Camden County Schools 2017 Plan Year by Pierce Group Benefits

CAMDEN COUNTY SCHOOLS PLAN YEAR: January 1, 2017 - December 31, 2017

What’s Inside Camden County Schools Plan Year January 1, 2017 through December 31, 2017

Camden County Schools is offering all eligible employees a comprehensive Benefits Program.

This booklet highlights the benefits offered through your employer for the current plan year. Benefits described in this booklet are voluntary, employee-paid benefits unless otherwise noted. You have the opportunity to select the benefits in which you wish to participate. Please see the Benefits Plan Overview section of the booklet for more details.

This is neither an insurance contract nor a Summary Plan Description and only the actual policy provisions will prevail. All information in this booklet including premiums quoted is subject to change. All policy descriptions are for information purposes only. Your actual policies may be different than those in this booklet.

Arranged & Enrolled by

Pierce Group Benefits Rev. 11/07/2016

Benefits Plan Overview.................................................................................

Online Enrollment Instructions …………………………...

Flexible Spending Accounts………………………………

Cancer Benefits…………………………………………...

State of North Carolina Disability BENEFITS AT A GLANCE**………………………………..

Disability Benefits…………………………………………

Accident Benefits…………………………………………

State of North Carolina Teachers’ and State Employees’ Health Plan – Plan Comparison**…………………………

Medical Bridge Indemnity Benefits………………………..

Group Critical Care Benefits………………………………

Life Insurance……………………………………………..

Dental Benefits……………………………………………

Vision Benefits……………………………………………

Optima Employee Assistance Program………………………………..

Authorization Form……………………………………………………

Notice of Insurance Information Practices…………………………….

Supplemental Continuation of Coverage Form………………………..

**The State of North Carolina Disability and State of North Carolina Teachers’ and State Employees’ Health Plan pages are included in this booklet for informational purposes only.

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CAMDEN COUNTY SCHOOLS EMPLOYEE BENEFITS PROGRAM Provided by Pierce Group Benefits

Pre-Tax Benefits Flexible Spending Accounts* o Medical Reimbursement Maximum $2,600/year o Dependent Care Reimbursement Maximum $5,000/year Cancer Benefits

Colonial Life

Accident Benefits

Colonial Life

Medical Bridge Indemnity Benefits

Colonial Life

Dental Insurance

Sun Life (formerly Assurant)

Vision Insurance

Superior

*You will need to re-sign for the Spending Accounts if you want them to continue next year. IF YOU DO NOT RE-SIGN, YOUR CONTRIBUTION WILL STOP EFFECTIVE December 31, 2016.

Post-Tax Benefits Disability Benefits

Colonial Life

Group Critical Care Benefits

Colonial Life

Life Insurance o Term Life Insurance o Universal Life Insurance o Whole Life Insurance o Group Term Life Insurance

Colonial Life Colonial Life Colonial Life Colonial Life

Insurance Products will remain in effect unless you see a representative to change them.

Enrollment Period November 14, 2016 through November 21, 2016 Effective Dates January 1, 2017 through December 31, 2017

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Qualifications • You must work 20 hours or more per week. Important Facts:  The plan year for Colonial Insurance products and Spending Accounts lasts from January 1, 2017 through

December 31, 2017. The plan year for Sun Life (formerly Assurant) Dental, Colonial Group Term Life and Superior Vision lasts from January 1, 2017 through December 31, 2017.  Deductions for Colonial Insurance products and Spending Accounts will begin January 2017. Deductions for Sun

Life (formerly Assurant) Dental, Colonial Group Term Life and Superior Vision will begin January 2017.  IMPORTANT UPDATE: If you enroll in the Medical Reimbursement Account and participate in the CDHP w/HRA

through the State Health Plan, there are some factors you should take into consideration. Please speak with your Benefits Representative during the Enrollment Period for important information that may impact the amount you choose to contribute.  If signing up for any coverage on your spouse and/or children, please have their dates of birth and social security

numbers available when meeting with the Benefits Representative.  If you will be receiving a new debit card, whether you are a new participant or to replace your expired card,

please be aware that it may take up to 30 days following your plan effective date for your card to arrive. Your card will be delivered by mail in a plain white envelope. During this time you may use manual claim forms for eligible expenses, available from your Benefits Representative during the open enrollment period. Please note that your debit card is good through the expiration date printed on the card.  Elections made during this enrollment period CANNOT BE CHANGED AFTER THE ENROLLMENT PERIOD

unless there is a family status change as defined by the Internal Revenue Code. Examples of a family status change are: marriage, divorce, death of a spouse or child, birth or adoption of a child, termination or commencement of a spouse's employment, or the transition of spouse's employment from full-time to part-time or vice-versa.  Once a family status change has occurred, an employee has 30 days to notify the North Carolina Service Center

at 1-888-662-7500 to request a change in elections.  Medical Reimbursement and Dependent Care Reimbursement expenses must be incurred during the Plan Year

in order to be eligible for reimbursement.  An employee has 90 days after the plan year ends to submit claims for medical reimbursement and/or dependent

care expenses that were incurred during the plan year. Please note that if employment terminates during the plan year, that employee's plan year ends the day employment ends. The employee has 30 days after the termination date to submit claims.  Unlike Medical Reimbursement Accounts, with Dependent Care Flexible Spending Accounts the maximum

reimbursement you can get is equal to the current account balance in your Dependent Care account.  The Colonial Cancer plan and the Health Screening Rider on the Colonial Accident and Colonial Medical Bridge

plan have a 30-day waiting period for new enrollees. Coverage, therefore, will not begin until January 31, 2017. 

Additionally, some policies may include a pre-existing condition clause. Please read your policy carefully for full details.

 Please be aware there are certain coverages that may be subject to federal and state tax when premium is paid

by pretax deduction or employee contribution.  An employee taking a leave of absence, other than under the Family & Medical Leave Act, may not be eligible to

re-enter the Flexible Benefits Program until the next plan year. Please contact your Camden County Schools Benefit Administrator for more information.

To enroll or make changes to your Flexible Benefits Plan, please see the representative while he/she is at your school or location.

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Online Enrollment Instructions for your Annual Enrollment Period You can make the following benefit elections online from November 14, 2016 through November 21, 2016:  Sign up/re-enroll your Flexible Spending Account (Medical Reimbursement and Dependent Care).  Enroll, change or cancel your Vision insurance.  Enroll, change or cancel your Dental insurance.  Enroll, change or cancel your Colonial products (please see further details below)

The following benefit elections must be made with your Benefits Representative during the enrollment period and are not available for online enrollment.  Enroll, change or cancel your Group Term Life insurance.  Enroll or change Colonial products (please see further details below)

HARMONY ONLINE ASSISTANCE 1. Complete the following steps to begin the online enrollment process. 

Go to https://harmonyenroll.coloniallife.com



Enter your User Name: CAM6L7J- and then your Social Security Number (ex. CAM6L7J-123456789)



Enter your Password: First 4 letters of your last name and then last 4 numbers of your Social Security Number (ex. SMIT6789)

Helpful Tips:  If you are a new employee and unable to log into the online system, please see the Benefits Representative while he/she is at your school or location or at the scheduled make-up day.  If you are an existing employee and unable to log into the online system, please contact the Harmony Help Desk at 866-875-4772 between 8:30am and 6:00pm or speak with your Benefits Representative while he/she is at your school or location or at the scheduled make-up day.

2. 3. 4. 5.

The screen prompts you to create a NEW password [____________________________]. Choose a security question and enter answer [______________________________________]. Click on ‘I Agree’ and then “Enter My Enrollment”. The screen shows ‘Me & My Family’. Verify that the information is correct and enter the additional required information (title, marital status, work phone, e-mail address). Click ‘Save & Continue’ twice. 6. The screen allows you to add family members. It is only necessary to enter family member information if adding or including family members in your coverage. Click ‘Continue’. 7. The screen shows updated personal information. Verify that the information is correct and make changes if necessary. Click ‘Continue’. 8. The screen shows ‘My Benefits’. Review your current benefits and make changes/selections for the upcoming plan year. Dental (Choose one of the options and click ‘Save & Continue’): 1. If you have existing coverage and would like to keep it without making changes, click ‘Keep This Benefit’; 2. If you would like to enroll in coverage, or change existing coverage, choose your plan in the Enroll section; 3. If you would like to decline coverage, click ‘Decline/Cancel Coverage’ Select family members that you wish to cover with your dental insurance by clicking ‘Add a Family Member’. Vision (Choose one of the options and click ‘Save & Continue’): 1. If you have existing coverage and would like to keep it without making changes, click ‘Keep This Benefit’; 2. If you would like to enroll in coverage, or change existing coverage, choose your plan in the Enroll section; 3. If you would like to decline coverage, click ‘Decline/Cancel Coverage’ Select family members that you wish to cover with your vision insurance by clicking ‘Add a Family Member’. Note: If you cancel your vision coverage, please be aware that you will not be allowed back into the plan for two years since the benefits are based on a 24month plan design.

Instructions continued on next page

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Online Enrollment Instructions

Health Care FSA (Choose one of the options and click ‘Save & Continue’): 1. Enter annual amount. MAX $2,600/year Dependent Care FSA (Choose one of the options and click ‘Save & Continue’): 1. Enter annual amount. MAX $5,000/year Cancer Assist You may enroll online in Cancer Assist coverage.

Disability – NCK1000 You may enroll online in NCK1000 – the North Carolina Educator Disability Plan.

Accident 1.0 You may enroll online in Accident 1.0; however persons over age 64 applying for coverage and employees wishing to purchase an individual policy for their spouse must meet with the Benefits Representative.

Individual Medical Bridge You may enroll online in Individual Medical Bridge coverage.

Group Critical Care You may enroll online in Group Critical Care coverage.

Term Life 1000 You may enroll online in Term Life 1000; however, employees wishing to purchase an individual policy for their spouse should meet with the Benefits Representative.

Universal Life 1000 You will need to meet with the Benefits Representative in order to enroll in Universal Life 1000 for yourself and/or your spouse

Whole Life 1000 You may enroll online in Whole Life 1000; however, employees wishing to purchase an individual policy for their spouse should meet with the Benefits Representative.

9. 10. 11. 12.

Click ‘Finish’. Click ‘I Agree’ to electronically sign the authorization for your benefit elections. Click ‘Print a copy of your Elections’ to print a copy of your elections. Please do not forget this important step!!! Click ‘Log out & close your browser window’ and click ‘Log Out’.

Please Note: When using the Harmony online enrollment system, Internet Explorer should be utilized for best results. Harmony is not compatible with other browsers (such as Google Chrome and Firefox), and web pages may not display properly when using browsers other than Internet Explorer.

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HEALTH CARE FLEXIBLE SPENDING ACCOUNT A plan that enhances your benefits Would you be interested in a plan that helps pay out-of-pocket medical costs while increasing your spendable income? Your employer is offering such a plan - it's called a health care flexible spending account. This benefit qualifies under Code Section 125 of the IRS. Code Section 125 was created by the United States Congress to make benefits more affordable for you.

How it works If you participate, you will elect to have a specified amount of pretaxed money deducted from your paycheck each pay period. These dollars are set aside in a reimbursement account and subtracted from your gross earnings before any taxes are taken out. After you submit a receipt for a qualifying health care expense, you will be reimbursed from this account.

For example… John’s Status Married Two fed./state exemptions Bimonthly salary: $1000

Based on these expenses, John knows he’ll be spending at least $1,680 on non-covered medical expenses over the course of the year.

Health Care FSA: $70 per pay period John’s daughter needs braces that will cost $1,200 next year. His major medical deductible is $250. Plus, he needs glasses, which cost $230.

Dental Care Major Med. Deductible Vision Care Total

$1,200 $250 $230 $1,680 per year or $70 per pay period

Review the sample below to see how a health care flexible spending account (FSA) can help increase John’s spendable income. After being reimbursed from the health care FSA, John’s spendable income increases $20.75 per pay period. Annually, he has increased his spendable income by $498.00!

Before Health Care FSA reim. $1000.00 -0$1000.00 -$296.50 $703.50

Gross pay Pre-tax Health Care FSA Taxable Income FICA, fed & state taxes Net pay Health care FSA reimbursement Spendable income

$703.50

After Health Care FSA reim. $1000.00 -$70.00 $930.00 -$275.75 $654.25 +70.00* $724.25*

How it benefits you The advantage of participating is that when you contribute pre-tax dollars to a reimbursement account, you lower your taxable income; therefore, you pay less in taxes and increase your spendable income!

*The amount and number of times John is reimbursed will depend on the receipts he submits for qualified medical expenses and the frequency with which his plan makes reimbursements. Illustration based on 2010 North Carolina tax tables.

Eligible Expenses A health care FSA may be used to pay health care expenses not covered under any other plan. Qualified expenses may include:  Deductibles and other payments you must make under your medical plan.  Charges that may not be covered by your medical plan, such as: • Dependent physicals • Well-baby care • Eyeglasses/contact lenses • Birth control pills • Some over the counter medications

• Hearing aids • Dental care • Braces • Routine exams

 Miscellaneous expenses, such as:     

Individual psychiatric or psychological counseling Special education devices for the blind (such as a typewriter) Special instructions or training for the deaf (such as lip reading) Cost of acquiring and training a dog for the deaf or blind Public transportation to receive medical care (must provide receipt)

 Other healthcare services that qualify as medical deductions under IRS rules:  Special medical equipment  Qualified medical products or services prescribed by a doctor for which you must pay out-of-pocket

Please refer to Section 213(d) of the Internal Revenue Code for the IRS definition of deductible medical expenses that are eligible for reimbursement. Note: An expense is not eligible if it is for cosmetic reasons only. Also, premiums for health coverage are not eligible for reimbursement.

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How much should I contribute? Now that you have a better idea of what qualifies, try to determine how much you might spend on these types of expenses during the next plan year. To be safe, be conservative in your estimates. Use the worksheet included in this booklet. And remember, the expenses you choose cannot be covered by any other medical plan.

The “Use it or lose it” rule: If you contribute dollars to a flexible spending account and do not use all of the monies you deposit, you will lose any remaining balance in the account at the end of the plan year. A very important thing to remember…the rule exists because the IRS has established strict guidelines on plans with tax advantages. Estimate carefully the amount you want to contribute, and only contribute dollars that you’re confident will be used before the end of the plan year.

Health Care Flexible Spending Account

What if the tax laws change?

The value of additional benefits

Tax advantages currently available are based on the law as it stands today. If a change in the law takes place, you will be notified.

During enrollment, you can take advantage of your increased spendable income by adding other benefits. Through your employer’s flexible benefits plan, you’ll be able to pay the premiums for qualifying benefits with pre-tax dollars, making your benefits even more affordable.

Will pretaxing have an impact on Social Security benefits? Any reduction in your taxable pay may also lead to a reduction in your Social Security benefits; however, for most employees, the reduction in Social Security benefits is insignificant compared to the value of paying lower taxes today.

Will I be able to change my election?



Cafeteria plan regulations have a process for determining if a participant is allowed to make a change in election during the plan year. The two-step process is: 1) A change in status must have occurred. A change in status has occurred if the event falls into one of the categories below:  Legal marital status  Number of dependents  Employment status Dependent satisfies (or ceases to satisfy) eligibility requirements  Change of residence 2) The participant’s election change must be consistent with the status change event. In order to be consistent, a requested change must be on account of and correspond with a change in status that affects eligibility for coverage under an employer-sponsored plan.

Let’s take another look at John’s situation. If John chooses to deduct $40 per pay period in qualified premiums from his gross pay, along with his $70 health care FSA deduction, here’s how it affects his paycheck:

Health care FSA and pretax premiums illustration John’s status: Married Two federal/state exemptions Bimonthly salary: $1000 Eligible expenses: Health care FSA: $70 Colonial pretax premium: $40

Gross pay Qualified pre-tax reduction Taxable gross FICA, fed. & state taxes Net pay Health care FSA reimbursement Spendable Income

w/ Health care FSA $1000.00 -70.00 930.00 -275.75 $654.25 +70.00 $724.25

w/ Health care FSA & pretax premium $1000.00 -110.00 890.00 -263.89 $626.11 +70.00 $696.11

John saves $11.86 in payroll taxes. You, too, can tailor your benefits package by choosing products you want and need while reducing your tax burden.

Health Care Flexible Spending Account Worksheet Estimating Your Eligible Medical Expenses Complete the following chart to estimate your health care expenses for last year and this year. This chart will help you determine how much of your salary you may want to contribute to a health care reimbursement account. Medical Last Year This Year Deductibles, plus 100% of out-of-pocket expenses not covered by medical plan……….. $ $ Doctor’s office visits……………………………………………………………………… $ $ Well-baby care……………………………………………………………………………. $ $ Pap-smear………………………………………………………………………………… $ $ Physicals………………………………………………………………………………….. $ $ Immunizations……………………………………………………………………………. $ $ Prescription Drugs……………………………….……………………………………….. $ $ Dental Fillings……………………………………………………………………………………. $ $ Bridges, Crowns, Dentures……………………………………………………………….. $ $ Orthodontia, Braces………………………………………………………………………. $ $ Exams……………………………………………………………………………………... $ $ Vision Exams……………………………………………………………………………………... $ $ Lenses, Frames…………………..………………………………………………………... $ $ Contact lenses…………………………………………………………………………….. $ $ Hearing Exams, Hearing Aids……………………………………………………………………... $ $ Miscellaneous……………………………………………………………………………. $ $ Total Eligible Medical Expenses……………………………………………………….. $ $ Please refer to Section 213(d) of the Internal Revenue Code of the IRS definition of deductible medical expenses that are eligible for reimbursement. Note: An expense is not eligible if it is for cosmetic reasons only. Also, premiums for health coverage are not eligible for reimbursement. A benefits representative can help you estimate your tax savings based on the amount you contribute to the health care reimbursement account.

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Health Care Flexible Spending Account

Examples of Eligible FSA Expenses IMPORTANT REMINDER – Some expenses may require additional documentation to establish eligibility, such as a physician’s statement that a certain expense will treat your existing medical condition. Please contact your Flexible Spending Account Administrator for more information on whether an expense is covered before submitting receipts if you have any questions. .

ELIGIBLE MEDICAL EXPENSES Prescription medication Drug & medical supplies Physician’s fees and co-pays Chiropractic treatments Psychological fees Psychoanalysis Laboratory fees Insulin Nurses’ fees (RN and LPN) Diagnostic fees Oxygen Hormone Therapy

Doctor Prescribed Weight Loss Artificial Limbs or Prosthesis Organ Transplants Doctor Prescribed Massage therapists Learning Disability associated costs Braille books, magazines, etc. Guide Dog Hearing devices & batteries Crutches Sterilization Ambulance costs Diabetic Testing Supplies

Co-pays & Deductibles Obstetrical expenses Expenses for handicapped dependent Psychiatric care Drug & alcoholism treatment X-Rays fees MRI charges Fertility Treatments Operations if medically necessary Wheelchairs Orthopedic shoes Blood Pressure Testing

ELIGIBLE MEDICALLY NECESSARY TRAVEL EXPENSES Meals if incurred at a hospital while seeking treatment Transportation to healthcare facility ($.14 per mile) Bus, taxi, train or plane fare to healthcare facility Transportation expenses of a nurse or other person who can give injections, medications or other treatment required by a patient who is traveling to get health care and is unable to travel alone.

Lodging (maximum of $50 per night & must be related to treatment in a hospital or equivalent) Parent’s transportation expenses if needed to go with a child who needs health care Associated parking fees and tolls Transportation expenses for regular visits to see a mentally ill dependent if these visits are recommended as part of treatment.

ELIGIBLE DENTAL EXPENSES Exams, prophylaxis (cleaning) Dentures, artificial teeth, bridges

X-rays Fluoride treatments Extractions, fillings

Root Canals Orthodontia Oral Surgery

ELIGIBLE VISION CARE Eye examinations Eye Glasses (including prescription sunglasses) LASIK Surgery

Contact lenses Contact lens solution Photo Refractive Keratotomy (PRK)

EXAMPLES OF INELIGIBLE FSA EXPENSES Any expenses incurred in an illegal operation or treatment Cosmetic Surgery Insurance premiums Funeral & burial expenses YMCA dues Maternity clothing, diaper service, etc. Over-the-Counter smoking cessation programs (such as Nicoderm CQ) Cellulite treatments Expenses incurred as or to a surrogate mother Sunscreens Dancing or swimming lessons Tattoo removal Minoxidil or Rogaine Contact lens insurance contracts(for replacement of damaged/lost lens)

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Bleaching of teeth Bottled water Cosmetics, toiletries, toothpaste, etc. Health Club dues/personal trainer fees Marriage or family counseling Low “carb” foods Treatment for varicose veins Vacuum cleaners, pillows or filters (in the case of allergies) Household help Chemical peels Breast implant repair Purchase of tanning bed (for a skin condition) Breast pumps Safety glasses

DEPENDENT CARE FLEXIBLE SPENDING ACCOUNT A plan that enhances your benefits If you’re one of the many people who spends money on the care of dependents, a dependent care flexible spending account can make these expenses more affordable. This valuable option is available through your employer’s flexible benefits plan and is a qualified benefit under Code Section 125 of the IRS. Code Section 125 was created by the United States Congress to make benefits more affordable for you.

How it works If you participate, you will elect to have a specified amount of pre-taxed money deducted from your paycheck each pay period. These dollars are set aside in a flexible spending account and subtracted from your gross earnings before any taxes are taken out. After you submit a receipt for a qualifying dependent care expense, you will be reimbursed from this account.

Gross pay Pre-tax Dependent Care FSA Taxable Income FICA, fed & state taxes Net pay Dependent Care expense Spendable income

For example…

Mary’s Status Married Two fed./state exemptions Bimonthly salary: $1000 Eligible expenses: dep. care/$110 Mary has one child. She pays $220 per month ($110 per pay period) for day care. Here’s how a dependent care plan can help her.

Before Dep. Care FSA reim. $1000.00 -0$1000.00 -$296.50 $703.50 -110.00 $593.50

After Dep. Care FSA reim. $1000.00 -$110.00 $890.00 -$263.89 $626.11

Mary chooses to have $110 each pay period deducted from her gross salary. When she incurs qualifying dependent care expenses, she simply files a claim and is reimbursed from the account. Because her taxable income is now lower, her taxes are less. After Mary is reimbursed from her account, her total spendable income increases by $32.61 each pay period. Annually, Mary has increased her spendable income by $782.64

How it benefits you The advantage of participating is that when you contribute pretax dollars to a reimbursement account, you lower your taxable income; therefore, you pay less in taxes and increase your spendable income!

$626.11

The amount and number of times Mary is reimbursed will depend on the receipts she submits for qualified dependent care expenses and the frequency with which her plan makes reimbursements. Illustrations based on 2010 North Carolina tax tables.

How much can I contribute?

Tax credits vs. dependent care FSA’s

The U.S. Congress has set these maximum allowable contributions for a dependent care flexible spending account:

If you participate in the plan, you cannot claim credits on your income tax return for the same expenses. Also, amounts reimbursed under this plan will reduce the amount of other dependent care expenses that you can claim for purposes of tax credits. Before you sign up, evaluate whether or not taking federal income tax credit will save you more money than a dependent care FSA. The worksheet included in this booklet will help you decide.

 $5,000 for a married couple filing jointly  $5,000 for a single parent  $2,500 for a married person filing separately

Eligible Expenses You may use the plan for expenses that meet the following qualifications:  The dependent care must enable you and your spouse to be employed.  The amount to be reimbursed must not be greater than your spouse’s income or one-half of your income, whichever is less.  The child must be under 13 years old and must be your dependent under federal tax rules. Note: If your child turns 13 during the plan year, reimbursements must stop. Your contributions, however, must continue throughout the plan year, so plan carefully.  The services may be provided in your home or another location but not by someone who is your minor child or dependent for income tax purposes (for example, an older child).  If the services are provided by a day care facility that cares for six or more children at the same time, the facility must comply with state and local day care regulations.  Services must be for the physical care of the child, not for education, meals, etc.

Qualified dependent care expenses also include costs for the care of a spouse or dependent who is incapable of self-care and regularly spends at least eight hours per day in your home (i.e. invalid parent). The same rules that apply for child care apply to the care of other dependents, except that the dependent need not be under age 13.

What do I need to know when I file my taxes? You must report on your tax return the correct name, address, and taxpayer identification number (TIN) of your dependent care provider to claim exclusion for employer-provided dependent care assistance benefits or the dependent care credit. If your dependent care provider is exempt from federal income taxation, you are not required to report the TIN on your tax return. However, you must report the correct name and address of the exempt provider and you must write "tax-exempt" in the space provided for reporting the TIN. If you fail to report the correct name, address and TIN of your dependent care provider and cannot establish upon request by the IRS that you exercised due diligence in attempting to provide that information, you are not entitled to either the Section 21 credit nor the Section 129 exclusion. Due diligence can be proven by having obtained and retained a copy of the Social Security card (or driver's license) of your dependent care provider, or by having obtained the required information from a recently printed letterhead or printed invoice from the dependent care provider.

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Dependent Care Flexible Spending Account

What if I want to make a change in my election? The latest set of cafeteria plan regulations develops a process for determining if a participant is allowed to make a change in election during the plan year. The two-step process is:

Understand your choices With this program, you have benefit choices and opportunities you've never had before, and it's important to understand everything completely. Reading this booklet is the first step. The next step is to attend a planning session. At the session, your representative will answer questions and estimate your tax savings, based on the amount you plan to contribute.

1. A change in status must have occurred. A change in status has occurred if the event falls into one of the categories below:  Legal marital status  Number of dependents  Employment status  Dependent satisfies (or ceases to satisfy) eligibility requirements  Change of residence  Change in the cost of coverage

The value of additional benefits

2. The participant’s election change must be consistent with the status change event. In order to be consistent, a requested change must be on account of and correspond with a change in status.

Mary’s status: Married, two federal/state exemptions Bi-weekly salary: $1000 Eligible expenses: Dep. Care FSA/$110 Colonial coverages: $18

During enrollment, you can take advantage of your increased spendable income by adding more benefits. Through your employer’s flexible benefits plan, you’ll be able to pay the premiums for qualifying benefits with pretax dollars and your benefits become even more affordable. Let's take another look at Mary's situation. If Mary chooses to deduct $18 per pay period in qualified premiums from her gross pay, along with her $110 dependent care deduction, here's how it would affect her paycheck:

Dependent care FSA and pretax premiums illustration

w/ Dep. care FSA

What if the tax laws change? Tax advantages currently available are based on the law as it stands today. If a change in the law takes place, you will be notified.

Gross pay Pre-tax dep. care reduction (and Premium) Taxable gross FICA, fed. & state taxes Net pay Insurance Dep. care FSA reimbursement Spendable Income

$1000.00 -110.00 890.00 -263.89 $626.11 18.00 +110.00 $718.11

w/ Dep. care FSA & pretax premium $1000.00 -128.00 872.00 -258.55 $613.45 +110.00 $723.45

Mary saves $5.34 in payroll taxes. You, too, can tailor your benefits package by choosing products you want and need while reducing your tax burden.

Dependent Care Reimbursement Plan Worksheet Last Year

This Year

Day Care………………………………………………….. Nursery Schools………………………………………….. Other Eligible Care………………………………………. Total Dependent Care…………………………………….

Reimbursement vs. Tax Credit Dependent care expenses eligible for reimbursement from your account are also eligible for a federal income tax credit. You can apply one or the other of these two tax advantages, but not both for the same expense. State income tax may impact this result. Your Representative will help explain this program to you.

How Does the Tax Credit Work? The tax credit applies to a maximum of the first $3,000 of expenses if you have one eligible dependent. The credit applies to the first $6,000 of expenses with two or more eligible dependents. Depending on your adjusted gross income, a certain percentage of those expenses may be taken as a credit.

Maximum Annual Contributions to Dependent Care Reimbursement Account Maximum $5,000 - Single-parent household, or married, filing jointly. Maximum $2,500 - Married, filing separately. Note: Dependent care expenses shall not include any amount paid for services outside the taxpayer's household at a camp where the qualified individual stays overnight.

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Dependent Care Flexible Spending Account

Tax Credit Complete the following to determine the maximum tax credit for your dependent care expenses.

1. Write the amount of qualified expenses you incurred and actually paid last year and expect to pay this year for the care of the qualified person*. DO NOT write more than $3,000 ($6,000 if you expect to pay for the care of two or more qualified persons*.) ………………............................................................................................ 2. Write your estimated earned income** for this year……………………………... 3. Write your spouse’s estimated earned income for this year……………………… 4. Compare amounts on line 2 & 3, and write the smaller of the two amounts on line 4…………………………………………………………………………………. 5. Compare amounts on line 1 & 4, and write the smaller of the two amounts on line 5…………………………………………………………………………………. 6. Write the percentage from the table below that applies to the Adjusted Gross Income (AGI) on Form 1040, line 36………………………………………………..

1. $__________ 2. $__________ 3. $__________ 4. $__________ 5. $__________ 6. $__________

If AGI is over:

But not over:

Percentage is:

If AGI is over:

But not over:

Percentage is:

If AGI is over:

But not over:

Percentage is:

$0 15,000 17,000 19,000 21,000 23,000

-15,000 -17,000 -19,000 -21,000 -23,000 -25,000

35% (.35) 34% (.34) 33% (.33) 32% (.32) 31% (.31) 30% (.30)

$25,000 27,000 29,000 31,000 33,000

-27,000 -29,000 -31,000 -33,000 -35,000

29% (.29) 28% (.28) 27% (.27) 26% (.26) 25% (.25)

$35,000 37,000 39,000 41,000 43,000

-37,000 -39,000 -41,000 -43,000 no limit

24% (.24) 23% (.23) 22% (.22) 21% (.21) 20% (.20)

7. Multiply the amount on line 5 by the percentage shown on line 6 and write result…………………………………………………………………………………. 7. $__________ This is the maximum amount of your credit for dependent care expenses (amount of credit may not exceed the amount you pay in taxes.) *Qualifying Person: 1. Under age of 13 whom you claim as a dependent. 2. Disabled Spouse who is mentally or physically incapable of self-care. 3. Any disabled person who is mentally or physically incapable of self-care and whom you claim as a dependent or could claim as a dependent except that the individual had an income of $3,050 or more. **Earned Income: Wages, salaries, tips ands other employee compensation. It also includes earnings from self-employment. Neither Colonial Life nor the employer assumes responsibility for the accuracy of the calculation nor the resulting tax savings and neither is in any way rendering tax advice.

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Flexible Spending Accounts Important Information

FlexSystem Flexible Benefits Plan Camden County Schools Plan Year: January 1, 2017 through December 31, 2017 Maximum Annual Contributions Medical Expense Reimbursement Plan: Dependent Care Assistance Plan:

$2,600.00 $5,000.00

Claims Reimbursement You can use your FlexSystem Claim Card anywhere Visa is accepted as long as the provider offers eligible services under your Medical and/or Dependent Care Flexible Spending Plan. If you have any problems with your card call us toll free at 800-422-4661. If you do not have the FlexSystem Claim Card or use a provider who does not accept Visa you can submit your claims online at www.tasconline.com, via the TASC Mobile app on your smartphone or by using your personalized Request for Reimbursement Form that was mailed to you at the beginning of the Plan Year. Additional Forms can be printed from www.tasconline.com. FlexSystem processes requests for reimbursements on a daily basis. Requests received by FlexSystem prior to noon CST will be processed that business day, with reimbursements deposited to your MyCash account the next business day. Please visit your MyCash Manager to set up your preferred method of reimbursement (MyCash, direct deposit or check). For the Health Care Flexible Spending Account you can access your annual contribution at the start of your plan year. For the Dependent Care Flexible Spending Account the maximum reimbursement you can get is equal to the current account balance in your Dependent Care account. Use it or lose it Only claims incurred during the plan year are eligible for reimbursement. You have 90 days following the plan year to submit claims. If you terminate employment, you have 90 days following your termination date to submit claims incurred while you were participating. Eligibility Employees who work at least 20 hours per week are eligible to participate. Eligible employees must sign a new enrollment form before the start of each plan year. New employees must wait until the Annual Enrollment in order to enroll in spending accounts. Eligible employees can claim expenses incurred by their dependents as defined under section 125 of the Internal Revenue Code. Termination Your participation in the Flexible Benefits Plan will terminate on the earliest of the following dates. 1. The date that you cease to satisfy the eligibility requirements of the Plan. 2. The date the Plan terminates. 3. The date you fail to make your required contributions to the Plan. Special rules, called COBRA provisions, apply to certain health or medical plans. If you terminate employment or have another “qualifying event” that affects your health plan, your Benefits Coordinator will give you an explanation of COBRA and your rights to continued coverage, if COBRA applies to your plan. Election Changes The laws governing Flexible Benefits Plans generally do not allow you to change the terms of your Benefits Enrollment Form during a Plan Year. There are, however, a few exceptions to this rule. You may change your benefit elections if there is a change in your status. Such a change in status might include your marriage or divorce; your spouse commencing or terminating employment; a change in work status (such as from full-time to part time or vice versa); you or your spouse taking an unpaid leave of absence from work; a significant change in health coverage due to your spouse’s employment; the birth, adoption or death of a child or other dependent of yours; a child reaching the age of majority or some other circumstance where that person is no longer considered a dependent. This list is only a partial list of what might be considered a change in status. It is up to the Plan Administrator to determine what is and is not a change in status, and the judgment of the plan administrator must be made in reliance with the laws governing Flexible Benefits Plans. If you do have a change in status you must notify the plan administrator within 30 days. If the Plan Administrator determines that your change in status is a permitted change under the law, and that the election change is consistent with your change in family status, the Plan Administrator will allow you to file a form, with new benefit choices that reflect your change in status. Information If you signed up for the FlexSystem Claim Card you can get your account information online at www.tasconline.com. You can contact us toll free between the hours of 8:00 AM and 5:00 PM EST Monday through Friday at 800-422-4661. To expedite your call, please have your 12-digit TASC Participant ID available. The Participant ID can be found on your TASC Claim Card or your personalized Request for Reimbursement form.

12 | Camden County Schools

Flexible Spending Accounts The FSAStore

The FSAStore – One Convenient Location for All Your FSA Purchases Pierce Group Benefits recently partnered with the FSAStore to provide one convenient location for all your FSA eligible purchases. Through our partnership, Pierce Group Benefits and the FSAStore can help you shop for FSA eligible items, search for local and eligible physicians, and answer the many questions that come along with having a Flexible Spending Account. COMPONENTS The FSAstore focuses on three main channels to help you better understand your benefits and eligible services and products as an FSA participant:   

Products – Shop for more than 4,000 FSA eligible products Services – Find FSA eligible services and providers in your area Learning Center – Learn more about your FSA and get answers to your questions BENEFITS

By utilizing FSAStore, you get the following benefits:      

Easily understand which products require a prescription and which do not Get access to FSA eligible services and providers in your area Find answers to commonly and not-so-commonly asked FSA questions Enjoy free shipping on orders over $50 with a short 1-2 day turnaround time Have access to 24/7 customer support Get your favorite brands at discounted prices ACCESSING FSASTORE

Accessing the FSAStore is easy. Simply visit www.PierceGroupBenefits.com and click on the button on the right side of the home page that reads “Use Your Flexible Spending Account Dollars”. FSAStore can also be accessed through clicking on the FSAStore links and buttons listed in various locations throughout your custom benefits website hosted on the Pierce Group Benefits website.

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Flexible Spending Accounts The TASC Card

14 | Camden County Schools

CANCER BENEFIT Cancer Assist Plan Provided by Colonial Life The following information highlights the benefits of the current Cancer policy available through your benefits package. If you enrolled in a Cancer Plan prior to this year, you may have different benefits and features than those shown here. You should refer to your personal policy for your exact benefits and features. Your Benefits Representative can provide you with further information on which plan you have, and assist with any questions. Please meet with your Benefits Representative during your enrollment period or call the Pierce Group Service Center at 1-888-662-7500 for any assistance.

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Cancer Benefit

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Cancer Benefit

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Cancer Benefit

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Cancer Benefit

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Cancer Benefit

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Cancer Benefit

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Cancer Benefit

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Cancer Benefit

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Cancer Benefit

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Cancer Benefit

Individual Cancer Rates LEVEL 1 – Monthly Premiums - Composite Rates Employee

Employee /Spouse

One-Parent Family

Two-Parent Family

$18.25

$28.75

Level 1 with $100 Cancer Wellness/Health Screening Premium

$18.10

$28.60

LEVEL 2 – Monthly Premiums - Composite Rates Employee

Employee /Spouse

One-Parent Family

Two-Parent Family

$21.95

$34.15

Level 2 with $100 Cancer Wellness/Health Screening Premium

$21.65

$33.85

LEVEL 3 – Monthly Premiums - Composite Rates Employee

Employee /Spouse

One-Parent Family

Two-Parent Family

$27.10

$44.85

Level 3 with $100 Cancer Wellness/Health Screening Premium

$26.65

$44.40

LEVEL 4 – Monthly Premiums - Composite Rates Employee

Employee /Spouse

One-Parent Family

Two-Parent Family

$36.20

$60.00

One-Parent Family

Two-Parent Family

$1.75

$1.25

$1.75

$2.50

$1.60

$2.60

$7.80

$17.05

Level 4 with $100 Cancer Wellness/Health Screening Premium

$35.60

$59.40

OPTIONAL RIDERS Employee

Employee /Spouse

Specified Disease Hospital Confinement Rider Premium

$1.25

Initial Diagnosis of Cancer Rider (per $1,000) Premium

$1.50

Initial Diagnosis of Cancer Progressive Payment Rider Premium

$7.80

$17.05

Camden County Schools | 25

State of North Carolina Disability Benefits at a Glance To be eligible for Short-Term Disability benefits you must have at least one year of contributing membership service in the Retirement System earned within the 36 calendar months preceding your disability. To be eligible for Long-Term Disability benefits you must have at least five years of contributing membership service in the Retirement System earned within the 96 calendar months prior to becoming disabled or upon cessation of continuous salary continuation payments, whichever is later.

THE STATE OF NORTH CAROLINA PROVIDES A DISABILITY INCOME PLAN FOR ITS PERMANENT, FULL-TIME TEACHERS AND STATE EMPLOYEES – AT NO COST TO THE INDIVIDUAL. The State Plan is designed to provide for the continuation of a portion of your salary should you suffer the misfortune of an accident or sickness which disables you for longer than 60 days. HERE’S HOW IT WORKS… 1.

WHEN YOU ARE DISABLED: First 12 Months of Disability

Thereafter**

Percentage of Your Total Monthly Salary the State Pays You*

50%

65%

Maximum Total Benefit

$3,000

$3,900

Workers’ Compensation

Workers’ Compensation Social Security

Social Security

----------------------

Reduced By

Not Reduced By

* 1/12 of your total pay during the 12 months prior to your disability. ** you must have at least five years of contributing membership service in the Retirement System earned within the 96 calendar months prior to the end of the short-term disability period. 2.

Benefits under the State Plan are payable for life, for “Disability,” which means that you are mentally or physically incapable of performing the duties of your usual occupation.

You become a member of the plan when you become a full-time, permanent employee of the State, and you are eligible to receive benefits from the Plan if you become disabled after you have completed one year’s service. Your coverage under the Plan ends when your employment with the State terminates.

Benefits of the Plan are payable beginning 60 DAYS AFTER THE DATE OF YOUR DISABILITY (60-day waiting period).

The Plan coordinates with other benefits related to your employment, so that after the amounts you are eligible to receive from Social Security (for the first six months only), Workers’ Compensation, or State retirement plans, etc., the State pays you enough, in addition, to total a) 50% the first twelve months and b) 65% thereafter of your total salary, as explained in the chart above. HOWEVER, ANY BENEFIT FROM A PLAN FOR WHICH YOU PAY THE ENTIRE COST YOURSELF DOES NOT AFFECT THE STATE PLAN IN ANY WAY.

This information provided by Colonial Life Columbia, South Carolina 29202 www.coloniallife.com

26 | Camden County Schools

DISABILITY BENEFIT Disability â&#x20AC;&#x201C; Educator Income Plan Provided by Colonial Life The following information highlights the benefits of the current Disability policy available through your benefits package. If you enrolled in a Disability Plan prior to this year, you may have different benefits and features than those shown here. You should refer to your personal policy for your exact benefits and features. Your Benefits Representative can provide you with further information on which plan you have, and assist with any questions. Please meet with your Benefits Representative during your enrollment period or call the Pierce Group Service Center at 1-888-662-7500 for any assistance.

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Disability Benefit

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Disability Benefit

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Disability Benefit

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Disability Benefit

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Disability Benefit

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Disability Benefit

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Disability Benefit

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Disability Benefit

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ACCIDENT BENEFIT Accident 1.0 Plan Provided by Colonial Life The following information highlights the benefits of the current Accident policy available through your benefits package. If you enrolled in an Accident Plan prior to this year, you may have different benefits and features than those shown here. You should refer to your personal policy for your exact benefits and features. Your Benefits Representative can provide you with further information on which plan you have, and assist with any questions. Please meet with your Benefits Representative during your enrollment period or call the Pierce Group Service Center at 1-888-662-7500 for any assistance.

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Accident Benefit

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Accident Benefit

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Accident Benefit

Accident 1.0 â&#x20AC;&#x201C; Preferred with Health Screening Monthly Premiums Named Insured Employee & Spouse One-Parent Family Two-Parent Family

$21.15 $28.97 $32.67 $40.48

Camden County Schools | 39

STATE OF NORTH CAROLINA TEACHERS’ AND STATE EMPLOYEES’ HEALTH PLAN The following summary is included in this benefit booklet for informational purposes only. Open enrollment for the State of North Carolina Teachers’ and State Employees’ Health Plan is not part of this Flexible Benefits Plan Open Enrollment Period.

40 | Camden County Schools

State of North Carolina Teachers’ and State Employees’ Health Plan

Camden County Schools | 41

MEDICAL BRIDGE INDEMNITY BENEFIT Individual Medical Bridge Plan Provided by Colonial Life The following information highlights the benefits of the current Medical Bridge policy available through your benefits package. If you enrolled in a Medical Bridge Plan prior to this year, you may have different benefits and features than those shown here. You should refer to your personal policy for your exact benefits and features. Your Benefits Representative can provide you with further information on which plan you have, and assist with any questions. Please meet with your Benefits Representative during your enrollment period or call the Pierce Group Service Center at 1-888-662-7500 for any assistance.

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Medical Bridge Indemnity Benefit

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Medical Bridge Indemnity Benefit

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Medical Bridge Indemnity Benefit

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Medical Bridge Indemnity Benefit

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GROUP CRITICAL CARE BENEFIT Group Critical Care Plan Provided by Colonial Life The following information highlights the benefits of the current Group Critical Care policy available through your benefits package. If you enrolled in a Critical Care Plan prior to this year, you may have different benefits and features than those shown here. You should refer to your personal policy for your exact benefits and features. Your Benefits Representative can provide you with further information on which plan you have, and assist with any questions. Please meet with your Benefits Representative during your enrollment period or call the Pierce Group Service Center at 1-888-662-7500 for any assistance.

GROUP CRITICAL CARE – PLAN 1 – CANCER AND SPECIFIED DISEASE

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Group Critical Care Benefit Plan 1 â&#x20AC;&#x201C; Cancer & Specified Disease

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Group Critical Care Benefit First Diagnosis Building Benefit Rider â&#x20AC;&#x201C; Specified Disease & Cancer (Plan 1)

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Group Critical Care Benefit Plan 3 – Specified Disease GROUP CRITICAL CARE – PLAN 3 – SPECIFIED DISEASE

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Group Critical Care Benefit Plan 3 â&#x20AC;&#x201C; Specified Disease

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Group Critical Care Benefit First Diagnosis Building Benefit Rider â&#x20AC;&#x201C; Specified Disease (Plan 3)

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Group Critical Care Benefit Health Screening Benefit

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TERM LIFE INSURANCE Term Life 1000 Plan Provided by Colonial Life The following information highlights the benefits of the current Term Life policy available through your benefits package. If you enrolled in a Term Life Plan prior to this year, you may have different benefits and features than those shown here. You should refer to your personal policy for your exact benefits and features. Your Benefits Representative can provide you with further information on which plan you have, and assist with any questions. Please meet with your Benefits Representative during your enrollment period or call the Pierce Group Service Center at 1-888-662-7500 for any assistance.

54 | Camden County Schools

Term Life Insurance

Camden County Schools | 55

UNIVERSAL LIFE INSURANCE Universal Life 1000 Plan Provided by Colonial Life The following information highlights the benefits of the current Universal Life policy available through your benefits package. If you enrolled in a Universal Life Plan prior to this year, you may have different benefits and features than those shown here. You should refer to your personal policy for your exact benefits and features. Your Benefits Representative can provide you with further information on which plan you have, and assist with any questions. Please meet with your Benefits Representative during your enrollment period or call the Pierce Group Service Center at 1-888-662-7500 for any assistance.

56 | Camden County Schools

Universal Life Insurance

Camden County Schools | 57

WHOLE LIFE INSURANCE Whole Life 1000 Plan Provided by Colonial Life The following information highlights the benefits of the current Whole Life policy available through your benefits package. If you enrolled in a Whole Life Plan prior to this year, you may have different benefits and features than those shown here. You should refer to your personal policy for your exact benefits and features. Your Benefits Representative can provide you with further information on which plan you have, and assist with any questions. Please meet with your Benefits Representative during your enrollment period or call the Pierce Group Service Center at 1-888-662-7500 for any assistance.

58 | Camden County Schools

Whole Life Insurance

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GROUP TERM LIFE INSURANCE Group Term Life Benefits Provided by Colonial

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Group Term Life Insurance

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Group Term Life Insurance

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Group Term Life Insurance

Colonial Group Term Life Employee Coverage 12 month 10 month $10,000 $1.60 $1.92 $20,000 $3.20 $3.84 $30,000 $4.80 $5.76 $40,000 $6.40 $7.68 $50,000 $8.00 $9.60 $60,000 $9.60 $11.52 $70,000 $11.20 $13.44 $80,000 $12.80 $15.36 $90,000 $14.40 $17.28 $100,000 $16.00 $19.20 $110,000 $17.60 $21.12 $120,000 $19.20 $23.04 $130,000 $20.80 $24.96 $140,000 $22.40 $26.88 $150,000 $24.00 $28.80 $160,000 $25.60 $30.72 $170,000 $27.20 $32.64 $180,000 $28.80 $34.56 $190,000 $30.40 $36.48 $200,000 $32.00 $38.40

Spouse Coverage 12 month $10,000 $1.60 $15,000 $2.40 $20,000 $3.20 $25,000 $4.00 $30,000 $4.80 $35,000 $5.60 $40,000 $6.40 $45,000 $7.20 $50,000 $8.00

10 month $1.92 $2.88 $3.84 $4.80 $5.76 $6.72 $7.68 $8.64 $9.60

Dependent Coverage 12 month $5,000 $0.68 $10,000 $1.36

10 month $0.82 $1.63

Camden County Schools | 63

DENTAL INSURANCE Dental Benefits Provided by Sun Life (formerly Assurant)

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Dental Insurance

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Dental Insurance

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Dental Insurance

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VISION INSURANCE Vision Benefits Provided by Superior

68 | Camden County Schools

Optima Employee Assistance Program Camden County Schools has invested in your wellbeing by offering an Employee Assistance Program. This free and confidential benefit is available for you and your household members. We can help you manage the problems of everyday life, both personal and work related. * stress * work-related concerns * substance abuse * improving family relations * child/adolescent issues * balancing work & family

* anger management * emotional distress * depression

You and your household members may receive up to 5 free EAP counseling sessions per presenting issue. If additional sessions are indicated, they may refer you to a provider that participates with your health insurance plan.

For a confidential consultation with our professional counseling staff, call Optima EAP at 1-800-899-8174 For more info visit our website at www.OptimaEAP.com Log-in Password: Camden County Schools

Camden County Schools | 69

Authorization for Colonial Life & Accident Insurance Company For the purpose of evaluating my application(s) for insurance submitted during the current enrollment and eligibility for benefits under any insurance issued including checking for and resolving any issues that may arise regarding incomplete or incorrect information on my application(s), I hereby authorize the disclosure of the following information about me and, if applicable, my dependents, from the sources listed below to Colonial Life & Accident Insurance Company (Colonial) and its duly authorized representatives. Health information may be disclosed by any health care provider or institution, health plan or health care clearinghouse that has any records or knowledge about me including prescription drug database or pharmacy benefit manager, or ambulance or other medical transport service. Health information may also be disclosed by any insurance company, Medicare or Medicaid agencies or the Medical Information Bureau (MIB). Health information includes my entire medical record, but does not include psychotherapy notes. Non-health information including earnings or employment history deemed appropriate by Colonial to evaluate my application may be disclosed by any person or organization that has these records about me, including my employer, employer representative and compensation sources, insurance company, financial institution or governmental entities including departments of public safety and motor vehicle departments. Any information Colonial obtains pursuant to this authorization will be used for the purpose of evaluating my application(s) for insurance or eligibility for benefits. Some information obtained may not be protected by certain federal regulations governing the privacy of health information, but the information is protected by state privacy laws and other applicable laws. Colonial will not disclose the information unless permitted or required by those laws. This authorization is valid for two (2) years from its execution and a copy is as valid as the original. A copy will be included with my contract(s) and I or my authorized representative may request access to this information. This authorization may be revoked by me or my authorized representative at any time except to the extent Colonial has relied on the authorization prior to notice of revocation or has a legal right to contest coverage under the contract(s) or the contract itself. If revoked, Colonial may not be able to evaluate my application(s) for insurance or eligibility for benefits as necessary to issue my contract(s). I may revoke this authorization by sending written notice to: Colonial Life & Accident Insurance Company, Underwriting Department, P.O. Box 1365, Columbia, SC 29202. You may refuse to sign this form; however, Colonial may not be able to issue your coverage. I am the individual to whom this authorization applies or that personâ&#x20AC;&#x2122;s legal Guardian, Power of Attorney Designee, or Conservator.

________________________ (Printed name of individual subject to this disclosure)

_____________ (Social Security Number)

___________________ (Signature)

________________ (Date Signed)

If applicable, I signed on behalf of the proposed insured as __________________________ (indicate relationship). If legal Guardian, Power or Attorney Designee, or Conservator.

________________________________ (Printed name of legal representative)

70 | Camden County Schools

_____________________________ (Signature of legal representative)

___________ (Date Signed)

Camden County Schools | 71

YES! I want to keep my Colonial Life Coverage. My premiums are no longer being payroll-deducted. Complete this form and mail it today – along with a check for your premium payment. Name:____________________________________

Daytime Telephone Number: (_____)_____________________

Mailing Address:___________________________

Social Security Number or Date of Birth:__________________

City:_____________________________________

State:____________________ Zip:______________________

Policy number(s) to be continued: _______________________, _______________________, _______________________, _______________________

Which Colonial Life & Accident Insurance do you want to continue? (check one or more)  Accident

 Disability

 Hospital

Income

 Cancer

or Critical Illness

 Life

Please choose one of the following payment options:  Deduct premiums each month from my checking account. Attach a voided check with this form and circle one range of dates you would like your account to be drafted. Your draft will occur on one of the dates within the range you have selected. Range:

(A) 1st-5th

(B) 6th-10th

(D) 16th-20th

(E) 21st-26th

Signature of Checking Account Owner:________________________________________________________ or  Bill

me directly. Choose one of the following:  Quarterly (Submit a payment 3 times your monthly premium)  Semi-annually (Submit a payment 6 times your monthly premium)  Annually (Submit a payment 12 times your monthly premium)

Date:________________________ Policy Owner’s Signature:____________________________________ Return to: Colonial Life & Accident Insurance Company P.O. Box 1365 Columbia, South Carolina 29202 1.800.325.4368 (phone) 1.800.561.3082 (fax) Colonial Life products are underwritten by Colonial Life & Accident Insurance Company, for which Colonial Life is the marketing brand.

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18514-15

TASC - Flexible Spending Accounts

Assurant - Dental Insurance

See pages 4-5 for online enrollment instructions

Customer Service.........................................................1-800-442-7742 Fax Claims …………………………………………..1-563-242-0184 Internet Address……………..…www.assurantemployeebenefits.com

Mailing Address 2302 International Lane, Madison, Wisconsin 53074-3140 Internet Address for FlexSystem…………….....www.tasconline.com

Superior - Vision Insurance Customer Service.........................................................1-800-507-3800 Internet Address….........................................www.superiorvision.com

Medical or Dependent Care Customer Service……....1-800-422-4661 Fax Requests for Reimbursements…...........................1-608-663-2762

Directions for accessing account balances for Flexible Spending Accounts: 1. Go to www.tasconline.com 2. Log in using your TASC Participant ID and password 3. Click on Account Manager

North Carolina State Health Plan Customer Service.........................................................1-888-234-2416 Internet Address…........................................................http://shpnc.org

Harmony Online Enrollment See pages 4-5 for online enrollment instructions Technical Help Desk ...................................................1-866-875-4772

Optima Employee Assistance Program

To view your benefits online visit

Website……………………………………….www.OptimaEAP.com Website Username…………….……………Camden County Schools Phone…………………………………………………1-800-899-8174

www.piercegroupbenefits.com/ camdencountyschools or for additional information concerning plans offered to employees of Camden County Schools, please contact our North Carolina Service Center at 1-888-662-7500, ext. 100

Colonial Life Visit ColonialLife.com to set up your personal account. Download the free My Colonial Life app available at the Apple iTunes store to access claims and policy information! Customer Service & Wellness Screenings 1-800-325-4368 TDD for hearing impaired customers call 1-800-798-4040

Internet Address www.coloniallife.com

Claims Fax 1-800-880-9325

If you wish to file a Wellness/Cancer Screening claim for a test performed within the past 12 months, you need the name and date of the test performed as well as your doctor’s name and phone number. Colonial also needs to know if this is for you or another covered individual and their name and social security number. You may:  FILE BY PHONE! Call 1-800-325-4368 and provide the information requested by Colonial’s Automated Voice Response System, 24 hours per day, 7 days a week, or  SUBMIT ON THE INTERNET using the Wellness Claim Form at www.coloniallife.com, or  Write your name, address, social security number and/or policy/certificate number on your bill and indicate “Wellness Test.” Fax this to Colonial at 1-800-880-9325 or MAIL to PO Box 100195, Columbia, SC 29202 If your Wellness/Cancer Screening test was more than one year ago, you must fax or mail Colonial a copy of the bill or statement from your doctor indicating the type of procedure performed, the charge incurred and the date of service. Please write your full name, social security number, and current address on the bill. Please Note: If your cancer policy includes a second part to the screening benefit, bills for tests covered and a copy of the diagnostic report (reflecting the abnormal reading of your first test) must be mailed or faxed to us for benefits to be provided.

When you terminate employment with Camden County Schools, you have the opportunity to continue your Colonial coverage either through direct billing or automatic payment through your bank account. Please contact Colonial at 1-800-325-4368 to request the continuation of benefits form.