Eliada Homes 2022 Booklet 22-23PY by Pierce Group Benefits

EMPLOYEE BENEFITS PLAN www.piercegroupbenefits.com PLAN YEAR: December 1, 2022 - November 30, 2023 ARRANGED BY: Pierce Group Benefits ELIADA HOMES

Welcome to the Eliada Homes comprehensive benefits program. This booklet highlights the benefits offered to all eligible employees for the plan year listed below. Benefits described in this booklet are voluntary, employee-paid benefits unless otherwise noted. page 2 ENROLLMENT PERIOD: OCTOBER 31, 2022 - NOVEMBER 11, 2022 EFFECTIVE DATES: DECEMBER 1, 2022 - NOVEMBER 30, 2023 Benefits Plan Overview page 83 page 81 page 82 Authorization Form Notice Of Insurance Information Practices Continuation Of Coverage for Benefits Form page 80 Additional Benefits Available page 9 Health Benefits EMPLOYEE BENEFITS GUIDE TABLE OF CONTENTS page 5 Online Enrollment Instructions page 21 page 30 Dental Benefits Vision Benefits page 33 Group Term Life Insurance page 40 Flexible Spending Accounts page 44 Cancer Benefits page 49 Critical Illness Benefits page 58 Disability Benefits page 64 page 68 page 75 Accident Benefits Medical Bridge Benefits Life Insurance page 18 Health Reimbursement Arrangement page 20 Employee Assistance Program Pet Insurance page 79

ENROLLMENT PERIOD: OCTOBER 31, 2022 - NOVEMBER 11, 2022 EFFECTIVE DATES: DECEMBER 1, 2022 - NOVEMBER 30, 2023 ELIADA HOMES PRE-TAX & POST-TAX BENEFITS PRE-TAX BENEFITS Health Insurance BlueCross BlueShield POST-TAX BENEFITS *EMPLOYEES WILL NEED TO RE-ENROLL IN VISION IN ORDER TO CONTINUE COVERAGE FOR THE NEW PLAN YEAR BEGINNING DECEMBER 1, 2022. Vision Insurance* EyeMed Dental Insurance MetLife **You will need to re-enroll in the Flexible Spending Accounts if you want them to continue next year. •Medical Reimbursement FSA Maximum: $2,850/year | Minimum: $100/year •Dependent Care Reimbursement FSA Maximum: $5,000/year Flexible Spending Accounts** Ameriflex Cancer Benefits Colonial Life Medical Bridge Benefits Colonial Life Accident Benefits Colonial Life Critical Illness Benefits Colonial Life Group Term Life Insurance The Hartford Employer-Paid Benefit Life Insurance Colonial Life •Term Life Insurance •Whole Life Insurance Short-Term Disability Benefits Colonial Life Long-Term Disability Benefits The Hartford Employer-Paid Benefit Pet Insurance Nationwide 2

QUALIFICATIONS & IMPORTANT INFO THINGS YOU NEED TO KNOW

QUALIFICATIONS:

•Employees must work 30 hours or more per week.

IMPORTANT FACTS:

•The plan year for BlueCross BlueShield Health, MetLife Dental, EyeMed Vision, The Hartford Group Term Life, Spending Accounts, Colonial Insurance products, and The Hartford Long-Term Disability lasts from December 1, 2022 through November 30, 2023. Please Note: Dental beneﬁts are based on the Calendar Year, running from January 1st through December 31st. Dental beneﬁts and deductibles will reset every January 1st.

•Deductions for BlueCross BlueShield Health, MetLife Dental, EyeMed Vision, Spending Accounts, Colonial Insurance products, and The Hartford Voluntary Group Term Lifewill begin December 2022. The Hartford Basic Group Term Life and The Hartford Long-Term Disability plans are provided by your employer.

•Your employer offers an Employee Assistance Program (EAP) for you and your eligible family members. An EAP is an employer-sponsored benefit that offers confidential support and resources for personal or work-related challenges and concerns. Please see the EAP pages of this benefit booklet for more details and contact information.

•If signing up for any coverage on your spouse and/or children, please have their dates of birth and social security numbers available when speaking 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. 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.

•Flexible Spending Account expenses must be incurred during the Plan Year in order to be eligible for reimbursement.

•An employee has 3 months after the plan year ends to submit claims for spending account 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 3 months after the termination date to submit claims.

•With Dependent Care Flexible Spending Accounts, the maximum reimbursement you can request is equal to the current account balance in your Dependent Care account. You cannot be reimbursed more than has actually been deducted from your pay.

•As a married couple, one spouse cannot be enrolled in a Medical Reimbursement FSA at the same time the other opens or contributes to an HSA.

•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 December 31, 2022.

•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 Beneﬁt Administrator for more information.

ELIADA HOMES

IN PERSON

During your open enrollment period, a Pierce Group Beneﬁts representative will be available by appointment to answer any questions you may have and to assist you in the enrollment process.

ONLINE

You may enroll or make changes online to your beneﬁts plan. To enroll online, please see the information below and on the following pages.

•Enroll in, change or cancel Health Insurance.

•Enroll in, change or cancel Dental Insurance.

•Enroll in, change or cancel Vision Insurance (must re-enroll to continue coverage)*.

•Enroll in, change or cancel Group Term Life Insurance.

•Enroll in, change or cancel Long-Term Disability Insurance.

•Enroll/Re-Enroll in Flexible Spending Accounts (Medical Reimbursement and Dependent Care)

•Enroll in, change or cancel Colonial coverage (see the following pages for enrollments/changes that can be completed online).

⁺You will need to re-enroll in the Flexible Spending Accounts if you want them to continue each year.

*EMPLOYEES WILL NEED TO MEET WITH A BENEFITS REPRESENTATIVE TO RE-ENROLL IN VISION BENEFITS IN ORDER TO CONTINUE COVERAGE FOR THE NEW PLAN YEAR BEGINNING DECEMBER 1, 2022.

• CANCER ASSIST - You may enroll online in Cancer Assist coverage.

• DISABILITY - EDUCATOR DISABILITY ADVANTAGE (EDA1100) - You may enroll online in Cancer Assist coverage.

• 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 should speak with the Beneﬁts Representative.

• MEDICAL BRIDGE - You may enroll online in Medical Bridge coverage.

• CRITICAL ILLNESS 6000 - You may enroll online in Critical Illness 6000 coverage.

• TERM LIFE 5000 - You may enroll online in Term Life 5000; however, employees wishing to purchase an individual policy for their spouse should speak with the Beneﬁts Representative.

• WHOLE LIFE 5000 Plus - You may enroll online in Whole Life 5000 Plus; however, employees wishing to purchase an individual policy for their spouse should speak with the Beneﬁts Representative.

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.

EMPLOYEE BENEFITS GUIDE

ACCESS YOUR BENEFITS ONLINE WHENEVER, WHEREVER.

ENROLLMENT PERIOD: OCTOBER 31, 2022 - NOVEMBER 11, 2022

IMPORTANT NOTE & DISCLAIMER Beneﬁts Details | Educational Videos | Download Forms | Online Chat with Service Center

To view your personalized benefits website, go to: www.piercegroupbenefits.com/EliadaHomes or piercegroupbenefits.com and click “Find Your Benefits”.

YOU CAN MAKE THE FOLLOWING BENEFIT ELECTIONS ONLINE DURING THE ENROLLMENT

PERIOD:

1.Overview

You will be able to use the Benefits Enterprise site to make your New Hire and/or Open Enrollment elections, view your current elections, make life event changes, update family and/or beneficiary information, access benefit materials (i.e. plan summary documents or forms), etc

2.

Accessing Benefits Enterprise

You will be able to access the Benefits Enterprise site directly from the Web Pay Employee Self Service Portal, by hovering over the Web Pay tab and selecting Enterprise Web Benefits from the dropdown options. You will not need a separate user ID or password when accessing the site via the Employee Self Service Portal.

For successful navigation of the site, do not use the back button in your internet browser, as this will automatically log you out of the site. To navigate through the site, use the navigation bar located at the top of the screen.

3. Making Your Benefit

Elections

From the homepage, click on Start Your Enrollment. If you do not see the Start Your Enrollment button, please contact your HR department.

The enrollment process consists of the following four steps. You will be taken through each step to make changes or confirm your information on file and choose your benefits for the new plan year.

1. Employee (Personal Information) 2. Family (Family Information) 3. Enroll 4. Confirm

VERIFY YOUR PERSONAL INFORMATION

Before beginning your enrollment, please verify the accuracy of all of your personal information (e.g., address, DOB, etc.). If you need to make any changes, please do so in your Employee Self Service Portal. All updates will reflect on this page within 24 hours. You can still move on with your enrollment. Verify that all information is accurate. When done, check I Agree at the bottom of the page and click Continue.

Any field that has an asterisk next to it is required.

VERIFY YOUR FAMILY INFORMATION

Please add all dependents that may be missing from the Family Information section before proceeding to the next section. To do this, click Add Dependents. When all of your family information is accurate, check I Agree and click Continue.

MAKING BENEFIT ELECTIONS

Below is a sample of what the Benefit Election screen will look like.

To review all available plan options, click the View Plan Options link.

Before you are able to select a plan, select all dependents you wish to cover (the system will generate your coverage tier based on this) and click Continue. If you wish to add a new dependent at this time, click Add Dependents to the family tab and add the dependent.

From here, you can use the View All Plans Side by Side section to compare all available plans. Once you have chosen the plan you wish to enroll in, click Select to the corresponding plan.

After each election that you make, you will see a summary of your election.

Basic Employee Life

This is a benefit provided to you by your employer at no cost to you. You do not need to make an election here. You can use the View Information button to review any applicable plan information.

If you enrolled in a plan that requires beneficiary designation, you will be asked to do that now. Any dependents on file will be listed automatically as beneficiaries. Enter your designations. Your percentages must equal 100 percent. When complete, click Continue. If you would like to add another beneficiary, click Add Beneficiary

Almost Finished!

You will now be on the final review page. Review all of your benefit elections and covered dependents. If you wish to make any changes, simply click on any one of the Edit Selection buttons. It will return you to the enrollment page.

Once you have completed your review, check “I agree, and I’m finished with my enrollment” and “Complete Enrollment.” If you stop at any point before this step, your progress will be saved, but your enrollment is not complete.

CONFIRMATION

You can send yourself an email confirmation of your elections or print it for your records. Click the printer icon on the right hand side of the screen.

Note: Although the online benefits enrollment site is a secure site and your information is encrypted during transit, it is important that you log off when you have completed your session. Click the Log Off icon in the upper right hand corner of the enrollment site to do so. For security purposes, the system will automatically log you out if you leave your system idle for more than 30 minutes.

Blue Options with HRA Fund Benefit Highlights (PPO)

The amounts that appear on this benefit highlight represent Member responsibility.

Deductibles, Out-of-Pocket Limits & Benefit Maximums

The following Deductibles, Out-of-Pocket Limits, and Benefit Maximums apply to all services. All copays are before deductible, if applicable.

Embedded Deductibles

In-network Out-of-network 1

$5,000 $10,000 Family (per Benefit Period) $10,000 $20,000

Individual (per Benefit Period)

Embedded Out-of-Pocket Limits

Individual (per Benefit Period)

$8,700 $17,400 Family (per Benefit Period) $17,400 $34,800

Benefit Maximums:

Lifetime Total Dollar Maximum UnlimitedUnlimited

Lifetime Infertility Benefit Maximum Ovulation Induction Cycles3 Cycle Limits (with or without insemination, per Member, in all places of service)

Annual Benefit Maximums:

Maximums apply to Home, Office and Outpatient Settings only, unless otherwise indicated. Maximums include both Habilitative and Rehabilitative services unless otherwise indicated. All maximums are on a combined In- and Out-of-Network basis per Member, per Benefit Period.

Physical, Occupational and Chiropractic Therapies (combined) 30 visits

Speech Therapy 30 visits

Adaptive Behavior Treatment is covered for members up to age 19. $40,000 Skilled Nursing Facility Stay 60 days

Provider Office visits for the evaluation and treatment of obesity 4 visits (maximum does not apply to dietician/nutritional visits)

Nutritional Counseling Visits 30 visits

Physician Office Services

(See "Outpatient Services" for "outpatient clinic" or "hospital-based" services.)

Office Visit

Includes all Office Visits regardless of specialty or diagnosis (including medical, mental health, substance use disorder, infertility, therapies and pre-natal/postdelivery care unable to be included in the global delivery fee). Includes Office Surgery, Consultation, and X-rays, unless otherwise specified.

Primary Care Provider $25 50% after deductible Log in to Blue Connect to select your Primary Care Provider (PCP). Your copay is waived for your first 3 visits to your selected PCP.

Specialist $50 50% after deductible Mental Health and Substance Use Disorder $10 50% after deductible

Vendor Telehealth $10 Benefits not available Includes Telehealth services for medical/acute care/behavioral health

Preventive Care (Primary Preventive Diagnosis Only)

For the most updated list of general preventive/screenings, immunizations, wellbaby/well-child care, women’s preventive care services, nutritional counseling and other services mandated under Federal law, see our website at bluecrossnc.com/preventive.

State mandated services include colorectal screening, bone mass measurement, newborn hearing screening, prostate specific antigen tests (PSAs), gynecological exams, cervical cancer screening, ovarian cancer screening and screening mammograms.

Primary Care Provider

ELIADA

0% no deductible 30% after deductible

0% no deductible 30% after deductible Specialist

HOMES, INC. Prospect 348882, Quote 5883938 Effective Date: 12/2022 Quote Date: 06/16/2022

Blue Options with HRA Fund Benefit Highlights (PPO)

Urgent

In-network Out-of-network 1 Ambulance 30% after deductible 30% after deductible

and Emergency Care

Emergency Room Visit* $500 $500 Urgent Care Centers $50 $100

*If admitted to the hospital for inpatient or observation services your ER benefit will continue to apply until you are considered stable. Out-of-Network Emergency Room services are payable at the In-Network level and applied to the In-Network Out-of-Pocket Limit regardless of where they are obtained.

Inpatient Hospital Services

Includes all Inpatient Hospital Services regardless of diagnosis (including, but not limited to, medical, mental health, substance use disorder, infertility, therapies, transplants, deliveries, and surgeries.) You may receive a better benefit if you receive care at a Blue Distinction Center (BDC). Visit bluecrossnc.com/bdc to find a BDC.

Inpatient Hospital Facility Services 30% after deductible 50% after deductible Inpatient Hospital Professional Services 30% after deductible 50% after deductible

Outpatient Services

Hospital Based or Free-standing Facility Services 30% after deductible 50% after deductible (other than preventive services above)

Outpatient lab tests 30% after deductible 50% after deductible Outpatient Mammography 0% no deductible 30% after deductible Outpatient X-rays, ultrasounds, and other diagnostic tests 30% after deductible 50% after deductible such as EEGs and EKGs

Other Services

Skilled Nursing Facility 30% after deductible 50% after deductible Home Health Care and Hospice 30% after deductible 50% after deductible Durable Medical Equipment, Prosthetics and Orthotics 30% after deductible 50% after deductible CT scans, MRIs, MRAs and PET scans in any location, including30% after deductible 50% after deductible a physician's office

ELIADA HOMES, INC.

Prospect 348882, Quote 5883938 Effective Date: 12/2022 Quote Date: 06/16/2022

Blue Options with HRA Fund Benefit Highlights (PPO)

Prescription Drugs In-network Out-of-network 1 Preventive OTC Medications and Contraceptive 0% no deductible 0% no deductible Drugs and Devices as listed at bluecrossnc.com/preventive Up to 30 day supply is one copayment. 31-60 day supply is two copayments. 61-90 day supply is three copayments. Prescription Drug copayments*, coinsurance* and deductibles* (*if applicable) apply to the Out-of-Pocket limit.

MAC B Pricing (Brand Penalty when Generic Equivalent is available and Provider does not require Brand to be dispensed). Essential 5 Tier Commercial, Limited NC Network Formulary. Prior Plan approval, step therapy and quantity limits may apply.

Tier 1 Drugs $10 $10

Tier 2 Drugs $25 $25

Tier 3 Drugs $40 $40

Tier 4 Drugs $80 $80

Tier 5 Drugs 25% 25%

There is a $100 per Prescription Minimum and a $200 per Prescription Maximum for each 30-day supply of Tier 5 drugs. You are responsible for charges over the allowed amount received from an Out-of-Network pharmacy. Limits apply to Infertility drugs, refer to your benefit booklet.

1NOTICE:

Your actual

for covered services may exceed the stated coinsurance

or co-payment amount because actual

ELIADA HOMES, INC. Prospect 348882, Quote 5883938 Effective Date: 12/2022 Quote Date: 06/16/2022 Employee Only Employee + Spouse Employee + Child(ren) Employee + Family Employee Portion $185.18 $651.99 $598.89 $848.75 Employer Portion $330.00 $330.00 $330.00 $330.00 Total $515.18 $981.99 $928.89 $1,178.75 11

expenses

percentage

provider charges may not be used to determine the payment obligations for Blue Cross NC and its members.

Benefit Period

The period of time, usually 12 months as stated in the group contract, during which charges for covered services provided to a member must be incurred in order to be eligible for payment by Blue Cross NC. A charge shall be considered incurred on the date the service or supply was provided to a member.

Allowed Amount

The maximum amount that Blue Cross NC determines is to be paid for covered services provided to a member.

Out-of-Pocket Limit

The dollar amount you pay for covered services in a benefit period before Blue Cross NC pays 100% of covered services. It includes deductible, coinsurance and copayments. It does not include charges over the allowed amount, premiums, and charges for non-covered services.

Utilization Management

To make sure you have access to high quality, cost-effective health care, we manage utilization through a variety of programs including certification, transplant management, concurrent and retrospective review. If you have a concern regarding the final determination of your care, you have the right to appeal the decision. For further information about our Utilization Management programs, please refer to your benefit booklet.

Certification

Certification is a program designed to make sure that your care is given in a cost effective setting and efficient manner. If you need to be hospitalized, you must obtain certification. Nonemergency and non-maternity hospital admissions must be certified prior to the hospitalization. If the admission is not certified, the claim will be denied.

For maternity admissions, your provider is not required to obtain certification from Blue Cross NC for prescribing a length of stay up to 48 hours for a normal vaginal delivery, or up to 96 hours for delivery by cesarean section. You or your provider must request certification for coverage for additional days, which will be given by Blue Cross NC, if medically necessary.

All inpatient and certain outpatient Mental Health and Substance Use Disorder services and all Adaptive Behavior Treatment must be certified in advance by Blue Cross NC or services will not be covered. Call Blue Cross NC at 1-800-359-2422. Mental Health and Substance Use Disorder office visits do not require certification. In-network providers in North Carolina are responsible for obtaining certifications. The member will bear no financial penalties if the innetwork provider in North Carolina fails to obtain the appropriate authorization. The member is responsible for obtaining certification for services rendered by an out-of-network provider in North Carolina or by any provider outside of North Carolina.

Health and Wellness Program

Because we want to help you stay healthy, we offer a variety of wellness benefits and services. You can take advantage of the Health Line Blue, our 24-hour free nurse support line, a health topics library, chronic condition management and a prenatal program. You will also have access to online health and wellness tools and trackers at BlueConnectNC.com. With our program you can get health advice anytime you need it, so you can learn how to take charge of your health.

What is Not Covered?

The following are summaries of some of the coverage restrictions. A full explanation and listing of restrictions will be found in your benefit booklet.

Your health benefit plan does not cover services, supplies, drugs or charges that are:

Not medically necessary

For injury or illness resulting from an act of war

For personal hygiene and convenience items

For inpatient admissions that are primarily for diagnostic studies

For palliative or cosmetic foot care

For investigative or experimental purposes

For hearing aids or tinnitus maskers, except as specifically covered by the benefit plan

For cosmetic services or cosmetic surgery

For custodial care, domiciliary care or rest cures

For treatment of obesity, except for surgical treatment of morbid obesity, or as specifically covered by your health benefit plan

For reversal of sterilization

For treatment of sexual dysfunction not related to organic disease

For assisted reproductive technologies as defined by the Centers for Disease Control and Prevention

For self-injectable drugs in the provider's office

Weight Loss Drugs

Embedded Deductible Definition

Members must meet their individual deductible before benefits are payable under the health benefit plan. However, once the family deductible is met, all covered family members will be in benefit. Any member who meets their individual Out-Of-Pocket Limit will have the benefit levels apply to them only and not the entire family. However, once the family Out-Of-Pocket Limit is met, the benefit levels will apply to the entire family.

Plan codes: PB90813 R063291 MP90016 SP90016 C003300 V000100 D000100

Facets codes: MED-FS005417 (base) DRU-BR002735 (base)

arrangement: ee, ee+spouse, ee+children, fam

ADDITIONAL INFORMATION ABOUT BLUE OPTIONS with HRA Fund

Billing

®, SM Registration and Service marks of the Blue Cross and Blue Shield Association Blue Cross NC is an Independent licensee of the Blue Cross and Blue Shield Association ELIADA HOMES, INC. Prospect 348882, Quote 5883938 Effective Date: 12/2022 Quote Date: 06/16/2022

Blue Options 1-2-3 with HRA Fund Benefit Highlights (PPO)

The amounts that appear on this benefit highlight represent Member responsibility.

Deductibles, Out-of-Pocket Limits & Benefit Maximums

The following Deductibles, Out-of-Pocket Limits, and Benefit Maximums apply to all services. All copays are before deductible, if applicable.

Embedded Deductibles

In-network Out-of-network 1

$5,000 $10,000 Family (per Benefit Period) $10,000 $20,000

Individual (per Benefit Period)

Embedded Out-of-Pocket Limits

Individual (per Benefit Period) $8,700 $17,400 Family (per Benefit Period) $17,400 $34,800

Benefit Maximums:

Lifetime Total Dollar Maximum UnlimitedUnlimited

Lifetime Infertility Benefit Maximum Ovulation Induction Cycles3 Cycle Limits (with or without insemination, per Member, in all places of service)

Annual Benefit Maximums:

Physical, Occupational and Chiropractic Therapies (combined) 30 visits

Speech Therapy 30 visits

Adaptive Behavior Treatment is covered for members up to age 19. $40,000

Skilled Nursing Facility Stay 60 days

Provider Office visits for the evaluation and treatment of obesity 4 visits (maximum does not apply to dietician/nutritional visits)

Nutritional Counseling Visits 30 visits

Preventive Care (See hospital based clinics-Level 3) (Primary Preventive Diagnosis Only)

For the most updated list of general preventive/screenings, immunizations, well-baby/well-child care, women's preventive care services, nutritional counseling and other services mandated under Federal law, see our website at bluecrossnc.com/preventive.

Primary Care Provider 0% no deductible 30% after deductible Specialist 0% no deductible 30% after deductible

Primary Care Office-based Services

Includes all Office Visits regardless of diagnosis (including medical, mental health, substance use disorder, therapies and pre-natal/post-delivery care unable to be included in the global delivery fee).

Includes Office Surgery, Consultation, X-rays and Labs. For these services provided by a specialist, see Level 3 Benefits.

Primary Care Provider $25 60% after deductible

Log in to Blue Connect to select your Primary Care Provider (PCP). Your copay is waived for your first 3 visits to your selected PCP. Vendor Telehealth $10 Benefits not available

Includes Telehealth services for medical/acute care/behavioral health

ELIADA HOMES, INC.

Prospect 348882, Quote 5883950 Effective Date: 12/2022 Quote Date: 06/16/2022

Level 1 In-network Out-of-network 1

Blue Options 1-2-3 with HRA Fund Benefit Highlights (PPO)

The amounts that appear on this benefit highlight represent Member responsibility.

Deductibles, Out-of-Pocket Limits & Benefit Maximums

The following Deductibles, Out-of-Pocket Limits, and Benefit Maximums apply to all services. All copays are before deductible, if applicable.

Embedded Deductibles

In-network Out-of-network 1

$5,000 $10,000 Family (per Benefit Period) $10,000 $20,000

Individual (per Benefit Period)

Embedded Out-of-Pocket Limits

Individual (per Benefit Period) $8,700 $17,400 Family (per Benefit Period) $17,400 $34,800

Benefit Maximums:

Lifetime Total Dollar Maximum UnlimitedUnlimited

Lifetime Infertility Benefit Maximum Ovulation Induction Cycles3 Cycle Limits (with or without insemination, per Member, in all places of service)

Annual Benefit Maximums:

Physical, Occupational and Chiropractic Therapies (combined) 30 visits

Speech Therapy 30 visits

Adaptive Behavior Treatment is covered for members up to age 19. $40,000

Skilled Nursing Facility Stay 60 days

Provider Office visits for the evaluation and treatment of obesity 4 visits (maximum does not apply to dietician/nutritional visits)

Nutritional Counseling Visits 30 visits

Preventive Care (See hospital based clinics-Level 3) (Primary Preventive Diagnosis Only)

Primary Care Provider 0% no deductible 30% after deductible Specialist 0% no deductible 30% after deductible

Primary Care Office-based Services

Includes Office Surgery, Consultation, X-rays and Labs. For these services provided by a specialist, see Level 3 Benefits.

Primary Care Provider $25 60% after deductible

Log in to Blue Connect to select your Primary Care Provider (PCP). Your copay is waived for your first 3 visits to your selected PCP. Vendor Telehealth $10 Benefits not available

Includes Telehealth services for medical/acute care/behavioral health

ELIADA HOMES, INC.

Prospect 348882, Quote 5883950 Effective Date: 12/2022 Quote Date: 06/16/2022

Level 1 In-network Out-of-network 1

Blue Options 1-2-3 with HRA Fund Benefit Highlights (PPO)

Level 2

Inpatient Hospital Services

Hospital and Hospital Based Services

Inpatient Professional Services

In-network Out-of-network 1

$250 per admission, then$500 per admission, then 30% after deductible 60% after deductible

Professional Services 30% after deductible 60% after deductible Skilled Nursing Facility 30% after deductible 60% after deductible Home Health Care and Hospice Care 30% after deductible 60% after deductible

Level 3 In-network Out-of-network 1

Specialist Office-Based Services

Professional Services50% after deductible60% after deductible Specialist Outpatient Facility-Based Service

Professional Services50% after deductible60% after deductible Urgent Care Center $100$200 Emergency Room Visit* 50% after deductible *If admitted to the hospital for inpatient or observation services your ER benefit will continue to apply until you are considered stable. Out-of-Network Emergency Room services are payable at the In-Network level and applied to the In-Network Out-ofPocket Limit regardless of where they are obtained.

Outpatient Services 50% after deductible60% after deductible

Includes hospital and hospital-based services, hospital based clinics, surgery, and outpatient diagnostic services such as lab tests, X-rays, ultrasounds, and other diagnostic tests, such as EEGs, EKGs, pulmonary function tests, rehabilitative, habilitative and other therapies.

Outpatient Diagnostic Services

Outpatient lab tests, in any location including physician's office50% after deductible60% after deductible 50% after deductible60% after deductible CT scans, MRIs, MRAs and PET scans in any location, including physician’s office, Durable Medical Equipment, Home Infusion Therapy, Medical Supplies, Orthotic Devices and Prosthetic Appliances

Ambulance 50% after deductible50% after deductible

ELIADA HOMES, INC.

Prospect 348882, Quote 5883950 Effective Date: 12/2022 Quote Date: 06/16/2022

Blue Options 1-2-3 with HRA Fund Benefit Highlights (PPO)

Tier 1 Drugs $10 $10

Tier 2 Drugs $25 $25

Tier 3 Drugs $40 $40

Tier 4 Drugs $80 $80

Tier 5 Drugs 25% 25% There is a $100 per Prescription Minimum and a $200 per Prescription Maximum for each 30-day supply of Tier 5 drugs. You are responsible for charges over the allowed amount received from an Out-of-Network pharmacy. Limits apply to Infertility drugs, refer to your benefit booklet.

1NOTICE:

Your actual expenses for covered services may

the

co-payment

ELIADA HOMES, INC. Prospect 348882, Quote 5883950 Effective Date: 12/2022 Quote Date: 06/16/2022 Employee Only Employee + Spouse Employee + Child(ren) Employee + Family Employee Portion $117.91 $523.77 $477.61 $649.84 Employer Portion $330.00 $330.00 $330.00 $330.00 Total $447.91 $853.77 $807.61 $1,024.84 16

exceed

stated coinsurance percentage or

amount because actual provider charges may not be used to determine the payment obligations for Blue Cross NC and its members.

Benefit Period

Allowed Amount

The maximum amount that Blue Cross NC determines is to be paid for covered services provided to a member.

Out-of-Pocket Limit

Utilization Management

Certification

Health and Wellness Program

What is Not Covered?

The following are summaries of some of the coverage restrictions. A full explanation and listing of restrictions will be found in your benefit booklet.

Your health benefit plan does not cover services, supplies, drugs or charges that are:

Not medically necessary

For injury or illness resulting from an act of war

For personal hygiene and convenience items

For inpatient admissions that are primarily for diagnostic studies

For palliative or cosmetic foot care

For investigative or experimental purposes

For hearing aids or tinnitus maskers, except as specifically covered by the benefit plan

For cosmetic services or cosmetic surgery

For custodial care, domiciliary care or rest cures

For treatment of obesity, except for surgical treatment of morbid obesity, or as specifically covered by your health benefit plan

For reversal of sterilization

For treatment of sexual dysfunction not related to organic disease

For assisted reproductive technologies as defined by the Centers for Disease Control and Prevention

For self-injectable drugs in the provider's office

Weight Loss Drugs

Embedded Deductible Definition

Plan codes: PT70233 R063291 MTI1900 STI1900 C000100 V000100 D000100

codes: MED-FS004093 (base) DRU-BR002735 (base)

arrangement: ee, ee+spouse, ee+children, fam

ADDITIONAL INFORMATION ABOUT BLUE OPTIONS 1-2-3 with HRA Fund

Facets

Billing

Health Reimbursement Arrangement (“HRA

Your HRA is integrated with your BCBSNC Health Plan and is provided by Health Equity.

Health Equity

Customer Service: 1-866-346-5800 Website: www.myhealthequity.com

I.Eligibility

What are the eligibility requirements for this HRA?

You will be automatically enrolled in the HRA when you enroll in the Employer’s group medical plan, unless you have opted out of the HRA.

When is my Entry Date?

Your entry date is the date you satisfy the eligibility requirements of and enroll in the Employer’s group medical plan.

II. Benefits

How are payments made from the HRA?

The group Health Plan Carrier will submit requests for reimbursement of expenses you have incurred during the course of a Coverage Period for Qualified Medical Expenses as described in Appendix A. All claims need to be submitted for reimbursements no later than 90 days after the end of the Coverage Period (that is, no later than 02/28). If the request qualifies as a benefit or expense that the HRA has agreed to pay, the claims processor will pay your Provider direct. You are responsible to pay your Provider for any expenses not covered by this HRA.

Remember, reimbursements made from the HRA are generally not subject to federal income tax or withholding, nor are they subject to Social Security taxes.

What happens if I terminate employment?

If your employment is terminated during the Plan Year for any reason, your participation in the HRA will cease on the date of your termination, and you will not be eligible to be reimbursed for any expenses incurred past that date. You must submit claims for any expenses incurred prior to your termination of employment within 90 days after you terminate employment. Any unused amounts will be forfeited.

Health Reimbursement Arrangement (“HRA

HRA Plan Benefit

Employee Class

• Individual

Qualified benefits

• Deductible- Medical Plan Coverage

• Medical

Reimbursement Schedule

• First, the Employee will pay $2,500.00 of qualifying expenses.

• Last, the HRA will pay $2,500.00 of qualifying expenses up to the max benefit limit of $2,500.00.

Unused HRA Funds

• Unused benefits at the end of the coverage period shall be forfeited.

HRA Plan Benefit

Employee Class

• Employee Plus One and Family

Qualified benefits

• Deductible- Medical Plan Coverage

• Medical

Reimbursement Schedule

• First, the Employee will pay $5,000.00 of qualifying expenses.

• Last, the HRA will pay $5,000.00 of qualifying expenses up to the max benefit limit of $5,000.00.

Unused HRA Funds

• Unused benefits at the end of the coverage period shall be forfeited.

") 19

MyLifeExpert Our work/life portal gives members access to thousands of up-to-date, topic relatedarticles,videos,podcasts, calculators, interactive checklists, webinars, and more related to: ▪ Financial & Legal ▪ Child Care & Education ▪ Eldercare ▪ Health & Wellness ▪ Career & Military ▪ Everyday Living and more… Available in English, Spanish and French Health&Lifestyle Assessments 50+ Soft Skills Courses Financial Calculators Nationwide Resources 24/7/365 Support Members have instant, confidential, 24/7/365 support to get access to the help they need all in the palm of their hand. Help is a one call or click away! Create your account at MyLifeExpert.com today! Scan Hereto Download: Use companycode: ELIADA NCE 20

Dental

Metropolitan Life Insurance Company

Plan Design for: Eliada Homes Inc

Original Plan Effective Date: December 1, 2022

Network: PDP Plus

The Preferred Dentist Program was designed to help you get the dental care you need and help lower your costs. You get benefits for a wide range of covered services both in and out of the network. The goal is to deliver cost effective protection for a healthier smile and a healthier you.

In-Network1

Out-of-Network1 High Plan

Coverage Type: In-Network % of Negotiated Fee2

Out-of-Network1 % of R&C Fee4

Type A Preventive 100% 100%

Type B Basic Restorative 80% 80%

Type C Major Restorative 50% 50%

Type D Orthodontia NA NA

Deductible3

Individual $50 $50 Family $150 $150

Annual Maximum Benefit: Per Individual $2250 $2250

Dependent Age: Eligible for benefits until the day that he or she turns 26.

Low Plan

Coverage Type: In Network % of Negotiated Fee2

Out of Network1 % of R&C Fee4

Type A Preventive 100% 100%

Type B Basic Restorative 80% 80%

Type C Major Restorative 0% 0%

Type D Orthodontia NA NA

Deductible3

Individual $50 $50 Family $150 $150

Annual Maximum Benefit: Per Individual $1250 $1250

Dependent Age: Eligible for benefits until the day that he or she turns 26.

1 "In Network Benefits" means benefits provided under this plan for covered dental services that are provided by a MetLife PDP dentist. "Out of Network Benefits" means benefits provided under this plan for covered dental services that are not provided by a MetLife PDP dentist. Utilizing an out of network dentist for care may cost you more than using an in network dentist.

2 Negotiated fees refer to the fees that participating dentists have agreed to accept as payment in full for covered services, subject to any copayments, deductibles, cost sharing and benefits maximums. Negotiated fees are subject to change.

High Plan

3. Applies to Type B and C services only.

4. Out of network benefits are payable for services rendered by a dentist who is not a participating provider. The Reasonable and Customary charge is based on the lowest of:

• the dentist’s actual charge (the 'Actual Charge'),

• the dentist’s usual charge for the same or similar services (the 'Usual Charge') or

• the usual charge of most dentists in the same geographic area for the same or similar services as determined by MetLife (the 'Customary Charge'). For your plan, the Customary Charge is based on the 90th percentile. Services must be necessary in terms of generally accepted dental standards.

Low Plan

3. Applies to Type B and C services only.

4. Out of network benefits are payable for services rendered by a dentist who is not a participating provider. The Reasonable and Customary charge is based on the lowest of:

• the dentist’s actual charge (the 'Actual Charge'),

• the dentist’s usual charge for the same or similar services (the 'Usual Charge') or

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Understanding Your Dental Benefits Plan

The Preferred Dentist Program is designed to provide the dental coverage you need with the features you want. Like the freedom to visit the dentist of your choice in or out of the network. .

If you receive in network services, you will be responsible for any applicable deductibles, cost sharing, negotiated charges after benefit maximums are met, and costs for non covered services. If you receive out of network services, you will be responsible for any applicable deductibles, cost sharing, charges in excess of the benefit maximum, charges in excess of the negotiated fee schedule amount or R&C Fee, and charges for non covered services.

• Plan benefits for in network covered services are based on a percentage of the Negotiated fee the Fee that participating dentists have agreed to accept as payment in full for covered services, subject to any deductibles, copayments, cost sharing and benefit maximums. Negotiated fees are subject to change.

• Plan benefits for out of network services are based on a percentage of the Reasonable and Customary (R&C) charge. If you choose a dentist who does not participate in the network, your out of pocket expenses may be greater.

Once you’re enrolled you may take advantage of online self-service capabilities with MyBenefits.

• Check the status of your claims

• Locate a participating dentist

• Access MetLife’s Oral Health Library

• Elect to view your Explanation of Benefits online

To register, just go to www.metlife.com/mybenefits and follow the easy registration instructions.

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IMPORTANT RATE INFORMATION

High Plan

Monthly Premium Payment

Low Plan

Monthly Premium Payment

Employee $37.48 Employee $21.52

Employee+Spouse $69.84 Employee+Spouse $41.60

Employee + Child(ren) $82.08 Employee + Child(ren) $52.20 Employee + Family $119.68 Employee + Family $76.08

Cancellation/Termination of Benefits:

Coverage is provided under a group insurance policy (Policy form GPN99) issued by Metropolitan Life Insurance Company. Subject to the terms of the group policy, rates are effective for one year from your plan's effective date. Once coverage is issued, the terms of the group policy permit Metropolitan Life Insurance Company to change rates during the year in certain circumstances. Coverage terminates when your full time employment ceases, when your dental contributions cease or upon termination of the group policy by the Policyholder. The group policy may also terminate if participation requirements are not met, or on the date of the employee’s death, if the Policyholder fails to perform any obligations under the policy, or at MetLife's option. The dependent's coverage terminates when a dependent ceases to be a dependent. There is a 30 day limit for the following services that are in progress: Completion of a prosthetic device, crown or root canal therapy after individual termination of coverage.

IMPORTANT ENROLLMENT INFORMATION

You may only enroll for Dental Expense Benefits within 31 days of your Personal Benefits Eligibility Date, or if you have a Qualifying Event or during the Plan's Annual Open Enrollment Period.

Qualifying Event: Request to be covered, or to change your coverage, upon a Qualifying Event If there is a Qualifying Event you may request to be covered, or to change your coverage, for Personal Dental Expense Benefits only within 31 days of a Qualifying Event. Such a request will not be a late request. Except for marriage or the birth or adoption of a child, you must give us proof of prior dental coverage under your spouse's plan if you are requesting coverage under This Plan because of a loss of the prior dental coverage. If you make a request to be covered for Personal Dental Expense Benefits or a request for change(s)in Personal Dental Expense Benefits within thirty one days of a Qualifying Event, your Personal Dental Expense Benefits or the change(s) in Personal Dental Expense Benefits will become effective on the first day of the month following the date of your request, subject to the Active Work Requirement, and provided that the change in coverage is consistent with your new family status.

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Selected Covered Services and Frequency Limitations*

High Plan

Type A - Preventive

Oral Examinations

1 in 6 months

Full Mouth X rays 1 in 5 years

Bitewing X rays (Adult/Child) 1 in a year

Prophylaxis Cleanings 1 in 6 months

Topical Fluoride Applications 1 in a year Children to age 19 Sealants 1 in 3 years Children to age 19

Space Maintainers No limit Children up to age 19 Harmful Habits Appliances

How Many/How Often:

Type B - Basic Restorative How Many/How Often:

Amalgam and Composite Fillings No Limit.

Prefabricated Crowns 1 per tooth in 24 months Repairs 1 in 12 months

Periodontal Maintenance 4 in 1 year, includes 2 cleanings

Oral Surgery (Simple Extractions) Emergency Palliative Treatment General Anesthesia Consultations 1 in 12 months

Type C - Major Restorative

Crowns/Inlays/Onlays 1 per tooth in 10 years

Endodontics Root Canal 1 per tooth in 24 months

Periodontal Surgery 1 in 36 months per quadrant

Periodontal Scaling & Root Planing 1 in 24 months per quadrant

Oral Surgery (Surgical Extractions)

Other Oral Surgery Bridges 1 in 10 years Dentures 1 in 10 years

How Many/How Often:

Implant Services 1 service per tooth in 10 years 1 repair per 12 months

*Alternate Benefits: Where two or more professionally acceptable dental treatments for a dental condition exist, reimbursement is based on the least costly treatment alternative. If you and your dentist have agreed on a treatment that is more costly than the treatment upon which the plan benefit is based, you will be responsible for any additional payment responsibility. To avoid any misunderstandings, we suggest you discuss treatment options with your dentist before services are rendered, and obtain a pretreatment estimate of benefits prior to receiving certain high cost services such as crowns, bridges or dentures. You and your dentist will each receive an Explanation of Benefits (EOB) outlining the services provided, your plan’s reimbursement for those services, and your out of pocket expense. Actual payments may vary from the pretreatment estimate depending upon annual maximums, plan frequency limits, deductibles and other limits applicable at time of payment.

The service categories and plan limitations shown above represent an overview of your Plan of Benefits. This document presents many services within each category, but is not a complete description of the Plan. Please see your Plan description/Insurance certificate for complete details. In the event of a conflict with this summary, the terms of your insurance certificate will govern.

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Low Plan

Type A - Preventive

Oral Examinations 1 in 6 months

Full Mouth X rays 1 in 5 years

Bitewing X rays (Adult/Child) 1 in a year

Prophylaxis Cleanings 1 in 6 months

Topical Fluoride Applications 1 in a year Children to age 19 Sealants 1 in 3 years Children to age 19

Space Maintainers No limit Children up to age 19 Harmful Habits Appliances

How Many/How Often:

Type B - Basic Restorative How Many/How Often:

Amalgam and Composite Fillings No Limit.

Prefabricated Crowns 1 per tooth in 24 months

Repairs 1 in 12 months

Periodontal Maintenance 4 in 1 year, includes 2 cleanings

Oral Surgery (Simple Extractions) Emergency Palliative Treatment General Anesthesia Consultations 1 in 12 months

Type C - Major Restorative How Many/How Often:

TYPE C SERVICES ARE NOT COVERED WITH THIS COVERAGE TYPE.

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Selected Covered Services and Frequency Limitations*

We will not pay Dental Insurance benefits for charges incurred for:

1 Services which are not Dentally Necessary, those which do not meet generally accepted standards of care for treating the particular dental condition, or which We deem experimental in nature;

2 Services for which You would not be required to pay in the absence of Dental Insurance;

3 Services or supplies received by You or Your Dependent before the Dental Insurance starts for that person;

4 Services which are primarily cosmetic (For residents of Texas, see notice page section in your certificate).

5 Services which are neither performed nor prescribed by a Dentist except for those services of a licensed dental hygienist which are supervised and billed by a Dentist and which are for:

• scaling and polishing of teeth; or

• fluoride treatments.

For NY Sitused Groups, this exclusion does not apply.

6 Services or appliances which restore or alter occlusion or vertical dimension.

7 Restoration of tooth structure damaged by attrition, abrasion or erosion.

8 Restorations or appliances used for the purpose of periodontal splinting.

9 Counseling or instruction about oral hygiene, plaque control, nutrition and tobacco.

10 Personal supplies or devices including, but not limited to: water piks, toothbrushes, or dental floss.

11 Decoration, personalization or inscription of any tooth, device, appliance, crown or other dental work.

12 Missed appointments.

13 Services

• covered under any workers’ compensation or occupational disease law;

• covered under any employer liability law;

• for which the employer of the person receiving such services is not required to pay; or

• received at a facility maintained by the Employer, labor union, mutual benefit association, or VA hospital.

For North Carolina and Virginia Sitused Groups, this exclusion does not apply.

14 Services paid under any worker’s compensation, occupational disease or employer liability law as follows:

• for persons who are covered in North Carolina for the treatment of an Occupational Injury or Sickness which are paid under the North Carolina Workers’ Compensation Act only to the extent such services are the liability of the employee, employer or workers’ compensation insurance carrier according to a final adjudication under the North Carolina Workers’ Compensation Act or an order of the North Carolina Industrial Commission approving a settlement agreement under the North Carolina Workers’ compensation Act;

• or for persons who are not covered in North Carolina, services paid or payable under any workers compensation or occupational disease law.

This exclusion only applies for North Carolina Sitused Groups.

15 Services:

• for which the employer of the person receiving such services is required to pay; or

• received at a facility maintained by the Employer, labor union, mutual benefit association, or VA hospital.

This exclusion only applies for North Carolina Sitused Groups.

16 Services covered under any workers' compensation, occupational disease or employer liability law for which the employee/or Dependent received benefits under that law.

This exclusion only applies for Virginia Sitused Groups.

17 Services:

• for which the employer of the person receiving such services is not required to pay; or

• received at a facility maintained by the policyholder, labor union, mutual benefit association, or VA hospital.

This exclusion only applies for Virginia Sitused Groups.

18 Services covered under other coverage provided by the Employer.

19 Temporary or provisional restorations.

20 Temporary or provisional appliances.

21 Prescription drugs.

22 Services for which the submitted documentation indicates a poor prognosis.

23 The following when charged by the Dentist on a separate basis:

• claim form completion;

• infection control such as gloves, masks, and sterilization of supplies; or

• local anesthesia, non intravenous conscious sedation or analgesia such as nitrous oxide.

24 Dental services arising out of accidental injury to the teeth and supporting structures, except for injuries to the teeth due to chewing or biting of food.

For NY Sitused Groups, this exclusion does not apply.

25 Caries susceptibility tests.

26 Initial installation of a fixed and permanent Denture to replace one or more natural teeth which were missing before such person was insured for Dental Insurance, except for congenitally missing natural teeth.

27. Other fixed Denture prosthetic services not described elsewhere in this certificate.

28. Precision attachments, except when the precision attachment is related to implant prosthetics.

29 Initial installation or replacement of a full or removable Denture to replace one or more natural teeth which were missing before such person was insured for Dental Insurance, except for congenitally missing natural teeth.

30 Addition of teeth to a partial removable Denture to replace one or more natural teeth which were missing before such person was insured for Dental Insurance, except for congenitally missing natural teeth.

31 Adjustment of a Denture made within 6 months after installation by the same Dentist who installed it.

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32 Implants to replace one or more natural teeth which were missing before such person was insured for Dental Insurance, except for congenitally missing natural teeth.

33 Implants supported prosthetics to replace one or more natural teeth which were missing before such person was insured for Dental Insurance, except for congenitally missing natural teeth.

34 Appliances or treatment for bruxism (grinding teeth), including but not limited to occlusal guards and night guards.1

35. Diagnosis and treatment of temporomandibular joint (TMJ) disorders. This exclusion does not apply to residents of Minnesota.1

36. Repair or replacement of an orthodontic device.1

37 Duplicate prosthetic devices or appliances.

38 Replacement of a lost or stolen appliance, Cast Restoration, or Denture.

39 Intra and extraoral photographic images.

40 Services or supplies furnished as a result of a referral prohibited by Section 1 302 of the Maryland Health Occupations Article. A prohibited referral is one in which a Health Care Practitioner refers You to a Health Care Entity in which the Health Care Practitioner or Health Care Practitioner’s immediate family or both own a Beneficial Interest or have a Compensation Agreement. For the purposes of this exclusion, the terms “Referral”, “Health Care Practitioner” , “Health Care Entity”, “Beneficial Interest” and Compensation Agreement have the same meaning as provided in Section 1 301 of the Maryland Health Occupations Article.

This exclusion only applies for Maryland Sitused Groups

1Some of these exclusions may not apply. Please see your Certificate of Insurance.

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Common Questions … Important Answers

Who is a participating dentist?

A participating, or network, dentist is a general dentist or specialist who has agreed to accept negotiated fees as payment in full for covered services provided to plan members, subject to any deductibles, copayments, cost sharing and benefit maximums. Negotiated fees typically range from 30 45% below the average fees charged in a dentist’s community for the same or substantially similar services.*

In addition to the standard MetLife network, your employer may provide you with access to a select network of dental providers that may be unique to your employer’s dental program. When visiting these providers, you may receive a better benefit, have lower out of pocket costs and/or have access to care at facilities at your worksite. Please sign into MyBenefits for more details.

* Based on internal analysis by MetLife. Negotiated fees refer to the fees that participating dentists have agreed to accept as payment in full for covered services, subject to any copayments, deductibles, cost sharing and benefits maximums. Negotiated fees are subject to change. Savings from enrolling in a dental benefits plan will depend on various factors, including the cost of the plan, how often members visit a dentist and the cost of services rendered. Negotiated fees are subject to change.

How do I find a participating dentist?

There are thousands of general dentists and specialists to choose from nationwide so you are sure to find one that meets your needs. You can receive a list of these participating dentists online at www.metlife.com/dental or call 1 800 275 4638 to have a list faxed or mailed to you.

What services are covered by my plan?

Please see your Certificate of Insurance for a list of covered services.

May I choose a non-participating dentist?

Yes. You are always free to select the dentist of your choice. However, if you choose a non participating (out of network) dentist, your out of pocket costs may be greater than your out of pocket costs when visiting an in network dentist.

Can my dentist apply for participation in the network?

Yes. If your current dentist does not participate in the network and you would like to encourage him or her to apply, ask your dentist to visit www.metdental.com, or call 1 866 PDP NTWK for an application.* The website and phone number are for use by dental professionals only.

* Due to contractual requirements, MetLife is prevented from soliciting certain providers.

How are claims processed?

Dentists may submit your claims for you which means you have little or no paperwork. You can track your claims online and even receive email alerts when a claim has been processed. If you need a claim form, visit www.metlife.com/dental or request one by calling 1 800 275 4638.

Can I get an estimate of what my out of pocket expenses will be before receiving a service?

Yes. You can ask for a pretreatment estimate. Your general dentist or specialist usually sends MetLife a plan for your care and requests an estimate of benefits. The estimate helps you prepare for the cost of dental services. We recommend that you request a pre treatment estimate for services in excess of $300. Simply have your dentist submit a request online at www.metdental.com or call 1 877 MET DDS9. You and your dentist will receive a benefit estimate for most procedures while you are still in the office. Actual payments may vary depending upon plan maximums, deductibles, frequency limits and other conditions at time of payment.

Can MetLife help me find a dentist outside of the U.S. if I am traveling?

Yes. Through international dental travel assistance services* you can obtain a referral to a local dentist by calling +1 312 356 5970 (collect) when outside the U.S. to receive immediate care until you can see your dentist. Coverage will be considered under your out of network benefits.** Please remember to hold on to all receipts to submit a dental claim.

** Refer to your Certificate of Insurance for your out of network dental coverage.

200 Park Ave., New York, NY 10166

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International Dental Travel Assistance services are administered by AXA Assistance USA, Inc. (AXA Assistance). AXA Assistance provides dental referral services only. AXA Assistance is not affiliated with MetLife and any of its affiliates, and the services they provide are separate and apart from the benefits provided by MetLife. Referral services are not available in all locations.

How does MetLife coordinate benefits with other insurance plans?

Coordination of benefits provisions in dental benefits plans are a set of rules that are followed when a patient is covered by more than one dental benefits plan. These rules determine the order in which the plans will pay benefits. If the MetLife dental benefit plan is primary, MetLife will pay the full amount of benefits that would normally be available under the plan. If the MetLife dental benefit plan is secondary, most coordination of benefits provisions require MetLife to determine benefits after benefits have been determined under the primary plan. The amount of benefits payable by MetLife may be reduced due to the benefits paid under the primary plan.

Do I need an ID card?

No, You do not need to present an ID card to confirm that you are eligible. You should notify your dentist that you are enrolled in a MetLife Dental Plan. Your dentist can easily verify information about your coverage through a toll free automated Computer Voice Response system.

Do my dependents have to visit the same dentist that I select?

No. You and your dependents each have the freedom to choose any dentist.

DN GCERT GOLD Multioption Dental Benefit Summary

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• eyemed.com •EyeMed Members App •For LASIK, call 1.800.988.4221

Heads up

VISION CARE SERVICES

EXAM SERVICES

Exam

SUMMARY OF BENEFITS

IN-NETWORK MEMBER COST

$10 copay

OUT-OF-NETWORK MEMBER REIMBURSEMENT

Up to $40

Retinal Imaging Up to $39 Not covered

CONTACT LENS FIT AND FOLLOW-UP

Fit & Follow-up Standard

Up to $40; contact lens fit and two follow-up visits Not covered

Fit & Follow-up - Premium 10% off retail price Not covered

FRAME

Frame

STANDARD PLASTIC LENSES

$0 copay; 20% off balance over $150 allowance

Up to $105

Single Vision $25 copay Up to $30

Bifocal $25 copay Up to $50

Trifocal $25 copay Up to $70

Lenticular $25 copay Up to $70

Progressive Standard $80 copay Up to $50

Progressive - Premium Tier 1 - 4 $110 - 200 copay Up to $50

LENS OPTIONS

Anti Reflective Coating - Standard $45 copay

Up to $23

Anti Reflective Coating - Premium Tier 1 - 3$57 - 85 copay Up to $23

Photochromic Non-Glass $75 Not covered

Polycarbonate - Standard $40 Not covered

Scratch Coating - Standard Plastic $15 Not covered

Tint Solid and Gradient $15 Not covered

UV Treatment $15 Not covered

All Other Lens Options 20% off retail price Not covered

CONTACT LENSES

Contacts - Conventional

$0 copay; 15% off balance over $150 allowance

Up to $105 Contacts Disposable $0 copay; 100% of balance over $150 allowance Up to $105 Contacts - Medically Necessary $0 copay; paid-in-full Up to $300

OTHER

Hearing Care from Amplifon NetworkDiscounts on hearing exam and aids; call 1.877.203.0675 Not covered

Lasik or PRK from U.S. Laser Network 15% off retail or 5% off promo price; call 1.800.988.4221

Not covered

FREQUENCY

You may have additional benefits. Log into eyemed.com/member to see all plans included with your benefits. (Plan allows member to receive either contacts and frame, or frame and lens services)

ALLOWED FREQUENCY –KIDS Exam

ALLOWED FREQUENCY –ADULTS

Once every plan year Once every plan year Frame Once every plan year Once every plan year Lenses Once every plan year Once every plan year Contacts Lenses Once every plan year Once every plan year

EyeMed reserves the right to make changes to the products available on each tier. All providers are not required to carry all brands on all tiers. For current listing of brands by tier, call 866-939-3633. No benefits will be paid for services or materials connected with or charges arising from: medical or surgical treatment, services or supplies for the treatment of the eye, eyes or supporting structures; Refraction, when not provided as part of a Comprehensive Eye Examination; services provided as a result of any Workers’ Compensation law, or similar legislation, or required by any governmental agency or program whether federal, state or subdivisions thereof; orthoptic or vision training, subnormal vision aids and any associated supplemental testing; Aniseikonic lenses; any Vision Examination or any corrective Vision Materials required by a Policyholder as a condition of employment; safety eyewear; solutions, cleaning products or frame cases; non-prescription sunglasses; plano (non-prescription) lenses; plano (nonprescription) contact lenses; two pair of glasses in lieu of bifocals; electronic vision devices; services rendered after the date an Insured Person ceases to be covered under the Policy, except when Vision Materials ordered before coverage ended are delivered, and the services rendered to the Insured Person are within 31 days from the date of such order; or lost or broken lenses, frames, glasses, or contact lenses that are replaced before the next Benefit Frequency when Vision Materials would next become available. Fees charged by a Provider for services other than a covered benefit and any local, state or Federal taxes must be paid in full by the Insured Person to the Provider. Such fees, taxes or materials are not covered under the Policy. Allowances provide no remaining balance for future use within the same Benefit Frequency. Some provisions, benefits, exclusions or limitations listed herein may vary by state.. Plan discounts cannot be combined with any other discounts or promotional offers. In certain states members may be required to pay the full retail rate and not the negotiated discount rate with certain participating providers. Please see online provider locator to determine which participating providers have agreed to the discounted rate.

Eliada Homes

%OFF additional complete pair of prescription eyeglasses 20%OFF non-covered items, including nonprescription sunglasses Find an eye doctor (Insight Network)

QL-0000053706

Subscriber

MONTHLY RATES

$7.10 Subscriber + Spouse $12.36 Subscriber + Child(ren) $13.96 Subscriber + Family $19.01

Feeling free is so you

YOUR STYLE. YOUR PERSONALITY. YOUR CHOICE OF FRAMES

You have a style all your own. Now you can get the frames to match with a special offer from Target Optical®. For $0 out-of-pocket expense get any available frame, any brand no matter the original retail price point. You’re free to choose any frame in the store at no additional cost to you.

For example, if you purchase a pair of frames that retails for $180, your out-of-pocket cost is still $0 even if you have a $130 frame allowance. That’s up to a $50 value! Plus, you get extra savings on lenses through your EyeMed vision benefits to complete your look.

Any frame, any price for $0 out-of-pocket

at Target Optical® PLUS ENJOY SAVINGS ON LENSES

HOW TO REDEEM

Take this flyer to any Target Optical®. They’ll handle the rest. OFFER CODE: 755288

SHOP THESE TOP BRANDS AND MORE

WANT MORE? YOU GOT IT

Visit eyemed.com to get special offers from other in-network providers

A special offer from Target Optical. $130 or higher frame allowance required. Valid for each year of the initial contract term and in-store only at Target Optical. Complete pair purchase required member is still responsible for lenses, which are covered based on benefits outlined in the vision benefits and may include an additional copay. Discounts are not insured benefits. Proof of offer is required at time of purchase. Store associates enter code: 755288.

PDF-2002-M-74 FREEDOM PASS

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More than half of Americans (53%) expressed a heightened need for life insurance because of COVID-19.1

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2Your beneﬁt will be reduced by 35% at age 65 and 50% at age 70. Reductions will be applied to the original amount.

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1LIMRA,FactsAboutLife2020:https://www.limra.com/globalassets/limra/newsroom/fact-tank/fact-sheets/liam-facts-2020-ﬁnal.pdf,asviewedonOctober14,2020.

3Ratesand/orbeneﬁtsmaybechangedonaclassbasis.Ratesarebasedontheageoftheinsuredpersonandincreaseonthepolicyanniversarydateonorfollowingyourbirthdayas youentereachnewagecategory.

TheBuck’sGotYourBack.®®

TheHartford®isTheHartfordFinancialServicesGroup,Inc.anditssubsidiaries,includingunderwritingcompanyHartfordLifeandAccidentInsuranceCompany.HomeOfficeisHartford,CT.Allbenefitsare subjecttothetermsandconditionsofthepolicy.Policiesunderwrittenbytheunderwritingcompanylistedabovedetailexclusions,limitations,reductionofbenefitsandtermsunderwhichthepoliciesmaybe continuedinforceordiscontinued.ThisBenefitHighlightsdocumentexplainsthegeneralpurposeoftheinsurancedescribed,butinnowaychangesoraffectsthepolicyasactuallyissued.Intheeventofa discrepancybetweenthisdocumentandthepolicy,thetermsofthepolicyapply.CompletedetailsareintheCertificateofInsuranceissuedtoeachinsuredindividualandtheMasterPolicyasissuedtothe policyholder.Benefitsaresubjecttostateavailability.©2020TheHartford.

TheHartfordcompensatesbothinternalandexternalproducers,aswellasothers,forthesaleandserviceofourproducts.ForadditionalinformationregardingTheHartford’scompensationpractices,please reviewourwebsitehttp://thehartford.com/group-beneﬁts-producer-compensation.LifeFormSeriesincludesGBD-1000,GBD-1100,orstateequivalent. 5962aand5962bNS07/21

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WHAT IS BENEFICIARY ASSIST COUNSELING SERVICES?

Beneficiary Assist®2 Counseling Services offers compassionate expertise to help you, your beneficiaries (those you name in your policy) and immediate family members cope with emotional, financial and legal issues that arise after a loss. Includes unlimited phone contact with professionals, as well as five face-to-face sessions* available for up to one year.

For more information on Beneficiary Assist® Counseling Services, call 1-800-411-7239.

*California residents are limited to three prepaid behavioral health counseling sessions in any six-month period. Except for acute emergencies and other special circumstances, additional sessions for California employees are available on a fee-for-service basis.

WHAT IS ESTATEGUIDANCE WILL SERVICES?

EstateGuidance®3 Will Services helps you protect your family’s future by creating a customized and legally binding online will. Online support is also available from licensed attorneys, if needed.

For more information on EstateGuidance® Will Services: www.estateguidance.com Use Code: WILLHLF

WHAT IS FUNERAL CONCIERGE SERVICES?

Funeral Concierge Services4 provides a suite of online tools to guide you through key decisions before a loss, including help comparing funeral-related costs. After a loss, this service includes family advocacy and professional negotiation of funeral prices with local providers— often resulting in significant financial savings. In addition, Express Pay is a service that delivers proceeds in as little as 48 hours, allowing beneficiaries to use proceeds immediately for funeral expenses.

For more information on Funeral Concierge Services: Call 1-866-854-5429 or visit www.everestfuneral.com/hartford Use Code: HFEVLC

WHAT IS TRAVEL ASSISTANCE AND ID THEFT PROTECTION SERVICES?

Travel Assistance Services and ID Theft Protection Services6 includes pre-trip information to help you feel more secure while traveling. It can also help you access medical professionals across the globe for medical assistance when traveling 100+ miles away from home for 90 days or less when unexpected detours arise. The ID theft protection services are available to you and your family at home or when you travel. Protection is provided two ways: educational materials to help prevent identity theft and access to caseworkers to help resolve problems that result from identity theft.

For more information on Travel Assistance Services or ID Theft Services:

Call from United States: 1-800-243-6108

Call collect from other locations: 202-828-5885 Fax: 202-331-1528

Travel Assistance Identification Number: GLD-09012

You’ll be asked to provide your employer’s name, a phone number where you can be reached, nature of the problem, Travel Assistance Identification Number, and your company policy number which can be obtained through your Human Resources/Personnel department.

If you have a serious medical emergency, please obtain emergency medical services first, and then contact Generali Global Assistance for follow-up.

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Flexible Spending Account

An account for setting aside tax-free money for healthcare expenses

Use the below information to determine if a Flexible Spending Account (FSA) is right for you and how to best take advantage of an FSA account.

How It Works

When you enroll in a Flexible Spending Account (FSA) you get to experience tax savings on qualiﬁed expenses such as copays, deductibles, prescriptions, over-the-counter drugs and medications, and thousands of other everyday items.

Can I have an FSA and an HSA?

You can’t contribute to an FSA and HSA within the same plan year. However, you can contribute to an HSA and a limited purpose FSA, which only covers dental and vision expenses.

As per IRS Publication 969, an employee covered by an HDHP and a health FSA or an HRA that pays or reimburses qualiﬁed medical expenses generally can’t make contributions to an HSA. An employee is also not HSA-eligible during an FSA Grace Period. An employee enrolled in a Limited Purpose FSA is HSA-eligible.

As a married couple, one spouse cannot be enrolled in an FSA at the same time the other is contributing to an HSA. FSA coverage extends tax beneﬁts to family members allowing the FSA holder to be reimbursed for medical expenses for themselves, their spouse, and their dependents.

The Value & Perks

• Election Accessibility: You will have access to your entire election on the ﬁrst day of the plan year.

• Save On Eligible Expenses: You can save up to 40% on thousands of eligible everyday expenses such as prescriptions, doctor’s visits, dental services, glasses, over-the-counter medicines, and copays.

• Keep More Money: The funds are taken out of your paycheck "pre-tax" (meaning they are subtracted from your gross earnings before taxes) throughout the course of the year. Let’s say you earn $40,000 a year and contribute $1,500 to an FSA; so, only $38,500 of your income gets taxed. That means you are increasing your take-home pay simply by participating!

• Easy Spending and Account Management: You will receive an Ameriﬂex Debit Mastercard linked to your FSA. You can use your card for eligible purchases everywhere Mastercard is accepted. Account information can be securely accessed 24/7 online and through the mobile app.

Learn more at myameriﬂex.com | 844.423.4636 | info@myameriﬂex.com

Eligible FSA Expenses

The IRS determines what expenses are eligible under an FSA. Below are some examples of common eligible expenses.

Copays, deductibles, and other payments you are responsible for under your health plan.

Routine exams, dental care, prescription drugs, eye care, hearing aids, etc.

Prescription glasses and sunglasses, contact lenses and solution, LASIK, and eye exams.

Certain OTC expenses such as Band-aids, medicine, First Aid supplies, etc. (prescription required).

For a full list of eligible expenses, go to myameriﬂex.com/eligibleexpenses.

The “Use-or-Lose” Rule

Diabetic equipment and supplies, durable medical equipment, and qualiﬁed medical products or services.

If you contribute dollars to a reimbursement account and do not use all the money you deposit, you will lose any remaining balance in the account at the end of the eligible claims period. This rule, established by the IRS as a component of tax-advantaged plans, is referred to as the “use-or-lose” rule.

To avoid losing any of the funds you contribute to your FSA, it’s important to plan ahead as much as possible to estimate what your expenditures will be in a given plan year. Learn

more at myameriﬂex.com | 844.423.4636 | info@myameriﬂex.com

Dependent Care Account

Set aside tax-free money for daycare and dependent care services

Use the below information to determine if a Dependent Care Account (DCA) is right for you and how to best take advantage of an DCA account.

How It Works

When you enroll in a Dependent Care Account (DCA) you get to experience tax savings on expenses like daycare, elderly care, summer day camp, preschool, and other services that allow you to work full time.

The Value & Perks

• Save On Eligible Expenses: You can use a DCA to pay for qualifying expenses such as daycare, summer day care, elder care, before and after school programs, and pre-school.

• Keep More Money: The funds are taken out of your paycheck "pre-tax" (meaning they are subtracted from your gross earnings before taxes) throughout the course of the year. Let’s say you earn $40,000 a year and contribute $1,500 to an DCA; so, only $38,500 of your income gets taxed. That means you are increasing your take-home pay simply by participating!

• Easy Spending and Account Management: You will receive an Ameriﬂex Debit Mastercard linked to your DCA. You can use your card for eligible purchases everywhere Mastercard is accepted. Account information can be securely accessed 24/7 online and through the mobile app.

Eligible DCA Expenses

The IRS determines what expenses are eligible under a DCA. Below are some examples of common eligible expenses:

Private sitter Before- and after-school care

Daycare and elder care

Nanny service

Summer day camp

For a full list of eligible expenses, go to myameriﬂex.com/eligibleexpenses. Learn more at myameriﬂex.com | 844.423.4636 |

Nursery school & Pre-school

info@myameriﬂex.com

Online Account Instructions

How to Access Your Ameriflex Account: Go to MyAmeriflex.com and click “Login” from the upper right hand corner. When prompted, select “Participant.”

How to Register Online For Your Ameriflex Spending Account: Click the register button atop the right corner of the home screen.

1.As the primary account holder, enter your personal information.

• Choose a unique User ID and create a password (if you are told that your username is invalid or already taken, you must select another).

• Enter your first and last name.

• Enter your email address.

• Enter your Employee ID, which in most cases, will be the account holder’s Social Security Number(no dashes or spaces needed).

2.Check the box if you accept the terms of use.

3.Click 'register'. This process may take a few seconds. Do not click your browser’s back button or refresh the page.

4.Last, you must complete your Secure Authentication setup. Implemented to protect your privacy and help us prevent fraudulent activity, setup is quick and easy. After the registration form is successfully completed, you will be prompted to complete the secure authentication setup process:

Step 1: Select a Security Question option, and type in a corresponding answer.

Step 2: Repeat for the following three Security Questions, then click next.

Step 3: Verify your email address, and then click next.

Step 4: Verify and submit setup information,

5.The registration process is complete! Should you receive an information error message that does not easily guide you through the information correction process, please feel free to contact our dedicated Member Services Team at 888.868.FLEX (3539).

www.myameriflex.com

Want to Manage Your Account on the go? Download the MyAmeriflex mobile app, available through the App Store or Google Play.

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This individual voluntary policy pays benefits that can be used for both medical and/or out-of-pocket, non-medical expenses traditional health insurance may not cover. Available exclusively at the workplace, Cancer Assist is an attractive addition to any competitive benefits package that won’t add costs to a company’s bottom line.

Cancer Insurance

Competitive advantages

n Composite rates.

n Four distinct plan levels, each featuring the same benefits with premiums and benefit amounts designed to meet a variety of budgets and coverage needs (benefits overview on reverse).

n Indemnity-based benefits pay exactly what’s listed for the selected plan level.

n The plan’s Family Care Benefit provides a daily benefit when a covered dependent child receives inpatient or outpatient cancer treatment.

n Employer-optional cancer wellness/health screening benefits available: n Part One covers 24 tests. If selected, the employer chooses one of four benefit amounts for employees: $25, $50, $75 or $100. This benefit is payable once per covered person per calendar year.

n Part Two covers an invasive diagnostic test or surgical procedure if an abnormal result from a Part One test requires additional testing. This benefit is payable once per calendar year per covered person and matches the Part One benefit.

Flexible family coverage options

n Individual, Individual/Spouse, One-parent and Two-parent family policies.

n Family coverage includes eligible dependent children (to age 26) for the same rate, regardless of the number of children covered.

Attractive features

n Available for businesses with 3+ eligible employees.

n Broad range of policy issue ages, 17-75.

n Each plan level features full schedule of 30+ benefits and three optional riders (benefit amounts may vary based on plan level selected).

n Benefits don’t coordinate with any other coverage from any other insurer.

n HSA compliant.

n Guaranteed renewable.

n Portable.

n Waiver of premium if named insured is disabled due to cancer for longer than 90 consecutive days and the date of diagnosis is after the waiting period and while the policy is in force.

n Form 1099s may not be issued in most states because all benefits require that a charge is incurred. Discuss details with your benefits representative, or consult your tax adviser if you have questions.

Optional

Talk to your benefits representative today to learn more about this product and how it helps provide extra financial protection to employees who may be impacted by cancer.

riders (available at an additional cost/payable once per covered person)

n Initial Diagnosis of Cancer Rider pays a one-time benefit for the initial diagnosis of cancer. A benefit amount in $1,000 increments from $1,000-$10,000 may be chosen. The benefit for covered dependent children is two and a half times ($2,500-25,000) the chosen benefit amount.

n Initial Diagnosis of Cancer Progressive Payment Rider pays a $50 lump-sum payment for each month the rider has been in force, after the waiting period, once cancer is first diagnosed. The issue ages for this rider are 17-64.

n Specified Disease Hospital Confinement Rider pays $300 per day for confinement to a hospital for treatment of one of 34 specified diseases covered under the rider.

Our Cancer Assist plan helps employees protect themselves and their loved ones through their diagnosis, treatment and recovery journey.

INDIVIDUAL CANCER INSURANCE 44

Cancer Assist Benefits Overview

This overview shows benefits available for all four plan levels and the range of benefit amounts payable for most common cancer treatments. Each benefit is payable for each covered person under the policy. Actual benefits vary based on the plan level selected.

Radiation/Chemotherapy

n Injected chemotherapy by medical personnel: $250-$1,000 once per calendar week

n Radiation delivered by medical personnel: $250-$1,000 once per calendar week

n Self-injected chemotherapy: $150-$400 once per calendar month

n Topical chemotherapy: $150-$400 once per calendar month

n Chemotherapy by pump: $150-$400 once per calendar month

n Oral hormonal chemotherapy (1-24 months): $150-$400 once per calendar month

n Oral hormonal chemotherapy (25+ months): $75-$200 once per calendar month

n Oral non-hormonal chemotherapy: $150-$400 once per calendar month

Anti-nausea Medication

$25-$60 per day, up to $100-$240 per calendar month

Medical

Imaging Studies

$75-$225 per study, up to $150-$450 per calendar year

Outpatient Surgical Center

$100-$400 per day, up to $300-$1,200 per calendar year

Skin Cancer Initial Diagnosis

$300-$600 payable once per lifetime Surgical

Procedures

Inpatient and Outpatient Surgeries: $40-$70 per surgical unit, up to $2,500-$6,000 per procedure

Reconstructive Surgery

$40-$60 per surgical unit, up to $2,500-$3,000 per procedure including 25% for general anesthesia

Anesthesia

General: 25% of Surgical Procedures Benefit

Local: $25-$50 per procedure

Hospital Confinement

Each benefit requires that charges are incurred for treatment. All benefits and riders are subject to a 30-day waiting period. Waiting period means the first 30 days following the policy’s coverage effective date during which no benefits are payable. States without a waiting period will have a pre-existing condition limitation. Product has exclusions and limitations that may affect benefits payable. Benefits vary by state and may not be available in all states. See your Colonial Life benefits representative for complete details. © 2014 Colonial Life & Accident Insurance Company

Colonial Life products are underwritten by Colonial Life & Accident Insurance Company, for which Colonial Life is the marketing brand.

30 days or less: $100-$350 per day 31 days or more: $200-$700 per day

Family Care

Inpatient and outpatient treatment for a covered dependent child: $30-$60 per day, up to $1,500-$3,000 per calendar year

Second Medical Opinion on Surgery or Treatment

$150-$300 once per lifetime

Home Health Care Services

Examples include physical therapy, speech therapy, occupational therapy, prosthesis and orthopedic appliances, durable medical equipment: $50-$150 per day, up to the greater of 30 days per calendar year or twice the number of days hospitalized per calendar year

Hospice Care

Initial: $1,000 once per lifetime Daily: $50 per day $15,000 maximum for initial and daily hospice care per lifetime

Transportation and Lodging

n Transportation for treatment more than 50 miles from covered person’s home: $0.50 per mile, up to $1,000-$1,500 per round trip

n Companion Transportation (for any companion, not just a family member) for commercial travel when treatment is more than 50 miles from covered person’s home: $0.50 per mile, up to $1,000-$1,500 per round trip

n Lodging for the covered person or any one adult companion or family member when treatment is more than 50 miles from the covered person’s home: $50-$80 per day, up to 70 days per calendar year

Benefits also included in each plan

Air Ambulance, Ambulance, Blood/Plasma/Platelets/Immunoglobulins, Bone Marrow or Peripheral Stem Cell Donation, Bone Marrow Donor Screening, Bone Marrow or Peripheral Stem Cell Transplant, Cancer Vaccine, Egg(s) Extraction or Harvesting/Sperm Collection and Storage (Cryopreservation), Experimental Treatment, Hair/External Breast/Voice Box Prosthesis, Private Full-time Nursing Services, Prosthetic Device/Artificial Limb, Skilled Nursing Facility, Supportive or Protective Care Drugs and Colony Stimulating Factors

1-14 |

INDIVIDUAL CANCER INSURANCE 45

101478 ColonialLife.com

To encourage early detection, our cancer insurance offers benefits for wellness and health screening tests.

Cancer Insurance Wellness

Benefits

For more information, talk with your benefits counselor.

Part One: Cancer Wellness/Health Screening

Provided when one of the tests listed below is performed after the waiting period and while the policy is in force. Payable once per calendar year, per covered person.

Cancer Wellness Tests

■ Bone marrow testing

■ Breast ultrasound

■ CA 15-3 [blood test for breast cancer] ■ CA 125 [blood test for ovarian cancer] ■ CEA [blood test for colon cancer] ■ Chest X-ray ■ Colonoscopy ■ Flexible sigmoidoscopy ■ Hemoccult stool analysis ■ Mammography ■ Pap smear

■ PSA [blood test for prostate cancer]

■ Serum protein electrophoresis [blood test for myeloma] ■ Skin biopsy ■ Thermography

■ ThinPrep pap test ■ Virtual colonoscopy

Health Screening Tests

■ Blood test for triglycerides

■ Carotid Doppler

■ Echocardiogram [ECHO]

■ Electrocardiogram [EKG, ECG]

■ Fasting blood glucose test

■ Serum cholesterol test for HDL and LDL levels

■ Stress test on a bicycle or treadmill

Part Two: Cancer Wellness — Additional Invasive Diagnostic Test or Surgical Procedure

Provided when a doctor performs a diagnostic test or surgical procedure after the waiting period as the result of an abnormal result from one of the covered cancer wellness tests in Part One. We will pay the benefit regardless of the test results. Payable once per calendar year, per covered person.

Colonial Life products are underwritten by Colonial Life & Accident Insurance Company, for which Colonial Life is the marketing brand.

Waiting period means the first 30 days following the policy’s coverage effective date during which no benefits are payable.

The policy has exclusions and limitations. For cost and complete details of the coverage, see your Colonial Life benefits counselor. Coverage may vary by state and may not be available in all states. Applicable to policy form CanAssist (and state abbreviations where applicable – for example: CanAssist-TX).

CANCER ASSIST WELLNESS – 101486

1-14 46

Individual Cancer Insurance Description of Benefits

The policy and its riders may have additional exclusions and limitations. For cost and complete details of the coverage, see your Colonial Life benefits counselor. Coverage may vary by state and may not be available in all states. Coverage is dependent on answers to health questions. Applicable to policy forms CanAssist-NC and rider forms R-CanAssistIndx-NC, R-CanAssistProg-NC and R-CanAssistSpDis-NC.

Cancer

Insurance Benefits

Air Ambulance, per trip

Level 1Level 2Level 3Level 4

$2,000$2,000$2,000$2,000

Maximum trips per confinement 2 2 2 2 $250$250$250$250

Ambulance, per trip Anesthesia, Local, per procedure Anti-Nausea Medication, per day

Anesthesia, General

Maximum trips per confinement 2 2 2 2 $25$30$40$50 $25$40$50$60

Blood/Plasma/Platelets/Immunoglobulins, per day

25% of Surgical Procedures Benefit

Maximum per month $100$160$200$240 $150$150$175$250

Bone Marrow or Peripheral Stem Cell Donation, per lifetime Bone Marrow or Peripheral Stem Cell Transplant, per transplant

Maximum per year $10,000$10,000$10,000$10,000 $500$500$750$1,000 $3,500$4,000$7,000$10,000

Companion Transportation, per mile

Maximum transplants per lifetime 2 2 2 2 $0.50$0.50$0.50$0.50

Egg(s) Extraction or Harvesting or Sperm Collection, per lifetime Egg(s) or Sperm Storage, per lifetime Experimental Treatment, per day

Maximum per round trip $1,000$1,000$1,200$1,500 $500$700$1,000$1,500 $175$200$350$500 $200$250$300$300

Family Care, per day

Maximum per lifetime $10,000$12,500$15,000$15,000 $30$40$50$60

Hair/External Breast/Voice Box Prosthesis, per year Home Health Care Services, per day

Maximum per year $1,500$2,000$2,500$3,000 $200$200$350$500 $50$75$100$150

Maximum per year

Hospice, Initial, per lifetime Hospice, Daily

Maximum combined Initial and Daily per lifetime

Hospital Confinement, 30 days or less, per day Hospital Confinement, 31 days or more, per day Lodging, per day

Medical Imaging Studies, per study

30 days or twice the days confined

$1,000$1,000$1,000$1,000 $50$50$50$50

$15,000$15,000$15,000$15,000 $100$150$250$350 $200$300$500$700 $50$50$75$80

Maximum days per year 70707070 $75$125$175$225

Outpatient Surgical Center, per day

Maximum per year $150$250$350$450 $100$200$300$400

Private Full-time Nursing Services, per day Prosthetic Device/Artificial Limb, per device or limb

Maximum per year $300$600$900$1,200 $50$75$125$150 $1,000$1,500$2,000$3,000

Maximum per lifetime $2,000$3,000$4,000$6,000

Individual Cancer Insurance Description of Benefits

Cancer Insurance Benefits

Radiation/Chemotherapy

Injected chemotherapy by medical personnel, per week

Level 1Level 2Level 3Level 4

$250$500$750$1,000

Radiation delivered by medical personnel, per week $250$500$750$1,000

Self-Injected Chemotherapy, per month $150$200$300$400

Pump Chemotherapy, per month $150$200$300$400

Topical Chemotherapy, per month $150$200$300$400

Oral Hormonal Chemotherapy (1-24 months), per month $150$200$300$400

Oral Hormonal Chemotherapy (25+ months), per month $75$100$150$200

Reconstructive Surgery, per surgical unit

Oral Non-Hormonal Chemotherapy, per month $150$200$300$400 $40$40$60$60

Second Medical Opinion, per lifetime Skilled Nursing Care Facility, per day, up to days confined Skin Cancer Initial Diagnosis, per lifetime

Supportive/Protective Care Drugs/Colony Stimulating Factors, per

Maximum per procedure, including 25% for general $2,500$2,500$3,000$3,000 $150$200$300$300 $75$100$100$150 $300$300$400$600 $50$100$150$200

Surgical Procedures, per surgical unit

Maximum per year $400$800$1,200$1,600 $40$50$60$70

Transportation, per mile

Maximum per procedure $2,500$3,000$5,000$6,000 $0.50$0.50$0.50$0.50

Waiver of Premium

Maximum per round trip $1,000$1,000$1,200$1,500 YesYesYesYes

Policy-Wellness Benefits

Bone Marrow Donor Screening, per lifetime Cancer Vaccine, per lifetime

Part 1: Cancer Wellness/Health Screening, per year Part 2: Cancer Wellness/Health Screening, per year

Additional Riders may be available at an additional cost

WAITING PERIOD

One amount per account: $0, $25, $50, $75 or $10 Same as Part 1

The policy and its riders may have a waiting period. Waiting period means the first 30 days following the policy’s coverage effective date during which no benefits are payable. If your cancer has a date of diagnosis before the end of the waiting period, coverage for that cancer will apply only to losses commencing after the policy has been in force for two years, unless it is excluded by name or specific description in the policy.

No recovery during the first 12 months of this policy for cancer with a date of diagnosis prior to 30 days after the effective date of coverage. If a covered person is 65 or older when this policy is issued, pre-existing conditions for that covered person will include only conditions specifically eliminated by rider.

EXCLUSIONS

We will not pay benefits for cancer or skin cancer:

■IfthediagnosisortreatmentofcancerisreceivedoutsideoftheterritoriallimitsoftheUnitedStatesandits possessions; or

■Forotherconditionsordiseases,exceptlossesduedirectlyfromcancer.

©2014 Colonial Life & Accident Insurance Company, Columbia, SC | Colonial Life insurance products are underwritten by Colonial Life & Accident Insurance Company, for which Colonial Life is the marketing brand.

$50$50$50$50 $50$50$50$50

Chris was mowing the lawn when he suffered a stroke. His recovery will be challenging and he's worried, since his family relies on his income.

HOW CHRIS’S COVERAGE HELPED

Group Critical Illness Insurance Plan 1

When life takes an unexpected turn due to a critical illness diagnosis, your focus should be on recovery — not finances. Colonial Life’s group critical illness insurance helps provide financial support by providing a lump-sum benefit payable directly to you for your greatest needs.

Coverage amount: ____________________________

COVERED CONDITION¹

Benign brain tumor 100%

Coma 100%

End stage renal (kidney) failure 100%

Co-payments and hospital bills not covered by his medical insurance

Physical therapy to get back to doing what he loves

Household expenses while he was unable to work

For illustrative purposes only.

Heart attack (myocardial infarction) 100%

Loss of hearing 100%

Loss of sight 100%

Loss of speech 100%

Major organ failure requiring transplant 100%

Occupational infectious HIV or occupational infectious hepatitis B, C, or D 100%

Permanent paralysis due to a covered accident 100%

Stroke 100%

Sudden cardiac arrest 100%

Coronary artery disease 25%

GCI6000 – PLAN 1 – CRITICAL ILLNESS

An unexpected moment changes life forever

The lump-sum payment from his critical illness insurance helped pay for: PERCENTAGE OF APPLICABLE COVERAGE AMOUNT

Critical illness benefit

KEY BENEFITS

Available coverage for spouse and eligible dependent children at 50% of your coverage amount

Cover your eligible dependent children at no additional cost

Receive coverage regardless of medical history, within specified limits

Works alongside your health savings account (HSA)

Benefits payable regardless of other insurance

Subsequent diagnosis of a different critical illness2

If you receive a benefit for a critical illness, and are later diagnosed with a different critical illness, 100% of the coverage amount may be payable for that particular critical illness.

Subsequent diagnosis of the same critical illness2

If you receive a benefit for a critical illness, and are later diagnosed with the same critical illness,3 25% of the coverage amount may be payable for that critical illness.

Additional covered conditions for dependent children

COVERED CONDITION¹ PERCENTAGE

Cerebral palsy 100%

Cleft lip or palate 100%

Cystic fibrosis 100%

Down syndrome 100%

Spina bifida 100%

For more information, talk with your benefits counselor.

ColonialLife.com

1. Refer to the certificate for complete definitions of covered conditions.

2. Dates of diagnoses of a covered critical illness must be separated by more than 180 days.

3. Critical illnesses that do not qualify include: coronary artery disease, loss of hearing, loss of sight, loss of speech, and occupational infectious HIV or occupational infectious hepatitis B,C,or D.

THIS INSURANCE PROVIDES LIMITED BENEFITS

Insureds in MA must be covered by comprehensive health insurance before applying for this coverage.

EXCLUSIONS AND LIMITATIONS FOR CRITICAL ILLNESS

We will not pay the Critical Illness Benefit, Benefits Payable Upon Subsequent Diagnosis of a Critical Illness or Additional Critical Illness Benefit for Dependent Children that occurs as a result of a covered person’s: alcoholism or drug addiction; felonies or illegal occupations; intoxicants and narcotics; suicide or injuring oneself intentionally, whether sane or not; war or armed conflict; or pre-existing condition, unless the covered person has satisfied the pre-existing condition limitation period shown on the Certificate Schedule on the date the covered person is diagnosed with a critical illness.

PRE-EXISTING CONDITION LIMITATION

This information is not intended to be a complete description of the insurance coverage available. The insurance or its provisions may vary or be unavailable in some states. The insurance has exclusions and limitations which may affect any benefits payable. Applicable to policy form GCI6000-P and certificate form GCI6000-C (including state abbreviations where used, for example: GCI6000-C-TX). For cost and complete details of coverage, call or write your Colonial Life benefits counselor or the company.

Underwritten by Colonial Life & Accident Insurance Company, Columbia, SC. ©2020 Colonial Life & Accident Insurance Company. All rights reserved. Colonial Life is a registered trademark and marketing brand of Colonial Life & Accident Insurance Company.

5-20 | 385403

APPLICABLE

COVERAGE AMOUNT

Preparing for the unexpected is simpler than you think. With Colonial Life, youʼll have the support you need to face lifeʼs toughest challenges.

Group Critical Illness Insurance Plan 2

When life takes an unexpected turn, your focus should be on recovery — not finances. Colonial Life’s group critical illness insurance helps relieve financial worries by providing a lump-sum benefit payable directly to you to use as needed.

Coverage amount: ____________________________

Preparing for a lifelong journey

Rebecca was born with Down syndrome. Her parents’ critical illness coverage provided a benefit that can help cover expenses related to Rebecca’s care and her changing needs.

HOW THEIR COVERAGE HELPED

The lump-sum amount from the family coverage benefit helped pay for:

Benign brain tumor 100%

Coma 100%

End stage renal (kidney) failure 100%

Heart attack (myocardial infarction) 100%

Loss of hearing 100%

Loss of sight 100%

Loss of speech 100%

Major organ failure requiring transplant 100%

Occupational infectious HIV or occupational infectious hepatitis B, C, or D 100%

Permanent paralysis due to a covered accident 100%

Stroke 100%

Sudden cardiac arrest 100%

Coronary artery disease 25%

Invasive cancer (including all breast cancer) 100%

Non-invasive cancer 25%

GCI6000 – PLAN 2 – CRITICAL ILLNESS AND CANCER

PERCENTAGE OF APPLICABLE COVERAGE AMOUNT

COVERED CRITICAL ILLNESS CONDITION¹

OF APPLICABLE COVERAGE AMOUNT

COVERED CANCER CONDITION¹ PERCENTAGE

needs daycare A hospital stay and treatment for corrective heart surgery Physical therapy to build muscle strength

Skin cancer initial diagnosis $400 per lifetime Critical illness and cancer benefits Special

For illustrative purposes only.

KEY BENEFITS

Available coverage for spouse and eligible dependent children at 50% of your coverage amount

Cover your eligible dependent children at no additional cost

Receive coverage regardless of medical history, within specified limits

Works alongside your health savings account (HSA)

Benefits payable regardless of other insurance

Subsequent diagnosis of a different critical illness2

If you receive a benefit for a critical illness, and are later diagnosed with a different critical illness, 100% of the coverage amount may be payable for that particular critical illness.

Subsequent diagnosis of the same critical illness2

If you receive a benefit for a critical illness, and are later diagnosed with the same critical illness,3 25% of the coverage amount is payable for that critical illness.

Reoccurrence of invasive cancer (including all breast cancer)

If you receive a benefit for invasive cancer and are later diagnosed with a reoccurrence of invasive cancer, 25% of the coverage amount is payable if treatment-free for at least 12 months and in complete remission prior to the date of reoccurrence; excludes non-invasive or skin cancer.

Additional covered conditions for dependent children

COVERED CONDITION¹

Cerebral palsy 100%

Cleft lip or palate 100%

Cystic fibrosis 100%

Down syndrome 100%

Spina bifida 100%

Preparing for the unexpected is simpler than you think.

With Colonial Life, youʼll have the support you need to face lifeʼs toughest challenges.

1. Refer to the certificate for complete definitions of covered conditions.

2. Dates of diagnoses of a covered critical illness must be separated by more than 180 days.

For more information, talk with your benefits counselor.

THIS INSURANCE PROVIDES LIMITED BENEFITS

Insureds in MA must be covered by comprehensive health insurance before applying for this coverage.

EXCLUSIONS AND LIMITATIONS FOR CRITICAL ILLNESS

EXCLUSIONS AND LIMITATIONS FOR CANCER

We will not pay the Invasive Cancer (including all Breast Cancer) Benefit, Non-Invasive Cancer Benefit, Benefit Payable Upon Reoccurrence of Invasive Cancer (including all Breast Cancer) or Skin Cancer Initial Diagnosis Benefit for a covered person’s invasive cancer or non-invasive cancer that: is diagnosed or treated outside the territorial limits of the United States, its possessions, or the countries of Canada and Mexico; is a pre-existing condition, unless the covered person has satisfied the pre-existing condition limitation period shown on the Certificate Schedule on the date the covered person is initially diagnosed as having invasive or non-invasive cancer. No pre-existing condition limitation will be applied for dependent children who are born or adopted while the named insured is covered under the certificate, and who are continuously covered from the date of birth or adoption.

PRE-EXISTING CONDITION LIMITATION

Underwritten by Colonial Life & Accident Insurance Company, Columbia, SC ©2020 Colonial Life & Accident Insurance Company. All rights reserved. Colonial Life is a registered trademark and marketing brand of Colonial Life & Accident Insurance Company.

ColonialLife.com 5-20 | 387100

PERCENTAGE OF APPLICABLE COVERAGE AMOUNT

Group Critical Illness Insurance

First Diagnosis Building Benefit Rider

For more information, talk with your benefits counselor.

The first diagnosis building benefit rider provides a lump-sum payment in addition to the coverage amount when you are diagnosed with a covered critical illness or invasive cancer (including all breast cancer). This benefit is for you and all your covered family members.

ColonialLife.com

First diagnosis building benefit

Payable once per covered person per lifetime

¾ Named insured

¾ Covered spouse/dependent children

Accumulates $1,000 each year

Accumulates $500 each year

The benefit amount accumulates each rider year the rider is in force before a diagnosis is made, up to a maximum of 10 years.

If diagnosed with a covered critical illness or invasive cancer (including all breast cancer) before the end of the first rider year, the rider will provide one-half of the annual building benefit amount.

Coronary artery disease is not a covered critical illness. Non-invasive and skin cancer are not covered cancer conditions.

THIS INSURANCE PROVIDES LIMITED BENEFITS.

This information is not intended to be a complete description of the insurance coverage available. The insurance or its provisions may vary or be unavailable in some states. The insurance has exclusions and limitations which may affect any benefits payable. Applicable to policy form GCI6000-P and certificate form GCI6000-C (including state abbreviations where used, for example: GCI6000-C-TX) and rider form R-GCI6000-BB. For cost and complete details of coverage, call or write your Colonial Life benefits counselor or the company.

– FIRST DIAGNOSIS BUILDING BENEFIT RIDER | 5-20 | 387381

GCI6000

Group Critical Illness Insurance

Infectious Diseases Rider

The sudden onset of an infectious or contagious disease can create unexpected circumstances for you or your family. The infectious diseases rider provides a lump sum which can be used toward health care expenses or meeting day-today needs. These benefits are for you as well as your covered family members. Payable

COVERED INFECTIOUS DISEASE¹

Hospital confinement for seven or more consecutive days for treatment of the disease

Antibiotic resistant bacteria (including MRSA) 50%

Cerebrospinal meningitis (bacterial) 50%

Diphtheria 50%

Encephalitis 50%

Legionnaires’ disease 50%

Lyme disease 50%

Malaria 50% Necrotizing fasciitis 50%

Osteomyelitis 50%

Poliomyelitis 50%

Rabies 50%

Sepsis 50%

Tetanus 50%

Tuberculosis 50%

Hospital confinement for 14 or more consecutive days for treatment of the disease

Coronavirus disease 2019 (COVID-19) 25%

each

talk with your benefits counselor. ColonialLife.com GCI6000 – INFECTIOUS DISEASES RIDER

for

covered infectious disease once per covered person per lifetime For

information,

PERCENTAGE OF APPLICABLE COVERAGE AMOUNT

ColonialLife.com

1. Refer to the certificate for complete definitions of covered diseases.

THIS INSURANCE PROVIDES LIMITED BENEFITS.

EXCLUSIONS AND LIMITATIONS FOR INFECTIOUS DISEASES RIDER

We will not pay benefits for a covered infectious disease that occurs as a result of a covered person’s: alcoholism or drug addiction; felonies or illegal occupations; intoxicants and narcotics; suicide or injuring oneself intentionally, whether sane or not; war or armed conflict; or pre-existing condition, unless the covered person has satisfied the pre-existing condition limitation period shown on the Certificate Schedule on the date the covered person is diagnosed with a covered infectious disease.

PRE-EXISTING CONDITION LIMITATION

We will not pay a benefit for a pre-existing condition that occurs during the 12-month period after the coverage effective date. Pre-existing condition means a sickness or physical condition for which a covered person was treated, had medical testing, received medical advice or had taken medication within 12 months before the coverage effective date. This information is not intended to be a complete description of the insurance coverage available. The insurance or its provisions may vary or be unavailable in some states. The insurance has exclusions and limitations which may affect any benefits payable. Applicable to policy form GCI6000-P and certificate form GCI6000-C (including state abbreviations where used, for example: GCI6000-C-TX) and rider form R-GCI6000-INF. For cost and complete details of coverage, call or write your Colonial Life benefits counselor or the company.

5-20 | 387523

For more information, talk with your benefits counselor.

Group Critical Illness Insurance Progressive Diseases Rider

The debilitating effects of a progressive disease not only impact you physically, but financially as well. Changes in lifestyle may require home modification, additional medical treatment and other expenses. These benefits are for you as well as your covered family members.

Payable for each covered progressive disease once per covered person per lifetime

COVERED PROGRESSIVE DISEASE¹

This benefit is payable if the covered person is unable to perform two or more activities of daily living2 and the 90-day elimination period has been met.

Amyotrophic Lateral Sclerosis (ALS) 25%

Dementia (including Alzheimer’s disease) 25%

Huntington’s disease 25%

Lupus 25%

Multiple sclerosis (MS) 25% Muscular dystrophy 25%

Myasthenia gravis (MG) 25%

Parkinson’s disease 25% Systemic sclerosis (scleroderma) 25%

1. Refer to the certificate for complete definitions of covered diseases.

2. Activities of daily living include bathing, continence, dressing, eating, toileting and transferring.

THIS INSURANCE PROVIDES LIMITED BENEFITS.

EXCLUSIONS AND LIMITATIONS FOR PROGRESSIVE DISEASES RIDER

We will not pay benefits for a covered progressive disease that occurs as a result of a covered person’s: alcoholism or drug addiction; felonies or illegal occupations; intoxicants and narcotics; suicide or injuring oneself intentionally, whether sane or not; war or armed conflict; or pre-existing condition, unless the covered person has satisfied the preexisting condition limitation period shown on the Certificate Schedule on the date the covered person is diagnosed with a covered progressive disease.

PRE-EXISTING CONDITION LIMITATION

This information is not intended to be a complete description of the insurance coverage available. The insurance or its provisions may vary or be unavailable in some states. The insurance has exclusions and limitations which may affect any benefits payable. Applicable to policy form GCI6000-P and certificate form GCI6000-C (including state abbreviations where used, for example: GCI6000-C-TX) and rider form R-GCI6000-PD. For cost and complete details of coverage, call or write your Colonial Life benefits counselor or the company.

PERCENTAGE OF APPLICABLE COVERAGE AMOUNT

GCI6000 – PROGRESSIVE DISEASES RIDER | 5-20 | 387594

ColonialLife.com

Group Critical Illness Insurance

Exclusions and Limitations

STATE-SPECIFIC EXCLUSIONS

AK: Alcoholism or Drug Addiction Exclusion does not apply

CO: Suicide exclusion: whether sane or not replaced with while sane

CT: Alcoholism or Drug Addiction Exclusion replaced with Intoxication or Drug Addiction; Felonies or Illegal Occupations Exclusion replaced with Felonies; Intoxicants and Narcotics Exclusion does not apply

DE: Alcoholism or Drug Addiction Exclusion does not apply

IA: Exclusions and Limitations headers renamed to Exclusions and Limitations for Critical Illness Covered Conditions and Critical Illness Cancer Covered Conditions

ID: War or Armed Conflict Exclusion replaced with War; Felonies and Illegal Occupations Exclusion replaced with Felonies; Intoxicants and Narcotics Exclusion does not apply; Domestic Partner added to Spouse

IL: Alcoholism or Drug Addiction Exclusion replaced with Alcoholism or Substance Abuse Disorder

KS: Alcoholism or Drug Addiction Exclusion does not apply

KY: Alcoholism or Drug Addiction Exclusion does not apply; Intoxicants and Narcotics Exclusion replaced with Intoxicants, Narcotics and Hallucinogenics.

LA: Alcoholism or Drug Addiction Exclusion does not apply; Domestic Partner added to Spouse

MA: Exclusions and Limitations headers renamed to Limitations and Exclusions for critical illness and cancer

MI: Intoxicants and Narcotics Exclusion does not apply; Suicide Exclusion does not apply

MN: Alcoholism or Drug Addiction Exclusion does not apply; Suicide Exclusion does not apply; Felonies and Illegal Occupations Exclusion replaced with Felonies or Illegal Jobs; Intoxicants and Narcotics Exclusion replaced with Narcotic Addiction

MS: Alcoholism or Drug Addiction Exclusion does not apply

ND: Alcoholism or Drug Addiction Exclusion does not apply

NV: Intoxicants and Narcotics Exclusion does not apply; Domestic Partner added to Spouse

PA: Alcoholism or Drug Addiction Exclusion does not apply; Suicide Exclusion: whether sane or not removed

SD: Alcoholism or Drug Addiction Exclusion does not apply; Intoxicants and Narcotics Exclusion does not apply

TX: Alcoholism or Drug Addiction Exclusion does not apply; Doctor or Physician Relationship added as an additional exclusion

UT: Alcoholism or Drug Addiction Exclusion replaced with Alcoholism

VT: Alcoholism or Drug Addiction Exclusion does not apply; Intoxicants and Narcotics Exclusion does not apply; Suicide Exclusion: whether sane or not removed

STATE-SPECIFIC PRE-EXISTING CONDITION LIMITATIONS

FL: Pre-existing is 6/12; Pre-existing Condition means a sickness or physical condition for which a covered person was treated, had medical testing, received medical advice or had taken medication within six months before the coverage effective date shown on the Certificate Schedule. Genetic information is not a pre-existing condition in the absence of a diagnosis of the condition related to such information.

GA: Pre-existing Condition means the existence of symptoms which would cause an ordinarily prudent person to seek diagnosis, care, or treatment, or a condition for which medical advice or treatment was recommended by or received within 12 months preceding the coverage effective date.

ID: Pre-existing is 6 months/12 months; Pre-existing Condition means a sickness or physical condition which caused a covered person to seek medical advice, diagnosis, care or treatment during the six months immediately preceding the coverage effective date shown on the Certificate Schedule.

IL: Pre-existing Condition means a sickness or physical condition for which a covered person was diagnosed, treated, had medical testing by a legally qualified physician, received medical advice, produced symptoms or had taken medication within 12 months before the coverage effective date shown on the Schedule of Benefits.

IN: Pre-existing is 6 months/12 months

MA: Pre-existing is 6 months/12 months; Pre-existing Condition means a sickness or physical condition for which a covered person was treated, had medical testing, or received medical advice within six months before the coverage effective date shown on the Certificate Schedule.

ME: Pre-existing is 6 months/6 months; Pre-existing Condition means a sickness or physical condition for which a covered person was treated, had medical testing, or received medical advice within six months before the coverage effective date shown on the Certificate Schedule.

MI: Pre-existing is 6 months/6 months

NC: Pre-existing Condition means those conditions for which medical advice, diagnosis, care, or treatment was received or recommended within the one-year period immediately preceding the effective date of a covered person. If a covered person is 65 or older when this certificate is issued, pre-existing conditions for that covered person will include only conditions specifically eliminated.

NV: Pre-existing is 6 months/12 months; Pre-existing Condition means a sickness or physical condition for which a covered person was treated, had medical testing, received medical advice or had taken medication within six months before the coverage effective date. Pre-existing Condition does not include genetic information in the absence of a diagnosis of the condition related to such information.

PA: Pre-existing is 90 days/12 months; Pre-existing Condition means a disease or physical condition for which you received medical advice or treatment within 90 days before the coverage effective date shown on the Certificate Schedule.

SD: Pre-existing is 6 months/12 months

TX: Pre-existing condition means a sickness or physical condition for which a covered person received medical advice or treatment within 12 months before the coverage effective date shown on the Certificate Schedule.

UT: Pre-existing is 6 months/6 months

This information is not intended to be a complete description of the insurance coverage available. The insurance, its name or its provisions may vary or be unavailable in some states. The insurance has exclusions and limitations which may affect any benefits payable. Applicable to policy form GCI6000-P and certificate form GCI6000-C (including state abbreviations where used, for example: GCI6000-C-TX). For cost and complete details of coverage, call or write your Colonial Life benefits counselor or the company. This form is not complete without base form 385403, 387100, 387169, 402383, 402558 or 387238, and rider form 387307, 387381, 387452, 387523, 387594, 387665, 402605 or 402671.

Underwritten by Colonial Life & Accident Insurance Company, Columbia, SC.

GCI6000 – EXCLUSIONS AND LIMITATIONS | 8-20 | 388113-1 57

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TheBuck’sGotYourBack.®

TheHartford®isTheHartfordFinancialServicesGroup,Inc.anditssubsidiaries,includingunderwritingcompanyHartfordLifeandAccidentInsuranceCompany.HomeOfficeisHartford,CT.Allbenefitsaresubjecttothe termsandconditionsofthepolicy.Policiesunderwrittenbytheunderwritingcompanylistedabovedetailexclusions,limitations,reductionofbenefitsandtermsunderwhichthepoliciesmaybecontinuedinforceor discontinued.ThisBenefitHighlightsdocumentexplainsthegeneralpurposeoftheinsurancedescribed,butinnowaychangesoraffectsthepolicyasactuallyissued.Intheeventofadiscrepancybetweenthisdocument andthepolicy,thetermsofthepolicyapply.CompletedetailsareintheCertificateofInsuranceissuedtoeachinsuredindividualandtheMasterPolicyasissuedtothepolicyholder.Benefitsaresubjecttostateavailability. ©2020TheHartford.

TheHartfordcompensatesbothinternalandexternalproducers,aswellasothers,forthesaleandserviceofourproducts.ForadditionalinformationregardingHartford’scompensationpractices,pleasereviewourwebsite http://thehartford.com/group-beneﬁts-producer-compensation.DisabilityFormSeriesincludesGBD-1000,GBD-1200,orstateequivalent.

LONG-TERM DISABILITY INSURANCE BENEFIT

GROUP

HIGHLIGHTS

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Educator

Disability Advantage Short-Term Disability

Advantage insurance1

financial protection

My Disability Coverage Worksheet (For use with your Colonial Life benefits counselor) Employee Coverage (includes both on- and off-job benefits) How much coverage do I need?

Total Disability On-Job Accident/Sickness Off-Job Accident/Sickness First three months $_____________/month $_____________/month Next nine months $_____________/month $_____________/month • Partial Disability Up to three months $____________/month $_____________/month When will my benefits start? After an accident: ___________ days After a sickness: ___________ days What additional features or benefits are included?

Educator Disability

from Colonial Life is designed to provide

for all education workers with plans that can help supplement and/or complement the Disability Income Plan of North Carolina. Educator Disability Advantage insurance provides flexible options for disability coverage and accidental injury benefits to help protect your income and maintain lifestyle needs if you become disabled due to a covered accident or sickness.

•

Normal pregnancy is covered the same as any other covered sickness.

Premium: We will waive your premium payments after 90 consecutive days of a covered disability.

• Waiver of

Benefit: $1,000, up to two benefits per year for adoption or

of a guardian

• Goodwill Child

ward

Disorders Benefit How much will it cost? Your cost will vary based on the level of coverage you select. How long could you afford to go without a paycheck? Monthly Expenses: Mortgage/rent $_____________ Groceries $_____________ Car $_____________ Medical bills $_____________ Utilities $_____________ Other $_____________ TOTAL $ EDUCATOR DISABILITY ADVANTAGE (EDA1100) – MENTAL & NERVOUS 60

• Mental

Nervous

Disability benefits and more

Anita teaches at a local community college and enjoys spending time on active hobbies and volunteering with nonprofits. When she was injured in a mountain biking accident, she worried that she might not be able to make ends meet for a while.

How Anita’s coverage helped*

With her coverage, she received benefits for:

• Accident emergency treatment $400

• X-ray $150

• Collarbone fracture requiring surgery .. $1,200

• Elbow dislocation (nonsurgical) $400

• Hospital stay of three nights $150

• Short-term disability benefits .......... $1,400

Total amount: ..... $3,700

*For illustrative purposes only. Coverage amounts may vary based on injury, treatment, income and more.

Additional Employee Coverage

In addition to disability coverage, this plan also provides employees with benefits related to accidental injuries, their treatment and more. Even if you’re not disabled, the following benefits are payable for covered accidental injuries or sickness:

ACCIDENTAL INJURIES BENEFITS

• Accident emergency treatment $400

• X-ray $150

• Accident follow-up treatment (including transportation)/Telemedicine .................................... $75 (up to six benefits per accident per person, up to twelve a year per person)

HOSPITAL CONFINEMENT BENEFIT FOR ACCIDENT OR SICKNESS

Pays in addition to disability benefit. Benefits begin on the first day of confinement in a hospital.

Up to three months

$1,500/month ($50/day) The Hospital Confinement benefit increases to $7,500/month when the Total Disability benefit ends at age 70.

ACCIDENTAL DEATH AND DISMEMBERMENT BENEFITS

• Accidental death $25,000

• Loss of a finger or toe Single dismemberment ..................................................$750 Double dismemberment ................................................ $1,500

• Loss of a hand, foot or sight of an eye Single dismemberment ................................................ $5,000 Dismemberment ..................................................... $10,000

• Common carrier death (includes school bus for school activities) $50,000

COMPLETE FRACTURES

Nonsurgical Surgical

• Hip, thigh ............................................

$1,500 .......... $3,000

• Vertebrae $1,350 $2,700

• Pelvis $1,200 $2,400

• Skull (depressed) $1,500 $3,000

• Leg $900 $1,800

• Foot, ankle, kneecap ................................... $750 .......... $1,500

• Forearm, hand, wrist $750 $1,500

• Lower jaw $600 $1,200

• Shoulder blade, collarbone ............................. $600 .......... $1,200

• Skull (simple) $525 $1,050

• Upper arm, upper jaw $525 $1,050

• Facial bones .......................................... $450 ........... $900

• Vertebral processes $300 $600

• Rib $300 $600

• Finger, toe ............................................. $175 ........... $350

• Coccyx $125 $250

COMPLETE DISLOCATIONS

Nonsurgical Surgical

• Hip ................................................. $1,500 .......... $3,000

• Knee $975 $1,950

• Shoulder $750 $1,500

• Collarbone (sternoclavicular) $750 $1,500

• Ankle, foot $750 $1,500

• Collarbone (acromioclavicular and separation) ............ $675 .......... $1,350

• Hand $525 $1,050

• Lower jaw $450 $900

• Wrist ................................................ $400 ........... $800

• Elbow $400 $800

• One finger, toe $125 $250

• For a chip fracture, your benefit would be 25% of the amount shown. Chip fractures are those in which a fragment of bone is broken off near a joint at a point where a ligament is attached.

• For multiple fractures or dislocations, we will pay for both, up to two times the highest amount.

• For your first dislocation, you would receive the amount shown; however, recurrent dislocations of the same joint are not covered.

Optional Spouse and Dependent Child(ren) Coverage

You may cover one or all of the eligible dependent members of your family for an additional premium. Eligible dependents include your spouse and ALL dependent children who are younger than age 26.

ACCIDENTAL INJURIES BENEFITS

• Accident emergency treatment $400

• X-ray $150

• Accident follow-up treatment (including transportation)/Telemedicine $75 (up to six benefits per accident per person, up to twelve a year per person)

HOSPITAL CONFINEMENT BENEFIT FOR ACCIDENT OR SICKNESS

Up to three months ...................................... $1,500/month ($50/day)

ACCIDENTAL DEATH AND DISMEMBERMENT BENEFITS

• Accidental death $5,000

• Loss of a finger or toe

Single dismemberment ................................................... $75

Double dismemberment $150

• Loss of a hand, foot or sight of an eye

Single dismemberment ................................................. $500

Double dismemberment ............................................... $1,000

• Common carrier death (includes school bus for school activities) $10,000

More than 1 in 4 of 20-year-olds become disabled before retirement age.2

Frequently Asked Questions

Will my disability income payment be reduced if I have other insurance?

Benefits are payable regardless of workers’ compensation or any other insurance you may have with other insurance companies. Benefits are payable directly to you (unless you specify otherwise).

When am I considered totally disabled?

Totally disabled means you are:

• Unable to perform the material and substantial duties of your occupation;

• Not, in fact, working at any occupation; and

• Under the regular and appropriate care of a doctor.

What if I want to return to work part time after I am totally disabled?

You may be able to return to work part time and still receive benefits. We call this “Partial Disability.” This means you may be eligible for coverage if:

• You are unable to perform the material and substantial duties of your job for more than half of your normally weekly scheduled hours;

• You are able to work at your job or your place of employment for less than half of your normally weekly scheduled hours;

• Your employer will allow you to return to your job or place of employment for less than half of your normally weekly scheduled hours; and

• You are under the regular and appropriate care of a doctor.

The total disability benefit must have been paid for at least fourteen days immediately prior to your being partially disabled.

When do disability benefits end?

The Total Disability Benefit will end on the policy anniversary date on or next following your 70th birthday, or when you are no longer considered disabled as defined in the policy, whichever comes first.

The Hospital Confinement benefit increases when the Total Disability Benefit ends.

Can

I keep my coverage if I change jobs?

If you change jobs or retire, you can take your coverage with you at no additional cost. Your coverage is guaranteed renewable for life as long as you pay your premiums when they are due or within the grace period.

How do I file a claim?

Visit ColonialLife.com or call our Policyholder Service Center at 1-800-325-4368 for additional information.

What is a pre-existing condition?

A pre-existing condition means a sickness or physical condition for which any covered person was treated, received medical advice, or had taken medication within twelve months before the effective date of the policy. If you are age 65 or older when the policy is issued, pre-existing conditions include only conditions specifically excluded from coverage by the rider.

If you become disabled due to a pre-existing condition, we will not pay for any disability period if it begins during the first twelve months the policy is in force.

What is the Mental or Nervous Disorder benefit?

This benefit provides coverage for a disability due to a mental or nervous condition. Coverage provides a benefit up to three months per occurrence, with a cumulative lifetime maximum benefit of 24 months.

For more information, talk with your Colonial Life benefits counselor.

1. Educator Disability Advantage is the marketing name of the insurance product filed as “Disability Income Insurance Policy.”

2. U.S. Social Security Administration, The Faces and Facts of Disability. https://www.ssa.gov/disabilityfacts/facts.html. Accessed April 2021.

EXCLUSIONS AND LIMITATIONS

We will not pay benefits for losses that are caused by or are the result of: Cosmetic Surgery, Felonies and Illegal Occupations, Flying, Hazardous Avocations, Intoxicants and Narcotics, Racing, Semiprofessional or Professional Sports, Substance Abuse, Suicide or Self-Inflicted Injuries, and War or Armed Conflict.

Underwritten by Colonial Life & Accident Insurance Company, Columbia, SC.

FOR EMPLOYEES 8-22 | 1006400-1

ColonialLife.com

Accident Insurance

Accidental injuries that send you to the Emergency Room, Urgent Care or doctor’s office

Back or knee injuries Colonial Life’s Accident Insurance is designed to help you fill some of the gaps caused by increasing deductibles, co-payments and out-of-pocket costs related to an accidental injury. The benefit to you is that you may not need to use your savings or secure a loan to pay expenses. Plus you’ll feel better knowing you can have greater financial security.

What if I change employers?

If you change jobs or leave your employer, you can take your coverage with you at no additional cost. Your coverage is guaranteed renewable as long as you pay your premiums when they are due or within the grace period.

Can my premium change?

Colonial Life can change your premium only if we change it on all policies of this kind in the state where your policy was issued.

How do I file a claim?

Visit coloniallife.com or call our Customer Service Department at 1.800.325.4368 for additional information.

Accident 1.0 -Preferred with Health Screening Benefit

What additional features are included? l Worldwide coverage l Portable l Compliant with Healthcare Spending Account (HSA) guidelines Will my accident claim payment be reduced if I have other insurance?

paid regardless of any other insurance you may have with other insurance companies, and the benefits are paid directly to you (unless you specify otherwise).

Accidents happen in places where you and your family spend the most time – at work, in the home and on the playground – and they’re unexpected. How you care for them shouldn’t be. In your lifetime, which of these accidental injuries have happened to you or someone you know?

Sports-related accidental injury

Broken bone

Burn

Concussion

Laceration

Car accidents

Falls & spills

Dislocation

You’re

Ankle – Bone or Bones of the Foot (other than Toes) $2,640 $5,280 Collarbone (Sternoclavicular) $1,650 $3,300

Lower Jaw, Shoulder, Elbow, Wrist $990 $1,980 Bone or Bones of the Hand $990 $1,980 Collarbone (Acromioclavicular and Separation) $330 $660 One Toe or Finger $330 $660

Fractures

Non-Surgical Surgical

Depressed Skull $5,500 $11,000

Non-Depressed Skull $2,200 $4,400 Hip, Thigh $3,300 $6,600

Body of Vertebrae, Pelvis, Leg $1,650 $3,300 Bones of Face or Nose (except mandible or maxilla) $770 $1,540

Upper Jaw, Maxilla $770 $1,540

Upper Arm between Elbow and Shoulder $770 $1,540 Lower Jaw, Mandible, Kneecap, Ankle, Foot $660 $1,320 Shoulder Blade, Collarbone, Vertebral Process $660 $1,320 Forearm, Wrist, Hand $660 $1,320 Rib $550 $1,100 Coccyx $440 $880 Finger, Toe $220 $440

Your Colonial Life policy also provides benefits for the following injuries received as a result of a covered accident. l Burn (based on size and degree) .................................................................................... $1,000 to $12,000 l Coma ............................................................................................................................................................. $10,000 l Concussion .......................................................................................................................................................$150 l Emergency Dental Work ....................................... $75 Extraction, $300 Crown, Implant, or Denture l Lacerations (based on size) ........................................................................................................... $50 to $800 Requires Surgery l Eye Injury $300 l Tendon/Ligament/Rotator Cuff $500 - one, $1,000 - two or more l Ruptured Disc $500 l Torn Knee Cartilage $500 Surgical Care l Surgery (cranial, open abdominal or thoracic) ................................................................................ $1,500 l Surgery (hernia) ..............................................................................................................................................$150 l Surgery (arthroscopic or exploratory) ....................................................................................................$250 l Blood/Plasma/Platelets ................................................................................................................................$300 Benefits listed are for each covered person per covered accident unless otherwise specified. Initial Care l Accident Emergency Treatment...........$150 l Ambulance ....................................... $400 l X-ray Benefit ................................................... $50 l Air Ambulance ............................. $2,000 Common Accidental Injuries Dislocations (Separated Joint) Non-Surgical Surgical Hip $6,600 $13,200 Knee (except patella) $3,300 $6,600

Transportation/Lodging Assistance

If injured, covered person must travel more than 50 miles from residence to receive special treatment and confinement in a hospital.

l Transportation $500 per round trip up to 3 round trips

l Lodging (family member or companion) $125 per night up to 30 days for a hotel/motel lodging costs

Accident Hospital Care

l Hospital Admission* $1,500 per accident

l Hospital ICU Admission* $3,000 per accident

* We will pay either the Hospital Admission or Hospital Intensive Care Unit (ICU) Admission, but not both.

l Hospital Confinement ......................................................... $250 per day up to 365 days per accident

l Hospital ICU Confinement ................................................... $500 per day up to 15 days per accident

Accident Follow-Up Care

l Accident Follow-Up Doctor Visit $50 (up to 3 visits per accident)

l Medical Imaging Study ...................................................................................................... $250 per accident (limit 1 per covered accident and 1 per calendar year)

l Occupational or Physical Therapy ..................................................... $35 per treatment up to 10 days l Appliances .......................................................................................... $125 (such as wheelchair, crutches)

l Prosthetic Devices/Artificial Limb .................................................... $500 - one, $1,000 - more than 1

l Rehabilitation Unit .................................................$100 per day up to 15 days per covered accident, and 30 days per calendar year. Maximum of 30 days per calendar year

Accidental Dismemberment

l Loss of Finger/Toe ................................................................................. $750 – one, $1,500 – two or more l Loss or Loss of Use of Hand/Foot/Sight of Eye ..................... $7,500 – one, $15,000 – two or more

Catastrophic Accident

For severe injuries that result in the total and irrecoverable: l Loss of one hand and one foot l Loss of the sight of both eyes l Loss of both hands or both feet l Loss of the hearing of both ears l Loss or loss of use of one arm and one leg or l Loss of the ability to speak l Loss or loss of use of both arms or both legs

Named Insured ................ $25,000 Spouse .............. $25,000 Child(ren) ......... $12,500 365-day elimination period. Amounts reduced for covered persons age 65 and over. Payable once per lifetime for each covered person.

Accidental Death

Accidental Death Common Carrier

l Named Insured $25,000 $100,000 l Spouse $25,000 $100,000

l Child(ren) $5,000 $20,000

Health Screening Benefit

l $50 per covered person per calendar year

Provides a benefit if the covered person has one of the health screening tests performed. This benefit is payable once per calendar year per person and is subject to a 30-day waiting period.

Tests include:

l Blood test for triglycerides

l Bone marrow testing

l Breast ultrasound

l CA 15-3 (blood test for breast cancer)

l CA125 (blood test for ovarian cancer)

l Carotid doppler

l CEA (blood test for colon cancer)

l Chest x-ray

l Colonoscopy

l Echocardiogram (ECHO)

l Electrocardiogram (EKG, ECG)

l Fasting blood glucose test l Flexible sigmoidoscopy

l Hemoccult stool analysis l Mammography l Pap smear

l PSA (blood test for prostate cancer)

l Serum cholesterol test to determine level of HDL and LDL

l Serum protein electrophoresis (blood test for myeloma)

l Stress test on a bicycle or treadmill l Skin cancer biopsy l Thermography l ThinPrep pap test l Virtual colonoscopy

EXCLUSIONS

We will not pay benefits for losses that are caused by or are the result of: hazardous avocations; felonies or illegal occupations; racing; semi-professional or professional sports; sickness; suicide or self-inflicted injuries; war or armed conflict; in addition to the exclusions listed above, we also will not pay the Catastrophic Accident benefit for injuries that are caused by or are the result of: birth; intoxication.

For cost and complete details, see your Colonial Life benefits counselor. Applicable to policy form Accident 1.0-HS-NC. This is not an insurance contract and only the actual policy provisions will control.

Colonial Life

1200 Colonial Life Boulevard Columbia, South Carolina 29210 coloniallife.com

71740-NC

6-14

Accident 1.0 -Preferred with Health Screening Benefit My Coverage Worksheet (For use with your Colonial

benefits counselor) Who will be covered? (check one) Employee Only Spouse Only One Child Only Employee & Spouse One-Parent Family, with Employee One-Parent Family, with Spouse Two-Parent Family When are covered accident benefits available? (check one) On and Off -Job Benefits Off -Job Only Benefits 67

Life

For more information, talk with your benefits counselor.

Hospital Confinement Indemnity Insurance

Plan 2

Our Individual Medical BridgeSM insurance can help with medical costs that your health insurance may not cover. These benefits are available for you, your spouse and eligible dependent children.

Hospital confinement $

Maximum of one benefit per covered person per calendar year

Observation room $100 per visit

Maximum of two visits per covered person per calendar year

Rehabilitation unit confinement

$100 per day

Maximum of 15 days per confinement with a 30-day maximum per covered person per calendar year

Waiver of premium

Available after 30 continuous days of a covered hospital confinement of the named insured

Outpatient surgical procedure

Tier 1 $_______________

Tier 2 $

Maximum of $________________ per covered person per calendar year for all covered outpatient surgical procedures combined

The surgeries listed below are only a sampling of the surgeries that may be covered. Surgeries must be performed by a doctor in a hospital or ambulatory surgical center. For complete details and definitions, please refer to your policy.

Tier 1 outpatient surgical procedures

Breast

Axillary node dissection

Breast capsulotomy

Lumpectomy

Cardiac

Pacemaker insertion

Digestive

Colonoscopy

Fistulotomy

Hemorrhoidectomy

Lysis of adhesions

Skin

Laparoscopic hernia repair

Skin grafting

Ear, nose, throat, mouth

Adenoidectomy

Removal of oral lesions

Myringotomy

Tonsillectomy

Tracheostomy

Tympanotomy

Gynecological

Dilation and curettage (D&C)

Endometrial ablation

Lysis of adhesions

Liver

Paracentesis

Musculoskeletal system

Carpal/cubital repair or release

Foot surgery (bunionectomy, exostectomy, arthroplasty, hammertoe repair)

Removal of orthopedic hardware

Removal of tendon lesion

IMB7000 – PLAN 2

–

..................................................................

ColonialLife.com

Tier 2 outpatient surgical procedures

Breast – Breast reconstruction – Breast reduction

Cardiac – Angioplasty – Cardiac catheterization

Digestive – Exploratory laparoscopy – Laparoscopic appendectomy – Laparoscopic cholecystectomy

Ear, nose, throat, mouth – Ethmoidectomy – Mastoidectomy – Septoplasty – Stapedectomy – Tympanoplasty Eye – Cataract surgery – Corneal surgery (penetrating keratoplasty) – Glaucoma surgery (trabeculectomy) – Vitrectomy

THIS POLICY PROVIDES LIMITED BENEFITS.

EXCLUSIONS

Gynecological – Hysterectomy – Myomectomy

Musculoskeletal system

– Arthroscopic knee surgery with meniscectomy (knee cartilage repair)

– Arthroscopic shoulder surgery – Clavicle resection

– Dislocations (open reduction with internal fixation)

– Fracture (open reduction with internal fixation) – Removal or implantation of cartilage – Tendon/ligament repair

Thyroid – Excision of a mass Urologic – Lithotripsy

We will not pay benefits for losses which are caused by: alcoholism or drug addiction, dental procedures, elective procedures and cosmetic surgery, felonies or illegal occupations, pregnancy of a dependent child, psychiatric or psychological conditions, suicide or injuries which any covered person intentionally does to himself or herself, or war. We will not pay benefits for hospital confinement of a newborn who is neither injured nor sick. We will not pay benefits for loss during the first 12 months after the effective date due to a pre-existing condition. Pre-exisiting conditions are those conditions whether diagnosed or not, for which a covered person received medical advice, diagnosis or care, or treatment was received or recommended within the one-year period immediately preceding the effective date of the policy. If a covered person is 65 or older when the policy is issued, pre-existing conditions will include only conditions specifically eliminated by rider.

For cost and complete details, see your Colonial Life benefits counselor. Applicable to policy number IMB7000-NC. This is not an insurance contract and only the actual policy provisions will control.

Underwritten by Colonial Life & Accident Insurance Company, Columbia, SC ©2018 Colonial Life & Accident Insurance Company. All rights reserved. Colonial Life is a registered trademark and marketing brand of Colonial Life & Accident Insurance Company.

5-18 | 101578-1-NC

For more information, talk with your benefits counselor.

Hospital Confinement Indemnity Insurance

Plan 3

Our Individual Medical BridgeSM insurance can help with medical costs that your health insurance may not cover. These benefits are available for you, your spouse and eligible dependent children.

Hospital confinement $

Maximum of one benefit per covered person per calendar year

Observation room $100 per visit

Maximum of two visits per covered person per calendar year

Rehabilitation unit confinement

$100 per day

Maximum of 15 days per confinement with a 30-day maximum per covered person per calendar year

Waiver of premium

Available after 30 continuous days of a covered hospital confinement of the named insured

Diagnostic procedure Tier 1 $250 Tier 2 $500

Maximum of $500 per covered person per calendar year for all covered diagnostic procedures combined

Outpatient surgical procedure Tier 1 $ Tier 2 $

Maximum of $___________ per covered person per calendar year for all covered outpatient surgical procedures combined

The following is a list of common diagnostic procedures that may be covered.

Tier 1 diagnostic procedures

Breast

Biopsy (incisional, needle, stereotactic)

Diagnostic radiology

Nuclear medicine test

Digestive

Barium enema/lower GI series

Barium swallow/upper GI series

Esophagogastroduodenoscopy (EGD)

Ear, nose, throat, mouth

Laryngoscopy

Gynecological

Amniocentesis

Cervical biopsy

Cone biopsy

Endometrial biopsy

Loop electrosurgical excisional procedure (LEEP)

Tier 2 diagnostic procedures

Cardiac

Angiogram

Arteriogram

Thallium stress test

Transesophageal echocardiogram (TEE)

Liver – biopsy

Lymphatic – biopsy

Miscellaneous

Bone marrow aspiration/biopsy

Renal – biopsy

Respiratory

Biopsy

Bronchoscopy

Pulmonary function test (PFT)

Biopsy

Excision of lesion

Thyroid – biopsy

Urologic

Cystoscopy

Diagnostic radiology

Computerized tomography scan (CT scan)

Electroencephalogram (EEG)

Magnetic resonance imaging (MRI)

Myelogram

Positron emission tomography scan (PET scan)

IMB7000 – PLAN 3

–

Skin

–

– Hysteroscopy

ColonialLife.com

Tier 1 outpatient surgical procedures

Breast – Axillary node dissection – Breast capsulotomy – Lumpectomy

Cardiac – Pacemaker insertion Digestive – Colonoscopy – Fistulotomy – Hemorrhoidectomy – Lysis of adhesions

Skin – Laparoscopic hernia repair – Skin grafting

Ear, nose, throat, mouth – Adenoidectomy – Removal of oral lesions – Myringotomy – Tonsillectomy – Tracheostomy – Tympanotomy

Tier 2 outpatient

surgical procedures

Breast – Breast reconstruction – Breast reduction Cardiac – Angioplasty – Cardiac catheterization Digestive – Exploratory laparoscopy – Laparoscopic appendectomy – Laparoscopic cholecystectomy Ear, nose, throat, mouth – Ethmoidectomy – Mastoidectomy – Septoplasty – Stapedectomy – Tympanoplasty Eye – Cataract surgery – Corneal surgery (penetrating keratoplasty) – Glaucoma surgery (trabeculectomy) – Vitrectomy

EXCLUSIONS

Gynecological – Dilation and curettage (D&C) – Endometrial ablation – Lysis of adhesions Liver – Paracentesis Musculoskeletal system – Carpal/cubital repair or release

– Foot surgery (bunionectomy, exostectomy, arthroplasty, hammertoe repair) – Removal of orthopedic hardware – Removal of tendon lesion

Gynecological – Hysterectomy – Myomectomy Musculoskeletal system – Arthroscopic knee surgery with meniscectomy (knee cartilage repair) – Arthroscopic shoulder surgery – Clavicle resection – Dislocations (open reduction with internal fixation) – Fracture (open reduction with internal fixation) – Removal or implantation of cartilage – Tendon/ligament repair Thyroid – Excision of a mass Urologic – Lithotripsy

For cost and complete details, see your Colonial Life benefits counselor. Applicable to policy number IMB7000-NC. This is not an insurance contract and only the actual policy provisions will control.

©2015 Colonial Life & Accident Insurance Company, Columbia, SC | Colonial Life insurance products are underwritten by Colonial Life & Accident Insurance Company, for which Colonial Life is the marketing brand. 7-15 | 101581-NC

For more information, talk with your benefits counselor.

Hospital Confinement Indemnity Insurance

Health Screening

Individual Medical BridgeSM insurance’s health screening benefit can help pay for health and wellness tests you have each year.

Health screening $_____________

Maximum of one health screening test per covered person per calendar year; subject to a 30-day waiting period

Blood test for triglycerides

Bone marrow testing

Breast ultrasound

CA 15-3 (blood test for breast cancer)

CA 125 (blood test for ovarian cancer)

CEA (blood test for colon cancer)

Carotid Doppler

Chest X-ray

Colonoscopy

Echocardiogram (ECHO)

Electrocardiogram (EKG, ECG)

Fasting blood glucose test

Flexible sigmoidoscopy

Hemoccult stool analysis

Mammography

Pap smear

PSA (blood test for prostate cancer)

Serum cholesterol test for HDL and LDL levels

Serum protein electrophoresis (blood test for myeloma)

Skin cancer biopsy

Stress test on a bicycle or treadmill

Thermography

ThinPrep pap test

Virtual colonoscopy

ColonialLife.com

Waiting period means the first 30 days following any covered person’s policy coverage effective date, during which no benefits are payable. For cost and complete details, see your Colonial Life benefits counselor. Applicable to policy number IMB7000 (including state abbreviations where used, for example: IMB7000-TX). Coverage may vary by state and may not be available in all states. This is not an insurance contract and only the actual policy provisions will control.

IMB7000 – HEALTH SCREENING BENEFIT | 2-15 | 101579

For more information, talk with your benefits counselor.

Hospital Confinement Indemnity Insurance

Medical Treatment Package

The medical treatment package for Individual Medical BridgeSM coverage can help pay for deductibles, co-payments and other out-of-pocket expenses related to a covered accident or covered sickness.

The medical treatment package paired with Plan 2 or Plan 3 provides the following benefits:

Air ambulance $1,000

Maximum of one benefit per covered person per calendar year

Ambulance $100

Maximum of one benefit per covered person per calendar year

Appliance $100

Maximum of one benefit per covered person per calendar year

Doctor’s office visit ................................................................................... $25 per visit

Maximum of three visits per calendar year for named insured coverage or maximum of five visits per calendar year for all covered persons combined

Emergency room visit $100 per visit

Maximum of two visits per covered person per calendar year

X-ray $25 per benefit

Maximum of two benefits per covered person per calendar year

EXCLUSIONS

This information is not intended to be a complete description of the insurance coverage available. The insurance has exclusions and limitations which may affect any benefits payable. Applicable to policy form IMB7000-NC. For cost and complete details of coverage, call or write your Colonial Life benefits counselor or the company.

Underwritten by Colonial Life & Accident Insurance Company, Columbia, SC. © 2021 Colonial Life & Accident Insurance Company. All rights reserved Colonial Life is a registered trademark and marketing brand of Colonial Life & Accident Insurance Company.

IMB7000-MEDICAL

EDUCATORS | 3-21 | NS-15014-1-NC

TREATMENT PACKAGE NORTH CAROLINA

ColonialLife.com

THIS POLICY PROVIDES LIMITED BENEFITS.

For more information, talk with your benefits counselor.

Hospital Confinement Indemnity Insurance

Optional Riders

Individual Medical BridgeSM offers two optional benefit riders – the daily hospital confinement rider and the enhanced intensive care unit confinement rider. For an additional cost, these riders can help provide extra financial protection to help with out-of-pocket medical expenses.

Daily hospital confinement rider

Per covered person per day of hospital confinement

Maximum of 365 days per covered person per confinement

Enhanced intensive care unit confinement rider

Per covered person per day of intensive care unit confinement Maximum of 30 days per covered person per confinement

Re-confinement for the same or related condition within 90 days of discharge is considered a continuation of a previous confinement.

$100 per day

$500 per day

EXCLUSIONS

For cost and complete details, see your Colonial Life benefits counselor. Applicable to rider numbers R-DHC7000-NC and R-EIC7000-NC. This is not an insurance contract and only the actual policy or rider provisions will control.

IMB7000 – DAILY HOSPITAL CONFINEMENT AND ENHANCED INTENSIVE CARE UNIT CONFINEMENT RIDERS | 7-15 | 101582-NC

ColonialLife.com

Term Life Insurance

Life insurance protection when you need

it most

Life insurance needs change as life circumstances change. You may need different coverage if you’re getting married, buying a home or having a child.

Term life insurance from Colonial Life provides protection for a specified period of time, typically offering the greatest amount of coverage for the lowest initial premium. This fact makes term life insurance a good choice for supplementing cash value coverage during life stages when obligations are higher, such as while children are younger. It’s also a good option for families on a tight budget — especially since you can convert it to a permanent cash value plan later.

With this coverage:

n A beneficiary can receive a benefit that is typically free from income tax.

n The policy’s accelerated death benefit can pay a percentage of the death benefit if the covered person is diagnosed with a terminal illness.

n You can convert it to a Colonial Life cash value insurance plan, with no proof of good health, to age 75.

n Coverage is guaranteed renewable up to age 95 as long as premiums are paid when due.

n Portability allows you to take it with you if you change jobs or retire.

Spouse coverage options

1. Spouse Term Life Policy: Offers guaranteed premiums and level death benefits equivalent to those available to you –whether or not you buy a policy for yourself.

2. Spouse Term Life Rider: Add a term rider for your spouse to your policy, up to a maximum death benefit of $50,000; 10-year and 20-year are available (20-year rider only available with a 20- or 30-year term policy).

Dependent coverage options

The Children’s Term Life Rider may be added to either the primary or spouse policy, not both.

If the insured dies by suicide, whether sane or insane, within two years (one year in ND) from the coverage effective date or the date of reinstatement, we will not pay the death benefit. We will terminate this policy and return the premiums paid, without interest. Product may vary by state. For cost and complete details of the coverage, call or write your Colonial Life benefits counselor or the company.

Colonial Life insurance products are underwritten by Colonial Life & Accident Insurance Company, Columbia, SC. ©2019 Colonial Life & Accident Insurance Company. All rights reserved. Colonial Life is a registered trademark and marketing brand of Colonial Life & Accident Insurance Company.

with your Colonial Life benefits counselor to learn more.

7-19 | NS-16570-1 Talk

ColonialLife.com

Two options are available for spouse coverage at an additional cost: You may add a Children’s Term Life Rider to cover all of your eligible dependent children with up to $20,000 in coverage each for one premium.

How much coverage do you need?

£ YOU $ ___________________

Select the term period: £ 10-year £ 15-year £ 20-year £ 30-year £ SPOUSE $ ___________________

Select the term period: £ 10-year £ 15-year £ 20-year £ 30-year Select any optional riders: £ Spouse term life rider $ _____________ face amount for ________-year term period £ Children’s term life rider $ _____________ face amount £ Accidental death benefit rider £ Chronic care accelerated death benefit rider £ Critical illness accelerated death benefit rider £ Waiver of premium benefit rider

Optional riders

At an additional cost, you can purchase the following riders for even more financial protection.

Spouse term life rider

Your spouse may receive a maximum death benefit of $50,000; 10-year and 20-year spouse term riders are available.

Children’s term life rider

You can purchase up to $20,000 in term life coverage for all of your eligible dependent children and pay one premium. The children’s term life rider may be added to either your policy or your spouse’s policy – not both.

Accidental death benefit rider

The beneficiary may receive an additional benefit if the covered person dies as a result of an accident before age 70. The benefit doubles if the accidental bodily injury occurs while riding as a fare-paying passenger using public transportation, such as ride-sharing services. An additional 25% will be payable if the injury is sustained while driving or riding in a private passenger vehicle and wearing a seatbelt.

Chronic care accelerated death benefit rider

If a licensed health care practitioner certifies that you have a chronic illness, you may receive an advance on all or a portion of the death benefit, available in a one-time lump sum or monthly payments.1 A chronic illness means you require substantial supervision due to a severe cognitive impairment or you may be unable to perform at least two of the six Activities of Daily Living.2 Premiums are waived during the benefit period.

Critical illness accelerated death benefit rider

If you suffer a heart attack (myocardial infarction), stroke or end-stage renal (kidney) failure, a $5,000 benefit is payable.1 A subsequent diagnosis benefit is included

Waiver of premium benefit rider

Premiums are waived (for the policy and riders) if you become totally disabled before the policy anniversary following your 65th birthday and you satisfy the six-month elimination period.3

To learn more, talk with your Colonial Life benefits counselor.

ColonialLife.com

1 Any payout would reduce the death benefit. Benefits may be taxable as income. Individuals should consult with their legal or tax counsel when deciding to apply for accelerated benefits. 2 Activities of daily living are bathing, continence, dressing, eating, toileting and transferring. 3 You must resume premium payments once you are no longer disabled.

EXCLUSIONS AND LIMITATIONS

If the insured dies by suicide, whether sane or insane, within two years (one year in ND) from the coverage effective date or the date of reinstatement, we will not pay the death benefit. We will terminate this policy and return the premiums paid without interest, minus any loans and loan interest to you.

This information is not intended to be a complete description of the insurance coverage available. The policy or its provisions may vary or be unavailable in some states. The policy has exclusions and limitations which may affect any benefits payable. Applicable to policy forms ICC18-ITL5000/ITL5000 and rider forms ICC18-R-ITL5000-STR/RITL5000- STR, ICC18-R-ITL5000-CTR/R-ITL5000-CTR, ICC18-R-ITL5000-WP/R-ITL5000-WP, ICC18-R-ITL5000-ACCD/RITL5000- ACCD, ICC18-R-ITL5000-CI/R-ITL5000-CI, ICC18-R-ITL5000-CC/R-ITL5000-CC. For cost and complete details of the coverage, call or write your Colonial Life benefits counselor or the company.

Underwritten by Colonial Life & Accident Insurance Company, Columbia, SC ©2021 Colonial Life & Accident Insurance Company. All rights reserved. Colonial Life is a registered trademark and marketing brand of Colonial Life & Accident Insurance Company.

9-21 | 101895-2

Whole Life Plus Insurance

Give your family peace of mind and coverage for final expenses with Whole Life Plus insurance from Colonial Life.

BENEFITS AND FEATURES

Choose the age when your premium payments end — Paid-Up at Age 70 or Paid-Up at Age 100

Stand-alone spouse policy available even without buying a policy for yourself

Ability to keep the policy if you change jobs or retire

Built-in terminal illness accelerated death benefit that provides up to 75% of the policy’s death benefit (up to $150,000) if you’re diagnosed with a terminal illness2

Immediate $3,000 claim payment that can help your designated beneficiary pay for funeral costs or other expenses

Provides cash surrender value at age 100 (when the policy endows)

ADDITIONAL COVERAGE OPTIONS

Spouse term rider

Cover your spouse with a death benefit up to $50,000, for 10 or 20 years.

Juvenile Whole Life Plus policy

Purchase a policy (paid-up at age 70) while children are young and premiums are low — whether or not you buy a policy for yourself. You may also increase the coverage when the child is 18, 21 and 24 without proof of good health.

Children’s term rider

You may purchase up to $20,000 in term life coverage for all of your eligible dependent children and pay one premium. The children’s term rider may be added to either your policy or your spouse’s policy — not both.

ADVANTAGES OF WHOLE LIFE PLUS INSURANCE

• Permanent coverage that stays the same through the life of the policy

• Premiums will not increase due to changes in health or age

• Accumulates cash value based on a non-forfeiture interest rate of 3.75%1

• Policy loans available, which can be used for emergencies

• Benefit for the beneficiary that is typically tax-free

Your cost will vary based on the amount of coverage you select.

You can’t predict your family’s future, but you can be prepared for it.

WHOLE LIFE PLUS (IWL5000) 77

Benefits worksheet

For use with your benefits counselor

How much coverage do you need?  YOU $

Select the option:  Paid-Up at Age 70  Paid-Up at Age 100 

SPOUSE $

Select the option:  Paid-Up at Age 70  Paid-Up at Age 100 

DEPENDENT STUDENT $

Select the option:  Paid-Up at Age 70  Paid-Up at Age 100

Select any optional riders: 

Spouse term rider $ _____________face amount for _________-year term period 

Children’s term rider $ face amount  Accidental death benefit rider  Chronic care accelerated death benefit rider  Critical illness accelerated death benefit rider  Guaranteed purchase option rider 

Waiver of premium benefit rider

To learn more, talk with your benefits counselor.

ADDITIONAL COVERAGE OPTIONS (CONTINUED)

Accidental death benefit rider

Chronic care accelerated death benefit rider

If a licensed health care practitioner certifies that you have a chronic illness, you may receive an advance on all or a portion of the death benefit, available in a one-time lump sum or monthly payments.2 A chronic illness means you require substantial supervision due to a severe cognitive impairment or you may be unable to perform at least two of the six Activities of Daily Living (bathing, continence, dressing, eating, toileting and transferring). Premiums are waived during the benefit period.

Critical illness accelerated death benefit rider

If you suffer a heart attack (myocardial infarction), stroke or end-stage renal (kidney) failure, a $5,000 benefit is payable.2 A subsequent diagnosis benefit is included.

Guaranteed purchase option rider

This rider allows you to purchase additional whole life coverage — without having to answer health questions — at three different points in the future. The rider may only be added if you are age 50 or younger when you purchase the policy. You may purchase up to your initial face amount, not to exceed a total combined maximum of $100,000 for all options.

Waiver of premium benefit rider

Premiums are waived (for the policy and riders) if you become totally disabled before the policy anniversary following your 65th birthday and you satisfy the six-month elimination period. Once you are no longer disabled, premium payments will resume.

1. Accessing the accumulated cash value reduces the death benefit by the amount accessed, unless the loan is repaid. Cash value will be reduced by any outstanding loans against the policy. 2. Any payout would reduce the death benefit. Benefits may be taxable as income. Individuals should consult with their legal or tax counsel when deciding to apply for accelerated benefits.

EXCLUSIONS AND LIMITATIONS: If the insured dies by suicide, whether sane or insane, within two years (one year in ND) from the coverage effective date or the date of reinstatement, we will not pay the death benefit. We will terminate this policy and return the premiums paid without interest, minus any loans and loan interest to you.

This information is not intended to be a complete description of the insurance coverage available. The policy or its provisions may vary or be unavailable in some states. The policy has exclusions and limitations which may affect any benefits payable. Applicable to policy forms ICC19IWL5000-70/IWL5000-70, ICC19-IWL5000-100/IWL5000-100, ICC19-IWL5000J/IWL5000J and rider forms ICC19-R-IWL5000-STR/R-IWL5000-STR, ICC19-R-IWL5000-CTR/R-IWL5000-CTR, ICC19-R-IWL5000-WP/R-IWL5000-WP, ICC19-R-IWL5000-ACCD/R-IWL5000-ACCD, ICC19-RIWL5000-CI/R-IWL5000-CI, ICC19-R-IWL5000-CC/R-IWL5000-CC, ICC19-R-IWL5000-GPO/RIWL5000-GPO. For cost and complete details of the coverage, call or write your Colonial Life benefits counselor or the company.

Underwritten by Colonial Life & Accident Insurance Company, Columbia, SC.

ColonialLife.com

FOR EMPLOYEES 6-21 | 642298 78

Nationwide is on your side ¹Some exclusions may apply. Certain coverages may be subject to pre-existing exclusion. See policy documents for a complete list of exclusions. Reimbursement options may not be available in all states. ²Starting prices indicated. Final cost varies according to plan, species and ZIP code. Products underwritten by Veterinary Pet Insurance Company (CA), Columbus, OH; National Casualty Company (all other states), Columbus, OH. Agency of Record: DVM Insurance Agency. All are subsidiaries of Nationwide Mutual Insurance Company. Nationwide, the Nationwide N and Eagle, and Nationwide is on your side are service marks of Nationwide Mutual Insurance Company. ©2021 Nationwide. 21GRP8274C Get reimbursed. 3 Submit claim. 2 Visit any vet, anywhere. 1 How to use your pet insurance plan $27-$47/month² 70% reimbursement $20-$35/month² 50% reimbursement Choose your level of coverage with My Pet Protection® Get cash back on eligible vet bills: Choose your reimbursement level of 50% or 70%1 Available exclusively for employees: Plans with preferred pricing only offered through your company Use any vet, anywhere: No networks, no pre-approvals Our popular My Pet Protection® pet insurance plans now feature more choices and more flexibility Pet insurance from Nationwide® With two budget-friendly options, there’s never been a better time to protect your pet. https://benefits.petinsurance.com/eliada 79

ADDITIONALBENEFITS

THE FSASTORE FLEX SPENDING WITH ZERO GUESSWORK

TakecontrolofyourhealthandwellnesswithguaranteedFSA-eligibleessentials.PierceGroup BenefitspartnerswiththeFSAstoretoprovideoneconvenientlocationforFlexibleSpending AccountholderstomanageandusetheirFSAfunds,andsaveonmorethan4,000healthand wellnessproductsusingtax-freehealthmoney.Throughourpartnership,we’realsoheretohelp answerthemanyquestionsthatcomealongwithhavingaFlexibleSpendingAccount!

GROUP BENEFITS

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Your

– The largest selection of guaranteed FSA-eligible products Phone and live chat support available 24 hours a day / 7 days a week – Fast and free shipping on orders over $50 Use your FSA card or any other major credit card for purchases

Great FSAstore Resources Available To You Eligibility List:Acomprehensivelistofeligibleproductsandservices FSA Calculator:EstimatehowmuchyoucansavewithanFSA Learning Center:EasytipsandresourcesforlivingwithanFSA Savings Center:WhereyoucansaveevenmoreonFSA-eligibleessentials FSAPerks:TakeyourhealthandfundsfurtherwiththeFSAstorerewardsprogram ShopFSAEligibleProductsThroughOurPartnershipwithTheFSAStore! BONUS: Get $20 off any order of $150+ with code PGB20FSA (one use per customer). 80

Other

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 person’s legal Guardian, Power of Attorney Designee, or Conservator. ___________________ _____

(Printed name of individual (Social Security (Signature) (Date Signed) subject to this disclosure) Number)

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) (Signature of legal representative) (Date Signed)

I’m Leaving, Now What?

Other Benefits

If you wish to continue coverage of any of the following benefits, Pierce Group Benefits will be happy to serve you:

•

Please visit www.piercegroupbenefits.com/individualfamily or call 888-662-7500 for more information on these policies, as well as to enroll/continue your benefits. You may also click on the “Individual & Family” button on the Pierce Group Benefits homepage, www.piercegroupbenefits.com to access this information.

Transferring from one Employer to Another?

If you are transferring from a current PGB client to another, some benefits may be eligible for transfer. Please call 888 662 7500 and a Service Specialist will be glad to help you.

Dental and Vision Insurance

Group Term Life Insurance

Supplemental/Voluntary Insurances - Cancer, Disability, Life, etc.

Flexible Spending Accounts

BLUECROSS BLUESHIELD - HEALTH INSURANCE

• Website: www.bcbsnc.com

METLIFE - DENTAL INSURANCE

• Customer Service: 1-800-438-6388

• Website: www.metlife.com/mybenefits

EYEMED - VISION INSURANCE

• Customer Service: 1-866-804-0982

• Website: www.eyemed.com

• Customer Service: 1-888-868-3539

• Website: www.myameriflex.com

• Claims Mailing Address: P.O. Box 269009, Plano,

EMPLOYEE ASSISTANCE NETWORKEMPLOYEE ASSISTANCE PROGRAM

• Customer Service: 1-800-454-1477

• Website: www.EANNC.com or www.MyLifeExpert.com

THE HARTFORD - LONG-TERM DISABILITY

• Customer Service: 1-800-523-2233

• Website: www.thehartford.com/employeebenefits

THE HARTFORD - TERM LIFE INSURANCE

• Customer Service: 1-800-523-2233

• Website: www.thehartford.com/employeebenefits

NATIONWIDE

- PET INSURANCE

• Customer Service: 1-877-738-7874

• Website: www.benefits.petinsurance.com/eliada

TO

ONLINE

COLONIAL

• Website: 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 18 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 18 months 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.

CONTACT INFORMATION:

LIFE

TDD for hearing impaired

VISIT COLONIALLIFE.COM TO SET UP YOUR PERSONAL ACCOUNT When you terminate employment, 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. AMERIFLEX - DEPENDENT CARE FLEXIBLE SPENDING ACCOUNT

• Customer Service & Wellness Screenings: 1-800-325-4368 •

customers call: 1-800-798-4040

75026 MANAGE YOUR ACCOUNT ONLINE OR DOWNLOAD THE MYAMERIFLEX MOBILE APP • Check your Balance • Submit a Claim • Check Claim Status

Mark Your Card Lost or Stolen Visit www.piercegroupbenefits.com/ EliadaHomes For additional information concerning plans offered to employees of Eliada Homes, please contact our North Carolina Service Center at 1-888-662-7500, ext. 100

•

VIEW YOUR BENEFITS

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Contact the Customer Service Center at the number shown

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