre-existing Conditions Benefits are not payable for medical conditions for which you incurred expenses, took prescription drugs, received medical treatment, care or services (including diagnostic measures,) during the 3 months just prior to the most recent effective date of insurance. Benefits are not payable for any disability resulting from a preexisting condition unless the disability occurs after you have been insured under this plan for at least 12 months after your most recent effective date of insurance.

Limited Benefit Period Disabilities caused by or contributed to by any one or more of the following conditions are subject to a lifetime limit of 24 months: Anxiety-disorders, delusional (paranoid) or depressive disorders, eating disorders, mental illness, somatoform disorders (including psychosomatic illnesses). Benefits are payable during periods of hospital confinement for these conditions for hospitalizations lasting more than 14 consecutive days that occur before the 24-month lifetime limit is exhausted. Once the 24-month benefits are exhausted, the plan pays no further benefits. Disabilities caused by or contributed to by any one or more of the following conditions are subject to a lifetime limit of 24 months: Alcoholism, drug addiction or abuse. Benefits are payable during periods of hospital confinement for these conditions for hospitalizations lasting more than 14 consecutive days that occur before the 24-month lifetime limit is exhausted. Once the 24-month benefits are exhausted, the plan pays no further benefits.

Exclusions This plan does not pay benefits for a disability which results, directly or indirectly, from any of the following: Suicide,

Long Term Disability attempted suicide, or whenever you injure yourself on purpose; war or any act of war, whether or not declared; active participation in a riot; commission of a felony; the revocation, restriction or non-renewal of your license, permit or certification necessary for you to perform the duties of your occupation, unless solely due to injury or sickness otherwise covered by the policy.

This information is a brief description of the important features of the plan. It is not a contract. Terms and conditions of insurance are set forth in Group Policy No. SGD607043. Please refer to your Certificate of Insurance or Summary Plan Description for more detailed information. Coverage is underwritten by Life Insurance Company of North America, a Cigna company. “Cigna” and the Tree of Life logo are registered service marks of Cigna Intellectual Property, Inc. © Cigna 2015

In addition, we will not pay disability benefits for any period of disability during which you are incarcerated in a penal or corrections institution for any reason.

When Coverage Takes Effect Your coverage takes effect on the later of the program’s effective date, the date you become eligible, the date we receive your completed enrollment form, or the date you authorize any necessary payroll deductions. If you have to submit evidence of good health, your coverage takes effect on the date we agree, in writing, to cover you. If you’re not actively at work on the date your coverage would otherwise take effect, you’ll be covered on the date you return to work.

Family Survivor Benefit If you die while receiving disability benefits, we will pay a survivor benefit based on 100% of the total of your last month’s benefit plus the amount of any disability earnings by which this benefit had been reduced for that month. This plan pays a single lump sum equal to 3 months of benefits. We pay this benefit directly to your lawful spouse, or to your children in equal shares, if there is no lawful spouse. If you have no lawful spouse or children, we pay this benefit to your estate.

AMERICAN PUBLIC LIFE

Cancer

YOUR BENEFITS PACKAGE

About this Benefit Cancer insurance offers you and your family supplemental insurance protection in the event you or a covered family member is diagnosed with cancer. It pays a benefit directly to you to help with expenses associated with cancer treatment.

DID YOU KNOW? Breast Cancer is the most commonly diagnosed cancer in women.

If caught early, prostate cancer is one of the most treatable malignancies.

GC13 Limited Benefit Group Cancer Indemnity Insurance City of Celina THE POLICY UNDER WHICH THIS CERTIFICATE IS ISSUED IS NOT A POLICY OF WORKERS’ COMPENSATION INSURANCE. THE EMPLOYER DOES NOT BECOME A SUBSCRIBER TO THE WORKERS’ COMPENSATION SYSTEM BY PURCHASING THE POLICY AND IF THE EMPLOYER IS A NON-SUBSCRIBER, THE EMPLOYEE LOSES THOSE BENEFITS WHICH WOULD OTHERWISE ACCRUE UNDER THE WORKERS’ COMPENSATION LAWS. THE EMPLOYER MUST COMPLY WITH THE WORKERS’ COMPENSATION LAW AS IT PERTAINS TO NON-SUBSCRIBERS AND THE REQUIRED NOTIFICATIONS THAT MUST BE FILED AND POSTED.

SUMMARY OF BENEFITS Benefits

Option 1

Option 2

Radiation Therapy/Chemotherapy/Immunotherapy Benefit Maximum per 12-month period

$15,000

$20,000

$50 per treatment

Hormone Therapy - Maximum of 12 treatments per Calendar Year Experimental Treatment Benefit Waiver of Premium

Paid in the same manner and under the same maximums as any other benefit Waive Premium

Waive Premium

Lump Sum Benefit Maximum 1 per Covered Person per lifetime

$5,000

$10,000

Lump Sum for Eligible Dependent Children Maximum 1 per Covered Person per lifetime

$7,500

$15,000

Lump Sum Benefit Maximum 1 per Covered Person per lifetime

$5,000

$10,000

Lump Sum for Eligible Dependent Children Maximum 1 per Covered Person per lifetime

$7,500

$15,000

Option 1

Option 2

Individual

$13.66

$23.00

Individual & Spouse

$29.48

$49.94

1 Parent Family

$15.70

$26.50

2 Parent Family

$31.52

$53.48

Internal Cancer First Occurrence Benefit

Heart Attack/Stroke First Occurrence Benefit

Monthly Premium*

*The premium and amount of benefits vary dependent upon the option selected at time of application. All benefits are per covered person, per calendar year unless otherwise stated.

APSB-22331(TX) MGM/FBS City of Celina

GC13 Limited Benefit Group Cancer Indemnity Insurance Eligibility

You and your Eligible Dependents are eligible to be insured under the Certificate if you and your Eligible Dependents meet APL’s underwriting rules and you are Actively at Work and qualify for coverage as defined in the Master Application.

Limitations & Exclusions

No benefits will be paid for care or treatment received outside the territorial limits of the United States, treatment by any program engaged in research that does not meet the definition of Experimental Treatment or losses or medical expenses incurred prior to the Covered Person’s Effective Date regardless of when Cancer was diagnosed.

Only Loss for Cancer

The Policy/Certificate pays only for loss resulting from definitive Cancer treatment including direct extension, metastatic spread or recurrence. Proof must be submitted to support each claim. The Policy/Certificate also covers other conditions or diseases directly caused by Cancer or the treatment of Cancer. The Policy/Certificate does not cover any other disease, sickness or incapacity which existed prior to the diagnosis of Cancer, even though after contracting Cancer it may have been complicated, aggravated or affected by Cancer or the treatment of Cancer.

Pre-Existing Condition Exclusion

No benefits are payable for any loss incurred during the Pre-Existing Condition Exclusion Period following the Covered Person’s Effective Date as the result of a Pre-Existing Condition. Pre-Existing Conditions specifically named or described as excluded in any part of the Policy/Certificate are never covered. If any change to coverage after the Certificate Effective Date results in an increase or addition to coverage, the Time Limit on Certain Defenses and Pre-Existing Condition Limitation for such increase will be based on the effective date of such increase.

Waiting Period

The Policy/Certificate contains a Waiting Period during which no benefits will be paid. If any Covered Person has a Specified Disease diagnosed before the end of the Waiting Period immediately following the Covered Person’s Effective Date, coverage for that person will apply only to loss that is incurred after one year from the Covered Person’s Effective Date. If any Covered Person is diagnosed as having a Specified Disease during the Waiting Period immediately following the Covered Person’s Effective Date, the Insured may elect to void the Certificate from the beginning and receive a full refund of premium. If the Policy/Certificate replaced Specified Disease Cancer coverage from another company that terminated within 30 days of the Certificate Effective Date, the Waiting Period will be waived for those Covered Persons that were covered under the prior coverage. However, the Pre-Existing Condition Limitation will still apply.

Termination of Certificate

Insurance coverage under the Certificate and any attached riders will end on the earliest of any of the following dates: the date the Policy terminates; the end of the grace period if the premium remains unpaid; the date insurance has ceased on all persons covered under this Certificate; the end of the Certificate Month in which the Policyholder requests to terminate this coverage; the date you no longer qualify as an Insured; or the date of your death.

Termination of Coverage

Insurance coverage for a Covered Person under the Certificate and any attached riders for a Covered Person will end as follows: the date the Policy terminates; the date the Certificate terminates; the end of the grace period if the premium remains unpaid; the end of the Certificate Month in which the Policyholder requests to terminate the coverage for an Eligible Dependent; the date a Covered Person no longer qualifies as an Insured or Eligible Dependent; or the date of the Covered Person’s death.

APSB-22331(TX) MGM/FBS City of Celina

Optionally Renewable

The policy is optionally renewable. The Policyholder has the right to terminate the policy on any premium due date after the first Anniversary following the Policy Effective Date. APL must give at least 60 days written notice prior to cancellation.

Portability (Voluntary Plans Only)

When the Insured no longer meets the definition of Insured, he or she will have the option to continue this coverage, including any attached riders. No Evidence of Insurability will be required. Portability must meet all of the following conditions: the Certificate has been continuously in force for the last 12 months; APL receives a request and payment of the first premium for the portability coverage no later than 30 days after the date the Insured no longer qualifies as an eligible Insured. All future premiums due will be billed directly to the Insured. The Insured is responsible for payment of all premiums for the portability coverage; the Policy, under which this Certificate was issued, continues to be in force on the date the Insured ceases to qualify for coverage. The benefits, terms and conditions of the portability coverage will be the same as those elected under the Certificate immediately prior to the date the Insured exercised portability. Portability coverage may include any Eligible Dependents who were covered under the Certificate at the time the Insured ceased to qualify as an eligible Insured. No new Eligible Dependents may be added to the portability coverage except as provided in the Newborn and Adopted Children provision. No increases in coverage will be allowed while the Insured is exercising his or her rights under this rider. If the Policy is no longer in force, then portability coverage is not available.

Heart Attack/Stroke First Occurrence Benefit Rider

Pays a lump sum amount when a Covered Person receives a first diagnosis of Heart Attack/Stroke and the Date of Diagnosis occurs after the Waiting Period. The Heart Attack/Stroke lump sum benefit amount will reduce by 50% at age 70.

Exclusions & Limitations

We will not pay benefits for any loss caused by or resulting from any of the following: intentionally self-inflicted bodily injury, suicide or attempted suicide, whether sane or insane; alcoholism or drug addiction; any act of war, declared or undeclared, or any act related to war, or active service in the armed forces; military service for any country at war. If coverage is suspended for any Covered Person during a period of military service, we will refund the pro-rata portion of any premium paid for any such covered person upon receipt of the Policyholder’s written request; participation in any activity or event while intoxicated or under the influence of any narcotic unless administered by a Physician or taken according to the Physician’s instructions; or participation in, or attempting to participate in, a felony, riot or insurrection (a felony is defined by the law of the jurisdiction in which the activity takes place).

Pre-Existing Condition Exclusion

No benefits are payable for any loss incurred during the Pre-Existing Condition Exclusion Period following the Covered Person’s Effective Date of this rider as the result of a Pre-Existing Condition.

Waiting Period

This rider contains a Waiting Period during which no benefits will be paid. If any Heart Attack or Stroke is diagnosed before the end of the Waiting Period immediately following the Covered Person’s Effective Date of this rider, coverage will apply only to loss that is incurred after one year from the Covered Person’s Effective Date.

GC13 Limited Benefit Group Cancer Indemnity Insurance Termination

This rider will terminate and coverage will end for all Covered Persons on the earliest of any of the following: the end of the grace period if the premium for this rider remains unpaid; the date the Policy or Certificate to which this rider is attached terminates; the end of the Certificate Month in which we receive a request from the Policyholder to terminate this rider; the date of your death; or the date the lump sum benefit amount for Heart Attack or Stroke has been paid for all Covered Persons under this rider. Coverage on an Eligible Dependent terminates under this rider when such person ceases to meet the definition of Eligible Dependent.

Internal Cancer First Occurrence Benefit Rider

Pays a lump sum benefit amount when a Covered Person receives a first diagnosis of a covered Internal Cancer and the Date of Diagnosis occurs after the Waiting Period. The Internal Cancer lump sum benefit amount will reduce by 50% at age 70.

Exclusions & Limitations

We will not pay benefits for a diagnosis of Internal Cancer received outside the territorial limits of the United States or a metastasis to a new site of any Cancer diagnosed prior to the Covered Person’s Effective Date, as this is not considered a first diagnosis of an Internal Cancer.

Pre-Existing Condition Exclusion

Waiting Period

This rider contains a Waiting Period during which no benefits will be paid. If any Internal Cancer is diagnosed before the end of the Waiting Period immediately following the Covered Person’s Effective Date of this rider, coverage will apply only to loss that is incurred after one year from the Covered Person’s Effective Date of this Rider.

Termination

This rider will terminate and coverage will end for all Covered Persons on the earliest of any of the following: the end of the grace period if the premium for this rider remains unpaid; the date the Policy or Certificate to which this rider is attached terminates; the end of the Certificate Month in which we receive a request from the Policyholder to terminate this rider; the date of your death; or the date the lump sum benefit amount for Internal Cancer has been paid for all Covered Persons under this rider. Coverage on an Eligible Dependent terminates under this rider when such person ceases to meet the definition of Eligible Dependent.

2305 Lakeland Drive | Flowood, MS 39232 ampublic.com | 800.256.8606 Underwritten by American Public Life Insurance Company. This is a brief description of the coverage. For complete benefits and other provisions, please refer to your policy/certificate/rider(s). This coverage does not replace Workers’ Compensation Insurance. This product is inappropriate for people who are eligible for Medicaid coverage. | This product contains Limitations and Exclusions | This policy is considered an employee welfare benefit plan established and/or maintained by an association or employer intended to be covered by ERISA, and will be administered and enforced under ERISA. Group policies issued to governmental entities and municipalities may be exempt from ERISA guidelines | Policy Form GC13APL | Limited Benefit Group Cancer Indemnity Insurance Series | Texas | (10/14) | City of Celina

APSB-22331(TX) MGM/FBS City of Celina

AMERICAN PUBLIC LIFE YOUR BENEFITS PACKAGE

Accident

About this Benefit Accident insurance is designed to supplement your medical insurance coverage by covering indirect costs that can arise with a serious, or a not-so-serious, injury. Accident coverage is low cost protection available to you and your family without evidence of insurability.

DID YOU KNOW?

2/3 of disabling injuries suffered by American workers are not work related. American workers 36% ofreport they always or

usually live paycheck to paycheck.

A-3 Supplemental Limited Benefit Accident Expense Insurance City of Celina THE POLICY UNDER WHICH THIS CERTIFICATE IS ISSUED IS NOT A POLICY OF WORKERS’ COMPENSATION INSURANCE. THE EMPLOYER DOES NOT BECOME A SUBSCRIBER TO THE WORKERS’ COMPENSATION SYSTEM BY PURCHASING THE POLICY AND IF THE EMPLOYER IS A NON-SUBSCRIBER, THE EMPLOYEE LOSES THOSE BENEFITS WHICH WOULD OTHERWISE ACCRUE UNDER THE WORKERS’ COMPENSATION LAWS. THE EMPLOYER MUST COMPLY WITH THE WORKERS’ COMPENSATION LAW AS IT PERTAINS TO NON-SUBSCRIBERS AND THE REQUIRED NOTIFICATIONS THAT MUST BE FILED AND POSTED.

Summary of Benefits* Benefit Description

Level 1 - 1 Unit

Level 4 – 4 Units

$5,000

$20,000

actual charges up to $500

actual charges up to $2,000

$75 per day

$300 per day

actual charges up to $1,250

actual charges up to $5,000

$500 $500 $2,500 $5,000

$2,000 $2,000 $10,000 $20,000

$2,500 $5,000

$10,000 $20,000

$100 upon admission $100 per unit

$400 upon admission $100 per unit

$150 per day / $150 per unit

$600 per day / $150 per unit

once per 24 hours $1,000 benefit

Accidental Death - per unit Medical Expense Accidental Injury Benefit - per unit Daily Hospital Confinement Benefit Air and Ground Ambulance Benefit Accidental Dismemberment Benefit Single finger or toe Multiple fingers or toes Single hand, arm, foot or leg Multiple hands, arms, feet or legs Accidental Loss of Sight Benefit - per unit Loss of Sight in one eye Loss of Sight in both eyes Optional Benefit Riders Hospital Admission Benefit Accident Only - Intensive Care Benefit Gunshot Wound Benefit Rider (Primary Insured Only/Public Safety Personnel Only)

Individual

Individual & Spouse

1 Parent Family

2 Parent Family

Level 1 - 1 Unit

$10.80

$19.40

$21.20

$29.80

Level 4 - 4 Units

$24.50

$44.90

$52.00

$72.40

Optional Benefit Riders Hospital Admission Benefit

Accident Only –Intensive Care Benefit

$100

$400

Individual

$0.45

$1.80

Individual & Spouse

$0.65

One-Parent Family Two-Parent Family

$150

$600

Individual

$0.45

$2.60

Individual & Spouse

$0.75

$3.00

$0.95

$3.80

Gunshot Wound Benefit Rider

$1.80

Monthly Premium

Benefit per 24 Hour Period

$0.65

$2.60

$1.00

$1,000

One-Parent Family

$0.75

$3.00

Two-Parent Family

$0.95

$3.80

*The premium and amount of benefits vary dependent upon the Plan selected at time of application. Premiums are subject to increase with notice. APSB-22329(TX)-MGM/FBS City of Celina

A-3 Supplemental Limited Benefit Accident Expense Insurance Eligibility

Gunshot Wound Benefit Rider Only

This policy will be issued to only those persons who meet American Public Life Insurance Company’s insurability requirements. Persons not meeting APL’s insurability requirements will be excluded from coverage by an endorsement attached to the policy.

This Rider does not pay benefits for: any non-fatal Gunshot Wound received in a non - occupational related shooting; or, non - fatal Gunshot Wounds received while on active duty in the armed services (the company will return any premium paid past the time of entry into the armed forces when notice is received).

Base Policy and Optional Benefits No benefits are payable for a pre-existing condition. Pre-existing condition means an Injury that pertains solely to an Accidental Bodily Injury which resulted from an accident sustained before the Effective Date of coverage. Pre-Existing Conditions specifically named or described as permanently excluded in any part of this contract are never covered.

This Rider does not pay benefits for self-inflected Gunshot Wound.

A Hospital is not an institution which is primarily a place for alcoholics or drug addicts; the aged; a nursing, rest or convalescent nursing home; a mental institution or sanitarium; a facility contracted for or operated by the United States Government for treatment of members or ex-members of the armed forces (unless You are legally required to pay for services rendered in the absence of insurance); or, a long-term nursing unit or geriatrics ward.

Gunshot Wound Benefit Rider is only available through payroll deduction.

Medical Expense Accidental Injury Benefit

The maximum benefit is 4 units.

Expenses must commence within 60 days of the covered accident. The maximum benefit amount payable for any one accident for the Insured Person shall not exceed the Medical Expense Benefit.

The Gunshot Wound Benefit Rider is guaranteed renewable to age 65 or age 70, if actively at work. While this Rider is in effect, premiums are due according to the terms of the Policy. We reserve the right to change premium rates by class.

Hospital Admission Benefit Accident Only – Intensive Care Benefit The maximum benefit is 4 units. The maximum benefit period for this benefit is up to 30 days for any one accident.

Air and Ground Ambulance Benefit

Exclusions

Emergency transportation must occur within 21 calendar days of the accident causing such Injury.

Benefits otherwise provided by this Policy will not be payable for services or expenses or any such Loss resulting from or in connection with:

Daily Hospital Confinement Benefit The maximum benefit period for this benefit is 30 days per covered accident.

Accidental Death Accidental Death must result within 90 days of the covered accident causing the injury.

This Rider is subject to all the Provisions, Conditions, Limitations and Exclusions of the Policy to which it is attached, which are not in conflict with those of the Rider.

(1) (2) (3) (4)

Accidental Dismemberment Benefit

(5) (6)

The total amount payable for all Losses resulting from the same accident will not exceed the Maximum Dismemberment Benefit of $5,000 cumulative per unit, per Accident. Loss must be within 90 days of the accident causing such Injury.

(7)

APSB-22329(TX)-MGM/FBS City of Celina

sickness, illness or bodily infirmity; suicide, attempted suicide or intentional self-inflicted Injury, whether sane or insane; dental care or treatment unless due to accidental Injury to natural teeth; war or any act of war (whether declared or undeclared) or participating in a riot or felony; alcoholism or drug addiction; travel or flight in or descent from any aircraft or device which can fly above the earth’s surface in any capacity other than as a fare paying passenger on a regularly scheduled airline; Injury originating prior to the effective date of the Policy;

A-3 Supplemental Limited Benefit Accident Expense Insurance (8)

(9) (10)

(11)

(12) (13) (14)

(15)

(16)

Injury occurring while intoxicated (Intoxication means that which is determined and defined by the laws and jurisdiction of the geographical area in which the loss or cause of loss is incurred.); Voluntary inhalation of gas or fumes or taking of poison or asphyxiation; Voluntary ingestion or injection of any drug, narcotic or sedative, unless administered on the advice and taken in such doses as prescribed by a Physician; Injury sustained or sickness which first manifests itself while on full-time duty in the armed forces; (Upon notice, We will refund the proportion of unearned premium while in such forces.) Injury incurred while engaging in an illegal occupation; Injury incurred while attempting to commit a felony or an assault; Injury to a covered person while practicing for or being a part of organized or competitive rodeo, sky diving, hang gliding, parachuting or scuba diving; driving in any race or speed test or while testing an automobile or any vehicle on any racetrack or speedway; hernia, carpal tunnel syndrome or any complication therefrom;

If You are entitled to benefits under this Policy as a result of sprained or lame back, or any intervertebral disk conditions, such benefits shall be payable for a maximum period of time, not exceeding in the aggregate three (3) months for any Injury.

Guaranteed Renewable You have the right to renew this Policy until the first premium due date on or after Your 69th birthday, if you pay the correct premium when due or within the Grace Period. When an Insuredâ&#x20AC;&#x2122;s coverage terminates at age 70, coverage for other Insured Persons, if any, shall continue under this Policy. We have the right to change premium rates by class.

2305 Lakeland Drive | Flowood, MS 39232 ampublic.com | 800.256.8606

Underwritten by American Life Insurance Company. This is a brief description of the coverage. For complete benefits, limitations, exclusions and other provisions, please refer to the certificate/policy and riders. This coverage does not replace Workersâ&#x20AC;&#x2122; Compensation Insurance. | This product is inappropriate for people who are eligible for Medicaid coverage. | Policy Form A3 Series | Texas | Supplemental Limited Benefit Accident Expense Insurance Policy | (10/14) | City of Celina

APSB-22329(TX)-MGM/FBS Matagorda County

APSB-22329(TX)-MGM/FBS City of Celina

TEXAS LIFE

Individual Life

YOUR BENEFITS PACKAGE

About this Benefit Individual life is a policy that provides a specified death benefit to your beneficiary at the time of death. The advantage of having an individual life insurance plan as opposed to a group supplemental term life plan is that this plan is guaranteed renewable, portable and typically premiums remain the same over the life of the policy.

DID YOU KNOW? Experts recommend at least

x 10 your gross annual income in coverage when purchasing life insurance.

Individual Life Life Insurance Highlights Voluntary permanent life insurance can be an ideal complement to the group term and optional term your employer might provide. Designed to be in force when you die, this voluntary universal life product is yours to keep, even when you change jobs or retire, as long as you pay the necessary premium. Group and voluntary term, on the other hand, typically are not portable if you change jobs and, even if you can keep them after you retire, usually costs more and declines in death benefit.

DID YOU KNOW? Those with no life insurance think it’s 3 times more expensive than it actually is.

The policy, PureLife-plus, is underwritten by Texas Life Insurance Company, and it has these outstanding features: 

High Death Benefit. With one of the highest death benefit available at the worksite,1 PureLife-plus gives your loved ones peace of mind, knowing there will be significant life insurance in force should you die prematurely.



Minimal Cash Value. Designed to provide high death benefit, PureLife-plus does not compete with the cash accumulation in your employer-sponsored retirement plans.



Long Guarantees. Enjoy the assurance of a policy that has a guaranteed death benefit to age 121 and level premium that guarantees coverage for a significant period of time (after the guaranteed period, premiums may go down, stay the same, or go up).



Refund of Premium. Unique in the marketplace, PureLifeplus offers you a refund of 10 years’ premium, should you surrender the policy if the premium you pay when you buy the policy ever increases. (Conditions apply.)



Accelerated Death Benefit Rider. Should you be diagnosed as terminally ill with the expectation of death within 12 months (24 months in Illinois), you will have the option to receive 92% (84% in Illinois) of the death benefit, minus a $150 ($100 in Florida) administrative fee. This valuable living benefit gives you peace of mind knowing that, should you need it, you can take the large majority of your death benefit while still alive. (Conditions apply.)

You may apply for this permanent, portable coverage, not only for yourself, but also for your spouse, minor children and grandchildren. Like most life insurance policies, Texas Life policies contain certain exclusions, limitations, exceptions, reductions of benefits, waiting periods and terms for keeping them in force. Please contact a Texas Life representative for costs and complete details. 1

Voluntary and Universal Whole Life Products, Eastbridge Consulting Group, October 2008

5STAR YOUR BENEFITS PACKAGE

Life and AD&D

About this Benefit Group term life is the most inexpensive way to purchase life insurance. You have the freedom to select an amount of life insurance coverage you need to help protect the well-being of your family. Accidental Death & Dismemberment is life insurance coverage that pays a death benefit to the beneficiary, should death occur due to a covered accident. Dismemberment benefits are paid to you, according to the benefit level you select, if accidentally dismembered.

DID YOU KNOW? Motor vehicle crashes are the

cause of accidental deaths in the US, followed by poisoning, falls, drowning, and choking.

Voluntary Term Life and AD&D This insurance is available to you at competitive group rates. And, you can buy this insurance through the convenience of automatic payroll deduction. If coverage is waived during the initial enrollment period, satisfactory evidence of insurability, including a completed health application and physical examination may be required for future election of coverage. If you are a New Hire, during your open enrollment you can elect Guaranteed Issue coverage without having to complete an Evidence of Insurable (EOI) application.

Plan Description Life Insurance Coverage Guidelines Your Employer has selected the following features to be included in your plan. A complete description of each provision will be provided in a certificate booklet, which will be issued to you, should you decide to select Voluntary Term Life coverage. 



Your plan includes the option to select Spouse and Dependent Children coverage. Dependent children include those 14 days old, up to age 21 (25 if a full-time student). Minimums, maximums and guarantee issue limits are listed above. To determine your cost, use the rate calculation worksheet provided in these materials. Your Plan includes Continuation of Life Insurance Benefits Due to Total Disability. If you became totally and continuously disabled through the Disability Elimination

Period, this feature will keep your life insurance coverage in force – without payment of premium. 

Your plan includes Portability. This feature allows you to continue this insurance program for you and your dependents should you leave your employer for any reason – without providing information about your health.



Your plan includes an Accelerated Death Benefit of up to 50% of your life benefit not to exceed a maximum of $50,000.



Benefits are reduced when the insured reaches age 70, and will continue to decrease every five years thereafter. (See the chart below.) Spouse coverage, if available, terminates at age 75.

Age

% Payable

65%

45%

30%

20%

15%

Employee

Spouse

Children

Minimum

$10,000

$5,000

$2,000

Maximum

3 times Annual Salary (up to) $300,000

100% of Employee Benefit (up to) $100,000

100% of Employee Benefit (up to) $10,000

Guarantee Issue Limit

3 times Annual Salary (up to) $150,000

100% of Employee Benefit (up to) $50,000

100% of Employee Benefit (up to) $10,000

Voluntary Term Life and AD&D To calculate monthly premiums 1.

2. 3. 4.

Locate the amount of coverage you wish to select along the top row of the Employee table. Then locate your age bracket along the left column of the table. Your monthly premium is the amount located where the row and column you have identified meet (down from top row and right from left column). If the amount you wish to select is greater than $100,000, select one of the top row numbers that when multiplied by another number, results in your desired life amount (e.g. selecting the rate for $150,000 can be obtained by multiplying the appropriate rate for $50,000 times 3). Enter the employee rate in the space provided below. Follow the same method to determine your spouse rate. Use the Spouse table (below the Employee table). Enter the spouse rate in the space provided below. Follow the same method to determine your children rate. Use the Children table (below the Spouse table). Enter the Children rate in the space provided below. Total the Employee, Spouse (if any) and Children (if any) rates to obtain your Total Monthly Premium.

Employee Life Rates $10,000

$20,000

$30,000

$40,000

$50,000

$60,000

$70,000

$80,000

$90,000

$100,000

<30

0.70

1.40

2.10

2.80

3.50

4.20

4.90

5.60

6.30

7.00

30 - 34

0.80

1.60

2.40

3.20

4.00

4.80

5.60

6.40

7.20

8.00

35 - 39

1.00

2.00

3.00

4.00

5.00

6.00

7.00

8.00

9.00

10.00

40 - 44

1.50

3.00

4.50

6.00

7.50

9.00

10.50

12.00

13.50

15.00

45 - 49

1.78

3.56

5.34

7.12

8.90

10.68

12.46

14.24

16.02

17.80

50 - 54

2.68

5.36

8.04

10.72

13.40

16.08

18.76

21.44

24.12

26.80

55 - 59

4.10

8.20

12.30

16.40

20.50

24.60

28.70

32.80

36.90

41.00

60 - 64

10.00

20.00

30.00

40.00

50.00

60.00

70.00

80.00

90.00

100.00

65 - 69

18.10

36.20

54.30

72.40

90.50

108.60

126.70

144.80

162.90

181.00

70 - 74

32.40

64.80

97.20

129.60

162.00

194.40

226.80

259.20

291.60

324.00

75 - 79

32.40

64.80

97.20

129.60

162.00

194.40

226.80

259.20

291.60

324.00

80+

32.40

64.80

97.20

129.60

162.00

194.40

226.80

259.20

291.60

324.00

Note: Spouse / Child coverage amounts cannot be more than 50% of the Employee coverage amounts selected.

Voluntary Term Life and AD&D Spouse Life Rates $5,000

$10,000

$15,000

$20,000

$25,000

$30,000

$35,000

$40,000

$45,000

$50,000

<30

0.35

0.70

1.05

1.40

1.75

2.10

2.45

2.80

3.15

3.50

30 - 34

0.40

0.80

1.20

1.60

2.00

2.40

2.80

3.20

3.60

4.00

35 - 39

0.50

1.00

1.50

2.00

2.50

3.00

3.50

4.00

4.50

5.00

40 - 44

0.75

1.50

2.25

3.00

3.75

4.50

5.25

6.00

6.75

7.50

45 - 49

0.89

1.78

2.67

3.56

4.45

5.34

6.23

7.12

8.01

8.90

50 - 54

1.34

2.68

4.02

5.36

6.70

8.04

9.38

10.72

12.06

13.40

55 - 59

2.05

4.10

6.15

8.20

10.25

12.30

14.35

16.40

18.45

20.50

60 - 64

5.00

10.00

15.00

20.00

25.00

30.00

35.00

40.00

45.00

50.00

65 - 69

9.05

18.10

27.15

36.20

45.25

54.30

63.35

72.40

81.45

90.50

70 - 74

16.20

32.40

48.60

64.80

81.00

97.20

113.40

129.60

145.80

162.00

Note: Spouse / Child coverage amounts cannot be more than 50% of the Employee coverage amounts selected.

Child Life Rates $1,000

$2,000

$3,000

$4,000

$5,000

$6,000

$7,000

$8,000

$9,000

$10,000

0.20

0.40

0.60

0.80

1.00

1.20

1.40

1.60

1.80

2.00

$10,000

$20,000

$30,000

$40,000

$50,000

$60,000

$70,000

$80,000

$90,000

$100,000

EMPLOYEE

$0.30

$0.60

$0.90

$1.20

$1.50

$1.80

$2.10

$2.40

$2.70

$3.00

FAMILY

0.33

0.66

0.99

1.32

1.65

1.98

2.31

2.64

2.97

3.30

All Children

AD&D Rates

___________________ + ___________________ + ___________________ = ___________________ Employee Premium Spouse Premium Child(ren) Premium Total Monthly Premium

5STAR

Critical Illness

YOUR BENEFITS PACKAGE

About this Benefit Critical illness insurance is designed to supplement your medical and disability coverage easing the financial impacts by covering some of your additional expenses. It provides a benefit payable directly to the insured upon diagnosis of a covered condition or event, like a heart attack or stroke.

DID YOU KNOW?

$16,500 Is the aggregate cost of a hospital stay for a heart attack.

Critical Illness Critical Illness Do you know someone who survived cancer, a heart attack or other critical illnesses? With nearly 3,000,000 critical illness cases being diagnosed each year, most families have experienced the financial hardship associated with the survival of a critical illness.

LEVEL BENEFITS TO AGE 65** Benefits remain level until insured reaches age 65, then they reduce 50%. Applicants age 60-65 benefits remain level for five (5) years. Applicants age 66-70 have a maximum benefit of $5,000.

Statistics show that a 25-year old male non-smoker has a 24% chance of having a critical illness (cancer, heart attack or stroke) prior to turning age 65, and a 49 percent chance if he smokes;* that’s four (4) times higher than premature death before age 65.

TRIPLE BENEFITS Critical Illness insurance provides a cash payment upon the first occurrence of a covered illness, and with our multiple benefit feature you may receive up to three (3) times the face amount of your policy upon diagnosis of a condition within each of the critical illness categories. No more than 100% will be paid in each category of critical illness.

Nearly two-thirds of U.S. bankruptcies are the result of medical expenses and 78% of those filing for bankruptcy had health insurance. Your employer is providing this new type of insurance in order to complement your overall benefit package. Group Critical Illness Coverage was designed to allow you an easy and affordable way to provide for your additional financial needs.

The Benefits of Group Critical Illness Coverage Until now, most employee benefits plans were designed to cover specific expenses. But, Group Critical Illness Coverage pays up to THREE (3) times the policy benefit amount in a lump sum directly to the policy owner – in addition to any other insurance plan the insured may have! There are no restrictions on how the money is used, providing the financial resources for expenses not covered by other insurance, including:  Co-payments, deductibles and non-covered “experimental” treatments.  Supplemental income to make house and car payments while recuperating.  Lost income of spouse or care-givers.  Home health care needs.  Housekeeping or child care expenses.  Necessary modifications to home or housekeeping expenses.

Group Critical Illness Coverage Highlights

PORTABILITY You and your family continue coverage with no loss of benefits should you terminate employment after the first premium is paid, in which case premiums can be paid on a direct billed basis. SPOUSE COVERAGE Spouse benefits are available up to 50% of the employee face amount, not to exceed $25,000. CHILD(REN) COVERAGE A $10,000 Children’s Benefit can be added to the employee’s policy for an additional premium of $.75/week or $3.25/ month. One premium covers all dependent children up to age 25. CONVENIENCE Premiums are taken care of simply and easily through payroll deductions. EASY APPLICATION PROCESS. Modified Guarantee Issue is available for Employees and their children up to $10,000 with just 2 medical questions. Simplified Issue underwriting for spouses and face amounts up to $100,000. This insurance does not require a medical exam or blood profile. PRE-TAX DEDUCTIONS Premiums may qualify for pre-tax deductions, reducing Federal and state income taxes. See your tax advisor for specifics.

Affordable rates. Low age banded group rates can not be increased individually on a particular insured due to a change in health or employment status, other than on a group basis.

Critical Illness Covered First-Occurrence Critical Illness Conditions Category 1—Cardiovascular condition benefit amounts Heart attack

100%

Stroke

100%

Heart Transplant

100%

Coronary Bypass Surgery

25%

Angioplasty

25%

Category 2—Cancer benefit amounts Invasive cancer (Diagnosis more than 30 days after effective date of coverage)

Invasive cancer (Diagnosis during the first 30 days of in force coverage)

Cancer in Situ (also called non-invasive) (Diagnosis more than 30 days after effective date of coverage)

Cancer in Situ (also called non-invasive) (Diagnosis during the first 30 days of in force coverage)

100% 10% 25% 2.5%

Category 3—Cardiovascular condition benefit amounts

Major Organ Transplant (not covered in Category 1)

100%

End-Stage Renal Failure

100%

Advanced Alzheimer’s diseases

100%

Paralysis

100%

Occupational HIV Infection

100%

Critical Illness Critical Illness Coverage Rates: Semi-Monthly Non-Smoker

$5,000*

$10,000

$12,500*

$25,000

$50,000

$75,000

$100,000

Ages 18-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65 66-69 70

$0.43 $0.54 $0.70 $1.04 $1.58 $2.61 $4.14 $6.65 $9.45 $13.02 $13.02 $15.95

$0.85 $1.08 $1.41 $2.08 $3.17 $5.22 $8.27 $13.30 $18.89 $26.04

$1.06 $1.34 $1.76 $2.60 $3.96 $6.53 $10.34 $16.63 $23.61 $32.55

$2.13 $2.69 $3.52 $5.20 $7.92 $13.06 $20.69 $33.26 $47.23 $65.10

$4.25 $5.38 $7.03 $10.39 $15.83 $26.12 $41.37 $66.51 $94.46 $130.20

$6.38 $8.06 $10.55 $15.59 $23.75 $39.17 $62.06 $99.77 $141.68 $195.30

$8.50 $10.75 $14.07 $20.78 $31.66 $52.23 $82.75 $133.03 $188.91 $260.40

Smoker

$5,000*

$10,000

$12,500*

$25,000

$50,000

$75,000

$100,000

Ages 18-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65 66-69 70

$0.63 $0.73 $1.14 $1.77 $2.90 $4.73 $7.74 $11.78 $17.75 $23.76 $23.76 $30.63

$1.25 $1.47 $2.28 $3.54 $5.80 $9.46 $15.47 $23.55 $35.50 $47.53

$1.57 $1.83 $2.85 $4.43 $7.25 $11.83 $19.34 $29.44 $44.38 $59.41

$3.13 $3.67 $5.70 $8.85 $14.50 $23.66 $38.68 $58.88 $88.75 $118.82

$6.27 $7.33 $11.39 $17.70 $29.01 $47.32 $77.35 $117.77 $177.50 $237.64

$9.40 $11.00 $17.09 $26.55 $43.51 $70.99 $116.03 $176.65 $266.25 $356.46

$12.54 $14.66 $22.78 $35.40 $58.01 $94.65 $154.70 $235.54 $355.00 $475.28

Critical Illness Coverage Rates: Monthly Non-Smoker

$5,000*

$10,000

$12,500*

$25,000

$50,000

$75,000

$100,000

Ages 18-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65 66-69 70

$0.85 $1.08 $1.41 $2.08 $3.17 $5.22 $8.27 $13.30 $18.89 $26.04 $26.04 $31.90

$1.70 $2.15 $2.81 $4.16 $6.33 $10.45 $16.55 $26.61 $37.78 $52.08

$2.13 $2.69 $3.52 $5.20 $7.92 $13.06 $20.69 $33.26 $47.23 $65.10

$4.25 $5.38 $7.03 $10.39 $15.83 $26.12 $41.37 $66.51 $94.46 $130.20

$8.50 $10.75 $14.07 $20.78 $31.66 $52.23 $82.75 $133.03 $188.91 $260.40

$12.75 $16.13 $21.10 $31.17 $47.49 $78.35 $124.12 $199.54 $283.37 $390.60

$17.00 $21.51 $28.14 $41.57 $63.33 $104.47 $165.50 $266.05 $377.83 $520.80

Smoker

$5,000*

$10,000

$12,500*

$25,000

$50,000

$75,000

$100,000

Ages 18-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65 66-69 70

$1.25 $1.47 $2.28 $3.54 $5.80 $9.46 $15.47 $23.55 $35.50 $47.53 $47.53 $61.26

$2.51 $2.93 $4.56 $7.08 $11.60 $18.93 $30.94 $47.11 $71.00 $95.06

$3.13 $3.67 $5.70 $8.85 $14.50 $23.66 $38.68 $58.88 $88.75 $118.82

$6.27 $7.33 $11.39 $17.70 $29.01 $47.32 $77.35 $117.77 $177.50 $237.64

$12.54 $14.66 $22.78 $35.40 $58.01 $94.65 $154.70 $235.54 $355.00 $475.28

$18.81 $21.99 $34.17 $53.10 $87.02 $141.97 $232.05 $353.30 $532.50 $712.92

$25.08 $29.33 $45.56 $70.81 $116.03 $189.30 $309.40 $471.07 $710.01 $950.56

NOTES