henry county government benefits booklet 2020

EMPLOYEE BENEFITS PLAN HENRY COUNTY GOVERNMENT & PUBLIC SERVICE AUTHORITY PLAN YEAR: JULY 1, 2020 - JUNE 30, 2021

ARRANGED BY PIERCE GROUP BENEFITS WWW.PIERCEGROUPBENEFITS.COM

EMPLOYEE BENEFITS GUIDE

TABLE OF CONTENTS Welcome to the Henry County Government & Public Service Authority 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.

ENROLLMENT PERIOD: APRIL 13, 2020 - APRIL 24, 2020 EFFECTIVE DATES: JULY 1, 2020 - JUNE 30, 2021 Benefits Plan Overview

page

2

Medical Bridge Benefits

page

39

Online Enrollment Instructions

page

5

Life Insurance

page

44

Health Benefits

page

7

Additional Benefits Available

page

46

Cobra Continuation Of Coverage Rights

page

47

Authorization Form

page

49

Notice Of Insurance Information Practices

page

50

Continuation Of Coverage for Benefits Form

page

51

Dental Benefits

Vision Benefits

Flexible Spending Accounts

page

page

page

13 15 16

Cancer Benefits

page

20

Critical Care Benefits

page

27

Disability Benefits

page

30

Accident Benefits

page

34 Rev. 11/30/2020

PRE-TAX & POST-TAX BENEFITS

HENRY COUNTY GOVERNMENT & PUBLIC SERVICE AUTHORITY ENROLLMENT PERIOD: APRIL 13, 2020 - APRIL 24, 2020 EFFECTIVE DATES: JULY 1, 2020 - JUNE 30, 2021

PRE-TAX BENEFITS Dental Insurance

Health Insurance

Delta

Anthem

Vision Insurance Superior

Flexible Spending Accounts*

Flexible Benefits Administrators • Medical Reimbursement FSA Maximum: $2,750/year • Dependent Care Reimbursement FSA Maximum: $5,000/year *You will need to re-sign for the Flexible Spending Accounts if you want them to continue each year.

Accident Benefits

Cancer Benefits

Colonial Life

Colonial Life

Medical Bridge Benefits

Colonial Life

POST-TAX BENEFITS Disability Benefits Colonial Life

Critical Care Benefits Colonial Life

Accident Benefits Gunshot Wound Policy Colonial Life

2

Life Insurance Colonial Life

• Term Life Insurance • Whole Life Insurance

QUALIFICATIONS & IMPORTANT INFO

THINGS YOU NEED TO KNOW QUALIFICATIONS: • Henry County Government monthly and semi-monthly employees working 35 hours or more per week are eligible for all benefits.

• Henry County PSA employees are eligible for all benefits. PSA employees: if you have questions about your current dental plan, please see HR.

IMPORTANT FACTS: • The plan year for Anthem Health, Delta Dental, Superior Vision, Spending Accounts and Colonial Insurance products lasts from July 1, 2020 through June 30, 2021.

• Deductions for Anthem Health, Delta Dental and Superior Vision will begin June 2020. Deductions for Spending Accounts and Colonial Insurance products will begin July 2020.

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

• If you will be receiving a new debit card, whether you are a new participant or to replace your expired card, please be aware that it may take up to 30 days following your plan effective date for your card to arrive. Your card will be delivered by mail in a plain white envelope. During this time you may use manual claim forms for eligible expenses.

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 Pierce Group Benefits Service Center at 1-800-387-5955 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 90 days 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 90 days 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.

• The Colonial Medical Bridge plan has a 30-day waiting period for new enrollees. Coverage, therefore, will not begin until July 31, 2020.

• 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.

3

EMPLOYEE BENEFITS GUIDE

HENRY COUNTY GOVERNMENT & PUBLIC SERVICE AUTHORITY IN PERSON

ONLINE

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

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.

ENROLLMENT PERIOD: APRIL 13, 2020 - APRIL 24, 2020 YOU CAN MAKE THE FOLLOWING BENEFIT ELECTIONS ONLINE DURING THE ENROLLMENT PERIOD: • • • • •

Enroll, change or cancel your Health Insurance.

Enroll, change or cancel your Vision Insurance.

Enroll, change or cancel your Dental Insurance.

Sign up/re-enroll your Flexible Spending Account (Medical Reimbursement and Dependent Care).

Enroll, change or cancel your Colonial products (see the following pages for changes that can be completed online).

ACCESS YOUR BENEFITS ONLINE WHENEVER, WHEREVER. Benefits Details | Educational Videos | Download Forms | Online Chat with Service Center To view your personalized benefits website, go to:

www.piercegroupbenefits.com/henrycounty or piercegroupbenefits.com and click “Find Your Benefits”.

IMPORTANT NOTE & DISCLAIMER

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.

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BenSelect

BENSELECT ONLINE ENROLLMENT: COMPLETE THE STEPS BELOW TO BEGIN THE ONLINE ENROLLMENT PROCESS

HELPFUL TIPS:

• If you are a new employee and unable to log into the online system, please speak with the Benefits Representative assigned to your location, or contact Human Resources.

• If you are an existing employee and unable to log into the online system, please contact Pierce Group Benefits at 888-662-7500 between 8:30am and 5:00pm, or speak with your Benefits Representative assigned to your location.

1.

Go to https://harmony.benselect.com/henrycounty • Enter your User Name: Social Security Number with or without dashes (ex. 123-45-6789 or 123456789) • Enter your PIN: Last 4 numbers of your Social Security Number followed by last 2 numbers of your Date of Birth year (ex. 678970)

2.

The screen prompts you to create a NEW PIN [____________________________].

3.

Choose a security question and enter answer [______________________________________].

4.

Confirm (or enter) an email address

5.

Click on ‘Save New PIN’ to continue to the enrollment welcome screen.

6.

From the welcome screen click “Next”.

7.

The screen shows ‘Personal Information’. Verify that the information is correct and enter the additional required information (marital status, work phone, e-mail address). Click ‘Next’.

8.

The screen allows you to add family members. It is only necessary to enter family member information if adding or including family members in your coverage. Click ‘Next’.

9.

The screen shows ‘Benefit Summary’. Review your current benefits and make changes/selections for the upcoming plan year.

• HEALTH: You may enroll online in Health coverage.

• DENTAL: You may enroll online in Dental coverage.

• VISION: You may enroll online in Vision coverage.

• HEALTH CARE FSA: Enter annual amount. MAX $2,750/year • DEPENDENT CARE FSA: Enter annual amount. MAX $5,000/year

<<< enrollment instructions continued on next page >>>

5

BenSelect

BENSELECT ONLINE ENROLLMENT CONT.:

• DISABILITY 3000 You may enroll online in Disability 3000.

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

• CRITICAL CARE You may enroll online in Critical Care coverage.

• MEDICAL BRIDGE You may enroll online in Medical Bridge 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.

• GUNSHOT WOUND POLICY You will need to speak to a Benefits Representative in order to enroll in the Gunshot Wound policy.

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

10.

Click ‘Sign & Submit’ once you have decided which benefits to enroll in.

11.

Review your coverage. If any items are ‘Pending’, you will need to decide whether to enroll or decline this benefit.

12.

Click ‘Next’ to review and electronically sign the authorization for your benefit elections.

13.

Review the confirmation, then if you are satisfied with your elections, enter your PIN and click ‘Sign Form’.

14.

Click ‘Download & Print’ to print a copy of your elections, or download and save the document. Please do not forget this important step!!!

15.

Click ‘Log Out’.

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Henry County Government & Public Service Authority July 1, 2020 - June 30, 2021 Anthem KeyCare 30 1000/20%/4500 In-Network

Plan Year Deductible Individual Family (two or more people)

$1,000 $2,000 In-Network

Plan Year Out-of-Pocket Expense Limit Individual Out-of-Pocket Maximum Family Out-of-Pocket Maximum

$4,500 $9,000 Unlimited

Lifetime Maximum

Covered Services

In-Network Benefits Only

Doctor's Visits (Outpatient or In-Office) Primary Care Physician Visits -

$30 Copayment

Chiropractic, Spinal Manipulations (visit limits apply)

Specialist Visits -

$50 Copayment

Chiropractic, Spinal Manipulations (visit limits apply)

$20 Copayment

On-line Medical Visit

No Charge

Labs (Office or Preferred Reference Lab) Diagnostic Tests, Labs, Advanced Diagnostic Imaging and X-Rays

20% Coinsurance, after deductible Covered at 100%

Preventive Care Visits

Hospital & Other Services Pre-certification may be required

20% Coinsurance, after deductible

Emergency Room Visits

$50 Copayment

Urgent Care Copay Inpatient Hospital Services (includes Maternity, Mental and

20% Coinsurance, after deductible

Substance Use Disorder)

Outpatient Hospital Services

20% Coinsurance, after deductible

Physical Therapy/OCC Therapy/Speech Therapy (visit

20% Coinsurance, after deductible

limits apply)

Essential Formualry

Prescription Drug Benefit

Retail Pharmacy (up to a 31-day supply)

A 90 day supply is available at most retail pharmacies Tier 1

$10 Copayment

Tier 2

$30 Copayment

Tier 3

$50 Copayment

Tier 4

20% up to $200 per prescription

7

Henry County Government & Public Service Authority July 1, 2020 - June 30, 2021 Contribution Schedule KeyCare 1000/20%/4500 Employee Only

Employee + Child

Total Monthly Premium

$723.17

$1,352.41

$1,551.96

$1,576.55

$2,169.59

$2,169.59

Employer Monthly Contribution

$723.17

$763.17

$783.17

$783.17

$843.17

$1,566.34

Employee Monthly Contribution

$0.00

$589.24

$768.79

$793.38

$1,326.42

$603.25

Employee Semi-Monthly Contribution

$0.00

$294.62

$384.40

$396.69

$663.21

$301.63

Employee + Children Employee + Spouse Employee + Family Balanced Family

8

LiveHealth Online What you need to know about video visits with a doctor, 24/7 What is LiveHealth Online?

LiveHealth Online should not be used for emergency care. If you have a medical emergency, call 911 right away.

LiveHealth Online lets you have a video visit with a boardcertified doctor using your smartphone, tablet or computer with a webcam. No appointments, no driving and no waiting at an urgent care center. Doctors are available 24/7 to assess your condition and, if it’s needed, they can send a prescription to your local pharmacy.*

When is LiveHealth Online available?

Doctors are available 24/7, 365 days a year.

How does LiveHealth Online work?

Use LiveHealth Online if you have pinkeye, a cold, the flu, a fever, rashes, infections, allergies or another common health condition. It’s faster, easier and more convenient than a visit to an urgent care center.

When you need to see a doctor, simply go to livehealthonline.com or use the LiveHealth Online mobile app.

Pick the state you’re in and answer a few questions.

Why would I use LiveHealth Online instead of going to visit my doctor in person?

Setting up an account allows you to securely store your personal and health information. Plus, you can easily connect with doctors in the future, share your health history and set up online visits at times that fit your schedule.

LiveHealth Online isn’t meant to replace your primary care doctor. It’s a convenient option for care when your doctor isn’t available. LiveHealth Online connects you with a doctor in minutes. Plus, you can get a LiveHealth Online visit summary from the MyHealth tab at livehealthonline.com to print, email or fax to your primary care doctor.

Once connected, you can talk with the doctor as if you were in a private exam room.

59965MUMENABS_M VPOD 03/17

9

How much does it cost to use LiveHealth Online?

Your Anthem plan includes benefits for video visits using LiveHealth Online, so you’ll just pay your share of the costs — usually $49 or less for a doctor visit.

Will I be charged more if I use LiveHealth Online on weekends, holidays or at night?

No, the cost is the same.

How do I pay for a LiveHealth Online visit?

You can use PayPal, American Express, Visa, MasterCard and Discover cards to pay for an online doctor visit. Keep in mind that charges for prescriptions aren’t included in the cost of your visit.

Is there a LiveHealth Online app that I can download to my smartphone?

Yes, search for “LiveHealth Online” in the App Store® or on Google Play . To learn what mobile devices are supported and get instructions, go to livehealthonline.com and select Frequently asked questions under the How it works tab.

TM

Can I get online care from a doctor if I’m traveling or in another state?

What type of computer do I need to use LiveHealth Online?

You’ll need high-speed Internet access, a webcam or built-in camera with audio. To learn what computer hardware and software you need, go to livehealthonline.com and select Frequently asked questions under the How it works tab.

Yes, just select the state you’re in under My Location on livehealthonline.com or with the app, and you’ll only see doctors licensed to treat you in that state. Don’t forget to change the state back when you get home.

Do doctors have access to my health information?

What if I still have questions about using LiveHealth Online?

It depends on whether or not you set up an account. With a LiveHealth Online account, you can allow doctors to access and review your health information from past visits. Also, to help keep track of your own health information, you can record it at livehealthonline.com. Once you sign in, go to the MyHealth tab and then select Health Record.

Send an email to customersupport@livehealthonline.com or call toll free at 1-888-548-3432.

How long is a LiveHealth Online visit?

A typical LiveHealth Online visit with a doctor lasts about 10 minutes.

* Prescription availability is defined by physician judgment and state regulations. Visit the home page of livehealthonline.com to view the service map by state.

LiveHealth Online is the trade name of Health Management Corporation, a separate company providing telehealth services on behalf of Anthem.

If you’re a retiree or have coverage that complements your Medicare benefits, your employer sponsored health plan may not include coverage for online visits using LiveHealth Online. Check your plan documents for details. You can still use LiveHealth Online, but you may have to pay the full cost of a visit. Online visits using LiveHealth Online may not be a covered benefit for HRA and HIA+ members.

Anthem Blue Cross and Blue Shield is the trade name of: In Colorado: Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc. Copies of Colorado network access plans are available on request from member services or can be obtained by going to anthem.com/co/networkaccess. In Connecticut: Anthem Health Plans, Inc. In Indiana: Anthem Insurance Companies, Inc. In Kentucky: Anthem Health Plans of Kentucky, Inc. In Maine: Anthem Health Plans of Maine, Inc. In Missouri (excluding 30 counties in the Kansas City area): RightCHOICE® Managed Care, Inc. (RIT), Healthy Alliance® Life Insurance Company (HALIC), and HMO Missouri, Inc. RIT and certain affiliates administer non-HMO benefits underwritten by HALIC and HMO benefits underwritten by HMO Missouri, Inc. RIT and certain affiliates only provide administrative services for self-funded plans and do not underwrite benefits. In Nevada: Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc., dba HMO Nevada. In New Hampshire: Anthem Health Plans of New Hampshire, Inc.; HMO plans are administered by Anthem Health Plans of New Hampshire, Inc. and underwritten by Matthew Thornton Health Plan, Inc. In Ohio: Community Insurance Company. In Virginia: Anthem Health Plans of Virginia, Inc. trades as Anthem Blue Cross and Blue Shield in Virginia, and its service area is all of Virginia except for the City of Fairfax, the Town of Vienna, and the area east of State Route 123. In Wisconsin: Blue Cross Blue Shield of Wisconsin (BCBSWi), underwrites or administers PPO and indemnity policies and underwrites the out of network benefits in POS policies offered by Compcare Health Services Insurance Corporation (Compcare) or Wisconsin Collaborative Insurance Corporation (WCIC). Compcare underwrites or administers HMO or POS policies; WCIC underwrites or administers Well Priority HMO or POS policies. Independent licensees of the Blue Cross and Blue Shield Association. ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association.

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Nine months.

Many questions.

Future Moms can help — any time, any day Ever wish you had a go-to source for all of your questions about pregnancy? Now, you do. Future Moms is a program that can answer your questions, help you make good choices and follow your health care provider’s plan of care. And it can help you have a safe delivery and a healthy child.

Sign up as soon as you know you’re pregnant. Just call us toll free at 800-828-5891. One of our registered nurses will help you get started.

You’ll get: }

A toll-free number so you can talk to a nurse coach 24/7 about your pregnancy. A nurse may also call you from time to time to see how you’re doing.

}

The Mayo Clinic Guide to a Healthy Pregnancy book that shows changes you can expect for you and your baby during the next nine months.

}

A screening to check your health risk for depression or early delivery.

}

Other useful tools to help you, your doctor and your Future Moms nurse keep track of your pregnancy and help you make healthier choices.

}

Free phone calls with pharmacists, nutritionists and other specialists, if needed.

}

A booklet with tips to help keep you and your new baby safe and well.

}

It’s easy to join

Other helpful information on labor and delivery, including options and how to prepare.

Visit with a lactation consultant online Using Future Moms with Breastfeeding Support on LiveHealth Online, you can make appointments for free video visits with a certified lactation consultant, counselor or registered dietitian at no extra cost to you! These professionals can provide personalized support to help you with breastfeeding techniques, learn about milk production, baby hunger cues, foods to avoid, nutrition while breastfeeding and more.

Sign up for Future Moms by calling us toll free at 800-828-5891. There’s no extra cost to you.

Once your baby is born, get lactation support with LiveHealth Online.

Sign up now for livehealthonline.com or use the free mobile app and enter your health plan information. Once you’ve created an account, select Future Moms with Breastfeeding Support to view the available lactation consultants, counselors and registered dietitians. Appointments are available 7 days a week and evenings, too. Schedule your appointment at any time by logging in to LiveHealth Online.

Health and wellness programs are not covered services under the health plan, but are additions; these programs’ features are not guaranteed under your health plan certificate and could be discontinued at any time. Anthem Health Plans of Virginia, Inc. trades as Anthem Blue Cross and Blue Shield in Virginia, and its service area is all of Virginia except for the City of Fairfax, the Town of Vienna, and the area east of State Route 123. Anthem Blue Cross and Blue Shield and its affiliate HealthKeepers, Inc. are independent licensees of the Blue Cross Blue Shield Association. ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. 62150VAMENBVA VPOD Rev. 8/16

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Say hi to Sydney Anthem’s new app is simple, smart — and all about you With Sydney, you can find everything you need to know about your Anthem benefits -- personalized and all in one place. Sydney makes it easier to get things done, so you can spend more time focused on your health.

Get started with Sydney Download the app today!

Ready for you to use quickly, easily, seamlessly — with one-click access to benefits info, Member Services, wellness resources and more.

Sydney acts like a personal health guide, answering your questions and connecting you to the right resources at the right time. And you can use the chatbot to get answers quickly.

With just one click, you can: 

Find care and check costs



Check all benefits



See claims

Get alerts, reminders and tips directly from Sydney. Get doctor suggestions based on your needs.

The more you use it, the more Sydney can help you stay healthy and save money.

Already using one of our apps? 

Get answers even faster with our chatbot



View and use digital ID cards

It’s easy to make the switch. Simply download the Sydney app and log in with your Anthem username and password.

Anthem Blue Cross and Blue Shield is the trade name of: In Colorado: Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc. In Connecticut: Anthem Health Plans, Inc. In Georgia: Blue Cross Blue Shield Healthcare Plan of Georgia, Inc. In Indiana: Anthem Insurance Companies, Inc. In Kentucky: Anthem Health Plans of Kentucky, Inc. In Maine: Anthem Health Plans of Maine, Inc. In Missouri (excluding 30 counties in the Kansas City area): RightCHOICE® Managed Care, Inc. (RIT), Healthy Alliance® Life Insurance Company (HALIC), and HMO Missouri, Inc. RIT and certain affiliates administer non-HMO benefits underwritten by HALIC and HMO benefits underwritten by HMO Missouri, Inc. RIT and certain affiliates only provide administrative services for self-funded plans and do not underwrite benefits. In Nevada: Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc., dba HMO Nevada. In New Hampshire: Anthem Health Plans of New Hampshire, Inc. HMO plans are administered by Anthem Health Plans of New Hampshire, Inc. and underwritten by Matthew Thornton Health Plan, Inc. In Ohio: Community Insurance Company. In Virginia: Anthem Health Plans of Virginia, Inc. trades as Anthem Blue Cross and Blue Shield in Virginia, and its service area is all of Virginia except for the City of Fairfax, the Town of Vienna, and the area east of State Route 123. In Wisconsin: Blue Cross Blue Shield of Wisconsin (BCBSWI), underwrites or administers PPO and indemnity policies and underwrites the out of network benefits in POS policies offered by Compcare Health Services Insurance Corporation (Compcare) or Wisconsin Collaborative Insurance Corporation (WCIC).

Compcare underwrites or administers HMO or POS policies; WCIC underwrites or administers Well Priority HMO or POS policies. Independent licensees of the Blue Cross and Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc. 115993MUMENABS 06/19

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     

13

Rev 1.2019

  

Employee Contribution Monthly Employee Contribution (semi-monthly)

Employee Only

Employee + Child

Employee + Spouse

Employee + Family

$26.78

$49.10

$64.68

$71.36

$13.39

$24.55

$32.34

$35.68

This plan is for Henry County employees. PSA employees, please see Human Resources if you have any questions about your current dental plan.

14

Rev 1.2019

Vision plan benefits for Henry County Government Copays

Monthly $9.07

SemiMonthly $4.54

Services/frequency

Exam

$15

Emp. only

Exam

12 months

Materials1

$15

12 months

$30

$7.14 $7.25

Frame

Contact lens fitting

Emp. + spouse $14.28 Emp. + child(ren) $14.50

Contact lens fitting

12 months

Emp. + family

$11.60

Lenses

12 months

(standard & specialty)

$23.19

Contact lenses

12 months

(based on date of service)

Benefits through Superior National network Exam (ophthalmologist) Exam (optometrist) Frames Contact lens fitting (standard2) Contact lens fitting (specialty2) Lenses (standard) per pair Single vision Bifocal Trifocal Progressives lens upgrade Factory scratch coat Polycarbonate for dependent children Contact lenses4

In-network

Out-of-network

Covered in full Covered in full $130 retail allowance Covered in full $50 retail allowance

Up to $34 retail Up to $26 retail Up to $61 retail Not covered Not covered

Covered in full Covered in full Covered in full See description3 Covered in full Covered in full $130 retail allowance

Up to $29 retail Up to $42 retail Up to $53 retail Up to $53 retail Not covered Not covered Up to $100 retail

Co-pays apply to in-network benefits; co-pays for out-of-network visits are deducted from reimbursements 1 Materials co-pay applies to lenses and frames only, not contact lenses 2 Standard contact lens fitting applies to a current contact lens user who wears disposable, daily wear, or extended wear lenses only. Specialty contact lens fitting applies to new contact wearers and/or a member who wear toric, gas permeable, or multi-focal lenses.

3 Covered to providerâ&#x20AC;&#x2122;s in-office standard retail lined trifocal amount; member pays difference between progressive and standard retail lined trifocal, plus applicable co-pay.

4 Contact lenses are in lieu of eyeglass lenses and frames benefit

Discount features

superiorvision.com

Look for providers in the provider directory who accept discounts, as some do not; please verify their services and discounts (range from 10%-30%) prior to service as they vary.

(800) 507-3800

Discounts on covered materials Frames: Lens options: Progressives:

20% off amount over allowance 20% off retail Discounts on non-covered exam, services and materials 20% off amount over retail lined trifocal Exams, frames, and prescription lenses: 30% off retail lens, including lens options Lens options, contacts, miscellaneous options: 20% off retail Specialty contact lens fit: 10% off retail, then apply allowance Disposable contact lenses: 10% off retail Retinal imaging: $39 maximum out-of-pocket Maximum member out-of-pocket The following options have out-of-pocket maximums5 on standard LASIK (not premium, brand, or progressive) lenses.

Laser vision correction (LASIK) is a procedure that can reduce or Single vision Bifocal & trifocal eliminate your dependency on glasses or contact lenses. This Ultraviolet coat $15 $15 corrective service is available to you and your eligible dependents Tints, solid or gradients $25 $25 at a special discount (20-50%) with your Superior Vision plan.

Anti-reflective coat $50 $50 Contact QualSight LASIK at (877) 201-3602 for more information.

Polycarbonate $40 20% off retail High index 1.6 Photochromics 5

$55 $80

The Plan discount features are not insurance.

20% off retail 20% off retail

All allowances are retail; the member is responsible for paying the provider directly for all non-covered items and/or any amount over the allowances, minus available discounts. These are not covered by the plan.

Discounts and maximums may vary by lens type. Please check with your provider

Discounts are subject to change without notice. .

Disclaimer: All final determinations of benefits, administrative duties, and definitions are governed by the Certificate of Insurance for your vision plan.

Please check with your Human Resources department if you have any questions.

Superior Vision Services, Inc. P.O. Box 967 Rancho Cordova, CA 95741 (800) 507-3800 superiorvision.com The Superior Vision Plan is underwritten by National Guardian Life Insurance Company. National Guardian Life Insurance Company is not affiliated with The Guardian Life Insurance Company of America, AKA The Guardian or Guardian Life NVIGRP 5-07 0220-BSv2/VA

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Get reimbursed for out-of-pocket healthcare and child/aged adult day care expenses with tax free dollars.

THE HEALTHCARE ACCOUNT IS A PRE-FUNDED ACCOUNT

MAXIMIZE YOUR INCOME! Flexible Spending Accounts (FSAs) allow you to pay certain healthcare and dependent care expenses with pre-tax money. You will not pay any Federal, State or Social Security taxes on funds placed in the plan.

You will save approximately $27.65 to $37.65 on every $100 you place in the Plan. The amount of your savings will depend on your Federal tax bracket.

This means that you can submit a claim for medical expenses on the first day of the Plan Year and you will be reimbursed your total claim amount up to your annual election. The funds that you are pre-funded will be recovered as deductions which are taken from your paycheck on a pre-tax basis.

ELIGIBILITY HEALTHCARE REIMBURSEMENT Those employees having a qualifying event are eligible to enroll within 30 days of the qualifying event. Deductions begin on the first pay period following your Plan start date. You must complete an enrollment to participate in the Flexible Spending Accounts each year during the enrollment period. If an enrollment is not completed during open enrollment, you will not be enrolled in the Plan and you will not be able to join until the next Plan Year or if you have a qualifying event.

With this account, you can pay for your out-of-pocket healthcare expenses for yourself, your spouse and all your tax dependents for healthcare services that are incurred during your Plan Year and while an active participant. Eligible expenses are those incurred for the diagnosis, cure, mitigation, treatment, or prevention of disease, or for affecting any structure or function of the body.

EXAMPLES OF ELIGIBLE HEALTH CARE EXPENSES Fees/Co-Pays/Deductibles For: • Acupuncture • Prescription eyeglasses/ reading glasses/ Contact lens and supplies/ Eye exams/ Laser eye surgery • Physician • Ambulance • Psychiatrist • Psychologist • Anesthetist • Hospital • Chiropractor • Laboratory/ diagnostic • Fertility treatments

ELECTION CHANGES Election changes are only allowed if you experience one of the following qualifying events: • Marriage or divorce • Birth or adoption • Involuntary loss of spouse’s medical or dental coverage

• Death of dependent (child or spouse) • Unpaid FMLA or Non-FMLA leave • Change in Dependent Care Providers

REIMBURSEMENT SCHEDULE All manual or paper claims received in the office of Flexible Benefit Administrators, Inc. will be processed within one week via check or direct deposit. You may also use your Benefits Card to pay for expenses. Please refer to the Benefits Card section for details.

• Surgery • Dental/ Orthodontic fees • Obstetrician • X-Rays • Eye exams • Prescription drugs • Artificial limbs & teeth • Birth control pills, patches • Orthopedic shoes/ inserts • Therapeutic care for drug and alcohol addiction • Vaccinations & immunizations

• Mileage • Take-home screening kits • Diabetic supplies • Routine physicals • Oxygen • Physical therapy • Hearing aids and batteries • Medical equipment

OVER-THE-COUNTER EXPENSES Examples of medications and drugs that may be purchased in reasonable quantities with a prescription:

ONLINE ACCESS Flexible Benefit Administrators, Inc. provides on-line account access for all FSA participants. Please visit their website at:

• Antacids • Pain relievers/aspirin • Ointments & creams for joint pain • Allergy & sinus medication

https://fba.wealthcareportal.com/ to view the following features: • FSA Login – View account transactions, create account alerts and download participation forms.

• FSA Educational Tools – FSA calculator: estimate how much you can save by utilizing an FSA.

16

• • • •

First aid creams Cough & cold medications Laxatives Anti-diarrhea medicine

DAY CARE/AGED ADULT CARE REIMBURSEMENT

HOW TO RECEIVE REIMBURSEMENT

The Day Care/Aged Adult Care FSA allows you to pay for day care To obtain a reimbursement from your Flexible Spending Account, expenses for your qualified dependent with pre-tax dollars. Eligible you must complete a Claim Form. This form is available to you Dependent Care expenses are those you must pay for the care of on our website. You must attach a receipt or bill from the service an eligible dependent so that provider which includes all the HOW THE FLEXIBLE BENEFIT PLAN WORKS you and your spouse can work. pertinent information regarding Eligible dependents, as revised the expense: Without With under Section 152 of the Code Flex Benefits Flex Benefits • Date of service by the Working Families Tax Act $ 2,500.00 $ 2,500.00 of 2005, are defined as either Gross Monthly Income • Patient’s name dependent children or dependent Eligible Pre-Tax employer medical insurance $ 0.00 $ 200.00 • Amount charged relatives that you claim as Eligible Pre-Tax Medical Expenses $ 0.00 $ 100.00 0.00 $ 300.00 dependents on your taxes. Refer to Eligible Pre-Tax Dependent Child Care Expenses$ • Provider’s name the Employee Guide for more details. Taxable Income $ 2500.00 $ 1900.00 • Nature of the expense Eligible dependents are further Federal Tax (15%) $ 375.00 $ 285.00 • Amount covered by defined as: State Tax (5.75%) $ 143.75 $ 109.25 insurance (if applicable) • Under age 13 FICA Tax (7.65%) $ 191.25 $ 145.35 • Physically or mentally After-Tax employer medical insurance $ 200.00 $ 0.00 Canceled checks, bankcard unable to care for After-Tax medical expenses $ 100.00 $ 0.00 receipts, credit card receipts themselves such as: After-Tax dependent child care expenses $ 300.00 $ 0.00 and credit card statements - Disabled spouse Monthly Spendable Income $ 1190.00 $ 1360.40 are NOT acceptable forms - Children who became disof documentation. You are abled prior to age 19.

By taking advantage of the Flexible Benefit Plan this employee was able responsible for paying your - Elderly parents that live to increase his/her spendable income by $170.40 every month! This healthcare or dependent care with you isan annual tax savings of $2,044.80. Remember, with the FLEXIBLE provider directly.

Contribution Limits: The BENEFIT PLAN, the better you plan the more you save! annual maximum contribution may not exceed the lesser of the FORFEITING FUNDS following: Plan carefully! Unused funds will be forfeited back to your employer • $5,000 ($2,500 if married filing separately) per household as governed by the IRS’s “use-it-or-lose-it” rule. Please see the Employ• Your wages for the year or your spouse’s if less than above ee Guide for more info.

• Maximum is reduced by spouse’s contribution to a Day Care/ Aged Adult Care FSA HOW TO ENROLL IN OUR FSA PLAN Step 1 Carefully estimate your eligible Healthcare and Day Care/Aged Adult Care expenses for the upcoming Plan Year. Then use our online FSA Educational Tools located at https://fba.wealthcareportal.com/ to help you determine your total expenses for the Plan Year.

ELIGIBLE DAY CARE/AGED ADULT CARE EXPENSES • Au Pair • Nannies • Before and After Care • Day Camps • Babysitters

• Daycare for an Elderly Dependent

• Nursery School

• Daycare for a Disabled Dependent

• Sick Child Center

• Private Pre School

Step 2 Complete your enrollment during the open enrollment period, which instructs payroll to deduct a certain amount of money for your expenses. This amount will be contributed on a pre-tax basis from your paychecks to your FSA. Remember the amount you elect will be set aside before any Federal, Social Security, and State taxes are calculated.

• Licensed Day Care Centers

Ineligible Expenses • Overnight Camps • Babysitting for Social Events • Food Expenses (if separate from dependent care expenses)

BENEFITS CARD

• Care Provided By Children Under 19 (or by anyone you claim as a dependent)

The Benefits Card can be used as a direct payment method for eligible expenses incurred at approved service providers and merchants.

Using your card allows you instant access to your funds with no out-of-pocket expense. Please keep all your itemized receipts.

Flexible Benefit Administrators, Inc. may request documentation to substantiate Benefits Card transactions to determine eligibility of an expense. Benefits Cards are available upon request of the account holder for dependents over the age of 18. Please contact Flexible Benefit Administrators, Inc. to order additional cards.

• Days Your Spouse Doesn’t Work (though you may still have to pay the provider) • Kindergarten expenses are ineligible as an expense because it is primarily educational, regardless if it is half or full day, private, public, state mandated or voluntary.

• Transportation, books, clothing, food, entertainment and registration fees are ineligible if these expenses are shown separately on your bill.

• Expenses incurred while on a Leave of Absence or Vacation.

P.O. Drawer 8188 • Virginia Beach, VA 23450 • Toll Free (800) 437-3539 • Phone (757) 340-4567 • Fax (757) 431-1155 www.flex-admin.com

17

a a o r healthcare f a ce ea w th the le ble e ef t m trator member portal e le ible enefit dministrators member ortal ro ides you it o erful self ser ice account access lus education and decision su ort tools t at el ut you in t e dri er s seat it your ealt care finances.

eat re ll acco t eta l at o r f ert p intuiti e online access to lan details account balances and transaction istory including rior years elf er ce co e e ce c ec balances submit claims and recei t documentation ay bills manage in estments and more

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et tarte oa

er ce a

offer

it access to more t an

to el you get t e most alue from your ealt care dollars

a e co trol of o r healthcare f a ce th ope e rollme t ea o b re ter for o l e acce to o r pre ta acco t at fba.wealthcareportal.com.

18

Click and Submit with online and mobile claimsâ&#x20AC;Ś Itâ&#x20AC;&#x2122;s that easy.

Introducing... online claims submission at your keyboard! With the online claim submission feature you can submit claims for your benefit accounts including benefit card substantiation requests.

You can also submit claims and take pictures of your documentation right from your smart phone app!

Follow the simple steps below to su mit our claim.

Get started by visiting ttps ba.wealthcareportal.com or open your mobile app and log-in to your account using your user name and password.

Hover over Claims and then click Submit Claim on the portal or click Claims in the app.

Fll in all of the information on the form including: Service Dates Account Type Claim Amount Enter the provider information if payment is to go to the provider Attach a file or snap picture of your documentation.

Check certification box and click OK Once you have entered all of your claims, check the certification box and then click Submit.

Once completed your claim will be posted immediately to your account and will be reviewed within 2-3 business days.

Submit Today!

If you have any questions regarding your claims submission, please contact us at 800-437-3539 or flexdivision@flex-admin.com.

19

Cancer Insurance How would cancer impact your way of life?

Hopefully, you and your family will never face cancer. If you do, a financial safety net can help you and your loved ones focus on what matters most — recovery.

If you were diagnosed with cancer, you could have expenses that medical insurance doesn’t cover. In addition to your regular, ongoing bills, you could have indirect treatment and recovery costs, such as child care and home health care services.

Help when you need it most Cancer coverage from Colonial Life & Accident Insurance Company can help protect the lifestyle you’ve worked so hard to build. It provides benefits you can use to help cover: ■ Loss of income ■ Out-of-network treatment ■ Lodging and meals ■ Deductibles and co-pays

20

CANCER ASSIST

One family’s journey

DOCTOR’S SCREENING

Paul and Kim were preparing for their second child when they learned Paul had cancer. They quickly realized their medical insurance wouldn’t cover everything.

Thankfully, Kim’s job enabled her to have a cancer insurance policy on Paul to help them with expenses.

SECOND OPINION

SURGERY

Wellness benefit

Travel expenses

Out-of-pocket costs

Paul’s wellness benefit helped pay for the screening that discovered his cancer.

When the couple traveled several hundred miles from their home to a top cancer hospital, they used the policy’s lodging and transportation benefits to help with expenses.

The policy’s benefits helped with deductibles and co-pays related to Paul’s surgery and hospital stay.

For illustrative purposes only

With cancer insurance: ■ Coverage options are available for you

and your eligible dependents.

■ Benefits are paid directly to you, unless

you specify otherwise.

■ You’re paid regardless of any insurance

you may have with other companies.

■ You can take coverage with you, even if you

change jobs or retire.

ONLY of ALL

CANCERS are

hereditary.

American Cancer Society, Cancer Facts & Figures, 2013

21

Cancer insurance provides benefits to help with cancer expenses — from diagnosis to recovery.

TREATMENT

RECOVERY

Experimental care

Follow-up evaluations

Paul used his plan’s benefits to help pay for experimental treatments not covered by his medical insurance.

Paul has been cancer-free for more than four years.

His cancer policy provides a benefit for periodic scans to help ensure the cancer stays in check.

Our cancer insurance offers more than 30 benefits that can help you with costs that may not be covered by your medical insurance.

Treatment benefits

(inpatient or outpatient)

Surgery benefits ■ Surgical procedures

■ Radiation/chemotherapy

■ Anesthesia

■ Anti-nausea medication

■ Reconstructive surgery

■ Medical imaging studies

■ Outpatient surgical center

■ S upportive or protective care drugs

■ Prosthetic device/artificial limb

and colony stimulating factors ■ Second medical opinion ■ B lood/plasma/platelets/

immunoglobulins ■ B one marrow or peripheral stem

LIFETIME RISK OF DEVELOPING CANCER

Travel benefits ■ Transportation ■ Companion transportation ■ Lodging

MEN 1 in 2

cell donation ■ B one marrow or peripheral stem

cell transplant ■ E gg(s) extraction or harvesting/

sperm collection and storage ■ Experimental treatment ■ H air/external breast/voice

box prosthesis ■ Home health care services ■ Hospice (initial or daily care)

Inpatient benefits ■ Hospital confinement ■ Private full-time nursing services ■ Skilled nursing care facility ■ Ambulance ■ Air ambulance

Additional benefits WOMEN

■ Family care

1 in 3

■ Cancer vaccine ■ Bone marrow donor screening ■ Skin cancer initial diagnosis ■ Waiver of premium

22

American Cancer Society, Cancer Facts & Figures, 2013

Optional riders For an additional cost, you may have the option of purchasing additional riders for even more financial protection against cancer.

Talk with your benefits counselor to find out which of these riders are available for you to purchase.

■

Diagnosis of cancer rider — Pays a one-time, lump-sum benefit for the initial diagnosis of cancer. You may choose a benefit amount in $1,000 increments between $1,000 and $10,000. If your dependent child is diagnosed with cancer, we will pay two and a half times ($2,500 - $25,000) the chosen benefit amount.

■

Diagnosis of cancer progressive payment rider — Provides a lump-sum payment of $50 for each month the rider has been in force and before cancer is first diagnosed.

■

Specified disease hospital confinement rider — Pays $300 per day if you or a covered family member is confined to a hospital for treatment for one of the 34 specified diseases covered under the rider.

ColonialLife.com

If cancer impacts your life, you should be able to focus on getting better — not on how you’ll pay your bills. Talk with your Colonial Life benefits counselor about how cancer insurance can help provide financial security for you and your family.

PRE-EXISTING CONDITION LIMITATION We will not pay benefits for the diagnosis of internal cancer or skin cancer that is a pre-existing condition, nor will we pay benefits for the treatment of internal cancer or skin cancer that is a pre-existing condition unless the covered person has satisfied the six-month pre-existing condition limitation period shown on the Policy Schedule. Pre-existing condition means a condition for which a covered person was diagnosed prior to the effective date of this policy, and for which medical advice or treatment was recommended by or received from a doctor within six months immediately preceding the effective date of this policy.

EXCLUSIONS We will not pay benefits for cancer or skin cancer: ■ If the diagnosis or treatment of cancer is received outside of the territorial limits of the United States and its possessions; or ■ For other conditions or diseases, except losses due directly from cancer.

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. Applicable to policy form CanAssist-VA and rider forms R-CanAssistIndx-VA, R-CanAssistProg-VA and R-CanAssistSpDis-VA. ©2016 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.

23

1-16 | 101481-VA

Cancer Insurance Level 4 Benefits BENEFIT DESCRIPTION

Cancer insurance helps provide financial protection through a variety of benefits.

These benefits are not only for you but also for your covered family members.

BENEFIT AMOUNT

Air ambulance. . . ............................................................................... $2,000 per trip

Transportation to or from a hospital or medical facility [max. of two trips per confinement]

Ambulance. . . . . . . ............................................................................... $250 per trip Transportation to or from a hospital or medical facility [max. of two trips per confinement]

Anesthesia

Administered during a surgical procedure for cancer treatment ■ General anesthesia. ......................................................................... 25% of surgical procedures benefit ■ Local anesthesia............................................................................. $50 per procedure

Anti-nausea medication. ..................................................................... $60 per day administered or Doctor-prescribed medication for radiation or chemotherapy [$240 monthly max.]

per prescription filled

Blood/plasma/platelets/immunoglobulins. . ............................................. $250 per day A transfusion required during cancer treatment [$10,000 calendar year max.]

Bone marrow donor screening.............................................................. $50 Testing in connection with being a potential donor [once per lifetime]

Bone marrow or peripheral stem cell donation.......................................... $1,000 Receiving another person’s bone marrow or stem cells for a transplant [once per lifetime]

Bone marrow or peripheral stem cell transplant........................................ $10,000 per transplant

Transplant you receive in connection with cancer treatment [max. of two bone marrow transplant benefits per lifetime]

Cancer vaccine.. . ............................................................................... $50 An FDA-approved vaccine for the prevention of cancer [once per lifetime]

Companion transportation. ................................................................. $0.50 per mile

Companion travels by plane, train or bus to accompany a covered cancer patient more than 50 miles one way for treatment [up to $1,500 per round trip]

Egg(s) extraction or harvesting/sperm collection and storage

Extracted/harvested or collected before chemotherapy or radiation [once per lifetime] ■ Egg(s) extraction or harvesting/sperm collection. ......................................... $1,500 ■ Egg(s) or sperm storage (cryopreservation). ............................................... $500

Experimental treatment. . .................................................................... $300 per day Hospital, medical or surgical care for cancer [$15,000 lifetime max.]

For more information, talk with your benefits counselor.

Family care. . . . . . . . .............................................................................. $60 per day Inpatient or outpatient treatment for a covered dependent child [$3,000 calendar year max.]

Hair/external breast/voice box prosthesis. ............................................... $500 per calendar year Prosthesis needed as a direct result of cancer

Home health care services................................................................... $175 per day Examples include physical therapy, occupational therapy, speech therapy and audiology; prosthesis and orthopedic appliances; rental or purchase of durable medical equipment [up to 100 days per covered person per lifetime]

Hospice (initial or daily care)

An initial, one-time benefit and a daily benefit for treatment [$15,000 lifetime max. for both] ■ Initial hospice care [once per lifetime]...................................................... $1,000 ■ Daily hospice care. .......................................................................... $50 per day

24

CANCER ASSIST – LEVEL 4

BENEFIT DESCRIPTION

BENEFIT AMOUNT

Hospital confinement

Hospital stay (including intensive care) required for cancer treatment ■ 30 days or less . . ........................................................................................ $350 per day ■ 31 days or more ........................................................................................ $700 per day

Lodging . . . . . . . . . . . . ......................................................................................... $80 per day Hotel/motel expenses when being treated for cancer more than 50 miles from home [70-day calendar year max.]

Medical imaging studies ................................................................................. $225 per study

Specific studies for cancer treatment [$450 calendar year max.]

Outpatient surgical center .............................................................................. $400 per day Surgery at an outpatient center for cancer treatment [$1,200 calendar year max.]

Private full-time nursing services ...................................................................... $150 per day Services while hospital confined other than those regularly furnished by the hospital

Prosthetic device/artificial limb ........................................................................ $3,000 per device or limb A surgical implant needed because of cancer surgery [payable one per site, $6,000 lifetime max.]

Radiation/chemotherapy

[per day with a max. of one per calendar week] ■ Injected chemotherapy by medical personnel ........................................................ $1,000 ■ Radiation delivered by medical personnel ............................................................ $1,000 [per day with a max. of one per calendar month] ■ Self-injected . . . ......................................................................................... $400 ■ Pump . . . . . . . . . . ......................................................................................... $400 ■ Topical . . . . . . . . . . ........................................................................................ $400 ■ Oral hormonal [1-24 months] .......................................................................... $400 ■ Oral hormonal [25+ months] ........................................................................... $350 ■ Oral non-hormonal ..................................................................................... $400

Reconstructive surgery .................................................................................. $60 per surgical unit

ColonialLife.com

A surgery to reconstruct anatomic defects that result from cancer treatment [min. $350 per procedure, up to $3,000, including 25% for general anesthesia]

Second medical opinion ................................................................................. $300

A second physician’s opinion on cancer surgery or treatment [once per lifetime]

Skilled nursing care facility ............................................................................. $175 per day Confinement to a covered facility after hospital release [up to 100 days per covered person per lifetime]

Skin cancer diagnosis .................................................................................... $600 A skin cancer diagnosis while the policy is in force [once per lifetime]

Supportive or protective care drugs and colony stimulating factors ........................... $200 per day Doctor-prescribed drugs to enhance or modify radiation/chemotherapy treatments [$1,600 calendar year max.]

Surgical procedures ...................................................................................... $70 per surgical unit Inpatient or outpatient surgery for cancer treatment [min. $350 per procedure, up to $6,000]

Transportation . . . . ........................................................................................ $0.50 per mile

Travel expenses when being treated for cancer more than 50 miles from home [up to $1,500 per round trip]

Waiver of premium ....................................................................................... Is available No premiums due if the named insured is disabled longer than 90 consecutive days

The policy has limitations and exclusions that may affect benefits payable. Most benefits require that a charge be incurred. Coverage may vary by state and may not be available in all states. For cost and complete details, see your benefits counselor.

This chart highlights the benefits of policy forms CanAssist-NJ and CanAssist-VA. This chart is not complete without form 101505-NJ or 101481-VA.

©2016 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.

25

1-16 | 101485-NJ-VA

Cancer Insurance Wellness Benefits

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

For more information, talk with your benefits counselor.

Part one: Cancer wellness/health screening Provided when one of the tests listed below is performed while the policy is in force.

Payable once per calendar year, per covered person.

Cancer wellness tests

Health screening tests

■

Bone marrow testing

■

Blood test for triglycerides

■

Breast ultrasound

■

Carotid Doppler

■

CA 15-3 (blood test for breast cancer)

■

Echocardiogram (ECHO)

■

CA 125 (blood test for ovarian cancer)

■

Electrocardiogram (EKG, ECG)

■

CEA (blood test for colon cancer)

■

Fasting blood glucose test

■

Chest X-ray

■

■

Colonoscopy

Serum cholesterol test for HDL and LDL levels

■

Flexible sigmoidoscopy

■

Stress test on a bicycle or treadmill

■

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

Part two: Cancer wellness — additional invasive diagnostic test or surgical procedure Provided when a doctor performs a diagnostic test or surgical procedure 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.

ColonialLife.com 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). ©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.

26

CANCER ASSIST WELLNESS | 8-15 | 101506-2

Group Specified Disease Insurance

How will you pay for what your health insurance won’t?

It’s true—a serious medical event such as heart attack or stroke could leave you in a period of financial difficulty.

Even if you have major medical coverage, there are typically uncovered expenses to consider, such as deductibles and copayments, travel expenses to and from treatment centers and the loss of wages or salary. If faced with this situation, would you be able to maintain your current way of life?

Group Critical Care Insurance may help guard you against financial hardship.

This specified disease coverage from Colonial Life & Accident Insurance Company offers the protection you need to concentrate on what is most important—your treatment, care and recovery.

You’re free to use the benefits however you choose. And coverage may be available for you, your spouse and your eligible dependents.

Plan Features: l l l

A lump sum payment allows you the flexibility to better plan your treatment and care.

You may adjust the face amount to best meet your personal needs.

May pay multiple times for a covered critical illness.

What benefits are included?

Face Amount: $____________ Critical Illness Benefit: This is a lump sum benefit to assist with the medical and/or non-medical costs associated with the diagnosis of a covered critical illness.

Group Critical Care 1.0 Plan 3 Full

Covered Critical Illness Conditions For this critical illness…

We will pay this percentage of the face amount:

Heart Attack (Myocardial Infarction)

100%

Stroke

100%

End Stage Renal (Kidney) Failure

100%

Major Organ Failure

100%

Coma

100%

Permanent Paralysis Due to a Covered Accident

100%

Blindness

100%

Occupational Infectious HIV or Occupational Infectious Hepatitis B, C or D

100%

Coronary Artery Bypass Graft Surgery/Disease1

25%

Benefit for Coronary Artery Disease applicable in lieu of benefit for Coronary Artery Bypass Graft Surgery when Health Savings Account (HSA) compliant plan is selected.

1

27

Can I use the critical illness coverage more than once?

Yes! This plan includes coverage for subsequent diagnosis of a different critical illness.2 If you receive a benefit for a critical illness, and later you are diagnosed with a different critical illness, we will pay the original percentage of the face amount for that particular critical illness.

Yes! This plan includes coverage for subsequent diagnosis of the same critical illness.2

If you receive a benefit for a critical illness and later you are diagnosed with the same critical illness (except those listed below), we will pay 25% of the original face amount. Critical illness conditions that do not qualify are: Coronary Artery Bypass Graft Surgery/ Coronary Artery Disease1 and Occupational Infectious HIV or Occupational Infectious Hepatitis B, C or D.

1 Benefit for Coronary Artery Disease applicable in lieu of benefit for Coronary Artery Bypass Graft Surgery when Health Savings Account (HSA) compliant plan is selected.

Group Critical Care 1.0 Plan 3 Full

2

Dates of Diagnoses of a covered critical illness must be separated by at least 180 days.

EXCLUSIONS AND LIMITATIONS - We will not pay the Critical Illness Benefit or Benefit Payable Upon Subsequent Diagnosis of a Critical Illness that occurs as a result of a covered personâ&#x20AC;&#x2122;s: alcoholism or drug addiction; felonies or illegal occupations; intoxicants and narcotics; psychiatric or psychological conditions; suicide or injuries which any covered person intentionally does to himself; 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.

This is not an insurance contract and only the actual certificate provisions will control. Applicable to certificate form GCC1.0-C (including state abbreviations where used, for example: GCC1.0-C-TX). Not available in all states. Please see your Colonial Life benefits counselor for details.

Colonial Life 1200 Colonial Life Boulevard Columbia, South Carolina 29210 coloniallife.com 1/12

Š 2011 Colonial Life & Accident Insurance Company Colonial Life products are underwritten by Colonial Life & Accident Insurance Company, for which Colonial Life is the marketing brand.

28

100363

Group Specified Disease Insurance

Health Screening Benefit This benefit helps you pay for part of the expense of tests you may normally have each year.

The benefit allows a maximum of 1 screening test per covered person per calendar year.

Group Critical Care 1.0 â&#x20AC;&#x201D; Health Screening Benefit

Tests that qualify: Stress test on a bicycle or treadmill

CEA (blood test for colon cancer)

Fasting blood glucose test

Chest x-ray

Blood test for triglycerides

Colonoscopy

Serum cholesterol test to determine level of HDL and LDL

Flexible sigmoidoscopy

Bone marrow testing

Hemoccult stool analysis

Carotid Doppler

Mammography

Electrocardiogram (EKG, ECG)

Pap smear

Echocardiogram (ECHO)

PSA (blood test for prostate cancer)

Skin cancer biopsy

Serum protein electrophoresis (blood test for myeloma)

Breast ultrasound

Thermography

CA 15-3 (blood test for breast cancer)

ThinPrep pap test

CA 125 (blood test for ovarian cancer)

Virtual colonoscopy

The person must incur a charge and the certificate must be in force for benefits to be payable. For cost and complete details, see your Colonial Life benefits counselor. Applicable to certificate form GCC-1.0-C (including state abbreviations where used, for example, GCC1.0-C-TX). Coverage may vary by state and may not be available in all states. This is not an insurance contract and only the actual certificate provisions will control. The certificate contains exclusions and limitations which may affect benefits payable.

Colonial Life 1200 Colonial Life Boulevard Columbia, South Carolina 29210 coloniallife.com 100355-1 11/12

Š 2012 Colonial Life & Accident Insurance Company Colonial Life products are underwritten by Colonial Life & Accident Insurance Company, for which Colonial Life is the marketing brand.

29

100355-1

Individual Short-Term Disability Insurance You never know when a disability could impact your way of life. Fortunately, there’s a way to help protect your income. If an accident or sickness prevents you from earning a paycheck, disability insurance can provide a monthly benefit to help you cover your ongoing expenses.

Can you afford to not protect your paycheck?

You don’t have the same lifestyle expenses as the next person. That’s why you need disability coverage that can be customized to fit your specific needs.

After calculating your monthly expenses, your benefits counselor can help you complete the benefits worksheet.

ESTIMATED MONTHLY EXPENSES

ColonialLife.com

AMOUNT

Mortgage or rent

$

Utilities (electric/gas, phone, water, TV, Internet)

$

Transportation costs (gas, car payments)

$

Food

$

Health (medical needs and prescription drugs)

$

Other

$

TOTAL

$

Benefits worksheet How much coverage do I need?

Monthly benefit amount for off-job accident and off-job sickness: ______________ Choose a monthly benefit amount between $400 and $6,500.* If your plan includes on-job accident/sickness benefits, the benefit is 50% of the off-job amount.

How long will I receive benefits?

Benefit period: _______ months The partial disability benefit period is three months.

When will my total disability benefits start?

After an accident: _______ days

After a sickness: _______ days

*Subject to income requirements

30

ISTD3000 BASE

Product information Total disability definition Totally disabled or total disability means you are: unable to perform the material and substantial duties of your job, not working at any job, and under the regular and appropriate care of a physician.

How partial disability works If you are able to return to work part-time after at least 14 days of being paid for a total disability, you may be able to still receive 50% of your total disability benefit.

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

Geographical limitations If you are disabled while outside of the United States, Canada or Mexico, you may receive benefits for up to 60 days before you have to return to the U.S. in order to continue receiving benefits.

Issue age Coverage is available from ages 17 to 74.

Keep your coverage You can keep your coverage to age 75 at no additional cost, even if you change jobs, as long as you pay your premiums when they are due.

Premium Your premium is based on your age when you purchase coverage and the amount of coverage you are eligible to buy. Your premium will not change as you age.*

For more information, talk with your benefits counselor.

EXCLUSIONS AND LIMITATIONS We will not pay benefits for losses that are caused by, contributed to by or occur as the result of: alcoholism or drug addiction, aviation, cosmetic surgery, felonies or illegal occupations, intoxicants and narcotics, psychiatric or psychological conditions, suicide or injuries which you intentionally do to yourself, war or armed conflict. We will not pay for losses due to you giving birth within the first nine months after the coverage effective date of the policy. We will not pay for loss when the disability is a pre-existing condition as described in the policy.

For cost and complete details, see your Colonial Life benefits counselor. Applicable to policy form ISTD3000-VA and rider form ISTD3000-ADIB-VA. This is not an insurance contract and only the actual policy and rider provisions will control. *Premiums can be changed only if we change them on all policies of this kind in force in the state where the policy is issued.

Underwritten by Colonial Life & Accident Insurance Company, Columbia, SC Š2016 Colonial Life & Accident Insurance Company. All rights reserved. Colonial Life is a registered trademark and marketing brand of Colonial Life & Accident Insurance Company.

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9-16 | 101629-VA

Individual Short-Term Disability Insurance Health Screening Rider Benefit The optional health screening benefit can help you reduce the risk of serious illness through early detection.

Health screening benefit ..................................................................................... $50 Maximum of one health screening test per calendar year; subject to a 30-day waiting period following the effective date of the rider

Blood test for triglycerides

Pap smear

Bone marrow testing

PSA (blood test for prostate cancer)

Breast ultrasound

Serum cholesterol test for HDL and LDL levels

CA 15-3 (blood test for breast cancer) CA 125 (blood test for ovarian cancer) Carotid Doppler CEA (blood test for colon cancer) Chest X-ray Colonoscopy Echocardiogram (ECHO) Electrocardiogram (EKG, ECG) Fasting blood glucose test

For more information, talk with your benefits counselor.

Serum protein electrophoresis (blood test for myeloma) Skin cancer biopsy Stress test on a bicycle or treadmill Thermography ThinPrep pap test Virtual colonoscopy

Flexible sigmoidoscopy Hemoccult stool analysis Mammography

With the health screening benefit: You’re paid regardless of any insurance you have with other companies.

You can keep coverage to age 75 as long as premiums are paid when they are due.

ColonialLife.com

Waiting period means the first 30 days following the rider coverage effective date, during which time no benefits are payable.

For cost and complete details, see your Colonial Life benefits counselor. Applicable to rider form ISTD3000-HS (including state abbreviations where used, for example: ISTD3000-HS-TX). Coverage may vary by state and may not be available in all states.

This is not an insurance contract and only the actual rider provisions will control. ©2016 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.

32

ISTD3000 – HEALTH SCREENING BENEFIT | 7-16 | 101634-1

Individual Short-Term Disability Insurance Psychiatric and Psychological Benefit

Although illnesses and accidents are often associated with disabilities, mental disorders can also leave you unable to earn an income.

If you’re disabled with a covered psychiatric or covered psychological condition, disability insurance from Colonial Life & Accident Insurance Company pays a monthly benefit that can help provide financial support while you focus on recovery.

Psychiatric and psychological benefit There is a maximum six-month benefit period limitation for any one occurrence of a psychiatric or psychological condition. There is a three-month benefit period limitation if you have a three-month benefit period.

For more information, talk with your benefits counselor.

There is a 24-month cumulative lifetime maximum benefit period for all psychiatric or psychological conditions. This maximum includes a combination of total disability and partial disability occurrences.

ColonialLife.com

The psychiatric and psychological benefit is only applicable when combined with the ISTD3000 base policy. The exclusions listed on the ISTD3000 base policy apply, except for the psychiatric or psychological conditions exclusion. For cost and complete details, talk with your Colonial Life benefits counselor. Applicable to policy form ISTD3000 and rider form ISTD3000-ADIB (plus state abbreviations where applicable, for example: ISTD3000-TX and ISTD3000-ADIB-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 and rider 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.

33

ISTD3000 – PSYCHIATRIC AND PSYCHOLOGICAL BENEFIT | 6-15 | 101630

Accident Insurance

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?

l

Sports-related accidental injury Broken bone Burn Concussion Laceration

l

Back or knee injuries

l l l l

l l l l

Car accidents Falls & spills Dislocation Accidental injuries that send you to the Emergency Room, Urgent Care or doctor’s office

Accident 1.0­-Preferred with Health Screening Benefit-VA

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 additional features are included? l

Worldwide coverage

l

Portable

l

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 for life as long as you pay your premiums when they are due or within the grace period.

Compliant with Healthcare Spending Account (HSA) guidelines

Can my premium change?

Will my accident claim payment be reduced if I have other insurance?

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.

You’re 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).

How do I file a claim?

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

34

Benefits listed are for each covered person per covered accident unless otherwise specified.

Initial Care l

Accident Emergency Treatment........... $125

l

Ambulance........................................$200

l

X-ray Benefit....................................................$30

l Air

Ambulance.............................. $2,000

Common Accidental Injuries Dislocations (Separated Joint) Hip Knee (except patella) Ankle â&#x20AC;&#x201C; Bone or Bones of the Foot (other than Toes) Collarbone (Sternoclavicular) Lower Jaw, Shoulder, Elbow, Wrist Bone or Bones of the Hand Collarbone (Acromioclavicular and Separation) One Toe or Finger Fractures Depressed Skull Non-Depressed Skull Hip, Thigh Body of Vertebrae, Pelvis, Leg Bones of Face or Nose (except mandible or maxilla) Upper Jaw, Maxilla Upper Arm between Elbow and Shoulder Lower Jaw, Mandible, Kneecap, Ankle, Foot Shoulder Blade, Collarbone, Vertebral Process Forearm, Wrist, Hand Rib Coccyx Finger, Toe

Non-Surgical

Surgical

$2,200 $1,100 $880 $550 $330 $330 $110 $110

$4,400 $2,200 $1,760 $1,100 $660 $660 $220 $220

Non-Surgical

Surgical

$2,750 $1,100 $1,650 $825 $385 $385 $385 $330 $330 $330 $275 $220 $110

$5,500 $2,200 $3,300 $1,650 $770 $770 $770 $660 $660 $660 $550 $440 $220

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.......................................................................................................................................................... $60

l l

Emergency Dental Work........................................$75 Extraction, $300 Crown, Implant, or Denture Lacerations (based on size)............................................................................................................$30 to $500

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).....................................................................................................$200

l

Blood/Plasma/Platelets.................................................................................................................................$300

35

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 l

Transportation..............................................................................$500 per round trip up to 3 round trips Lodging (family member or companion)................................................$125 per night up to 30 days for a hotel/motel lodging costs

Accident Hospital Care l

Hospital Admission*......................................................................................................... $1,000 per accident

Hospital ICU Admission*................................................................................................. $2,000 per accident * We will pay either the Hospital Admission or Hospital Intensive Care Unit (ICU) Admission, but not both. l

l

Hospital Confinement.......................................................... $225 per day up to 365 days per accident

l

Hospital ICU Confinement ....................................................$450 per day up to 15 days per accident

Accident Follow-Up Care l l

Accident Follow-Up Doctor Visit........................................................... $50 (up to 3 visits per accident) Medical Imaging Study.......................................................................................................$150 per accident (limit 1 per covered accident and 1 per calendar year)

l

Occupational or Physical Therapy...................................................... $25 per treatment up to 10 days

l

Appliances ........................................................................................... $100 (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

36

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.

Tests include: l.

Blood test for triglycerides

l.

Hemoccult stool analysis

l.

Bone marrow testing

l.

Mammography

l.

Breast ultrasound

l.

Pap smear

l.

CA 15-3 (blood test for breast cancer)

l.

PSA (blood test for prostate cancer)

l.

CA125 (blood test for ovarian cancer)

l.

l.

Carotid doppler

Serum cholesterol test to determine level of HDL and LDL

l.

CEA (blood test for colon cancer)

l.

l.

Chest x-ray

Serum protein electrophoresis (blood test for myeloma)

Colonoscopy

l.

l.

Stress test on a bicycle or treadmill

Echocardiogram (ECHO)

l.

l.

Skin cancer biopsy

Electrocardiogram (EKG, ECG)

l.

l.

Thermography

Fasting blood glucose test

l.

l.

ThinPrep pap test

Flexible sigmoidoscopy

l.

l.

Virtual colonoscopy

My Coverage Worksheet (For use with your Colonial Life benefits counselor) Who will be covered? (check one) Employee Only

Spouse Only

One-Parent Family, with Spouse

Employee & Spouse Two-Parent Family

When are covered accident benefits available? (check one) On and Off -Job Benefits

Off -Job Only Benefits

EXCLUSIONS We will not pay benefits for losses that are caused by or are the result of: felonies or illegal occupations; 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 -VA. 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 10/11

©2011 Colonial Life & Accident Insurance Company.

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

Colonial Life and Making benefits count are registered service marks of Colonial Life & Accident Insurance Company.

37

74231-2

Accident 1.0­-Preferred with Health Screening Benefit-VA

One-Parent Family, with Employee

One Child Only

Gunshot Wound Policy

You can’t always prevent injuries from happening, but you can have a financial safety net in place in case they do. A gunshot wound policy from Colonial Life & Accident Insurance Company can provide a benefit to help pay your medical expenses if you receive a non-fatal gunshot wound.

This policy pays a lump-sum benefit for an injury regardless of any other insurance you may have.

Gunshot wound benefit.................................................... $_____________________ Guaranteed issue You can get this coverage without answering any health questions.

Portability You can keep coverage even if you change jobs or leave your company.

For more information, talk with your benefits counselor.

Guaranteed renewable You can keep your coverage as long as you pay your premiums when they are due.

On/off-job coverage You may receive benefits regardless of whether the injury occurs on or off the job.

Direct payment Benefits are paid directly to you unless you specify otherwise. You can use these benefits however you choose.

This policy covers a non-fatal gunshot wound from a conventional firearm that requires treatment by a doctor and overnight hospitalization within 24 hours of the injury. If you are shot more than once in a 24-hour period, we will pay benefits only for the first wound.

THIS POLICY PROVIDES LIMITED BENEFITS.

ColonialLife.com

EXCLUSIONS AND LIMITATIONS We will not pay benefits for an injury which is caused by or occurs as the result of: war, illegal activities, or suicide or injuries which you intentionally do to yourself.

For cost and complete details, see your Colonial Life benefits counselor. Applicable to policy form PYWOL (including state abbreviations where used; for example: PYWOL-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. ©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.

38

GUNSHOT WOUND | 12-15 | 43200-9

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. . . . . . ........................................................................................... $_______________

For more information, talk with your benefits counselor.

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 – Hysteroscopy – Amniocentesis – L oop electrosurgical – Cervical biopsy excisional procedure – Cone biopsy (LEEP) – Endometrial biopsy

Liver – biopsy Lymphatic – biopsy Miscellaneous – Bone marrow aspiration/biopsy Renal – biopsy Respiratory – Biopsy – Bronchoscopy – Pulmonary function test (PFT) Skin – Biopsy – Excision of lesion Thyroid – biopsy Urologic – Cystoscopy

Tier 2 diagnostic procedures Cardiac – Angiogram – Arteriogram – Thallium stress test – Transesophageal echocardiogram (TEE)

39

Diagnostic radiology – Computerized tomography scan (CT scan) – Electroencephalogram (EEG) – Magnetic resonance imaging (MRI) – Myelogram – Positron emission tomography scan (PET scan) IMB7000 – PLAN 3

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

Gynecological

Cardiac

Liver

Digestive

Musculoskeletal system

– Axillary node dissection – Breast capsulotomy – Lumpectomy

– Dilation and curettage (D&C) – Endometrial ablation – Lysis of adhesions

– Pacemaker insertion

– Paracentesis

– Colonoscopy – Fistulotomy – Hemorrhoidectomy – Lysis of adhesions

– Carpal/cubital repair or release – Foot surgery (bunionectomy, exostectomy, arthroplasty, hammertoe repair) – Removal of orthopedic hardware – Removal of tendon lesion

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

Gynecological

Cardiac

Musculoskeletal system

– Breast reconstruction – Breast reduction

– Hysterectomy – Myomectomy

– Angioplasty – Cardiac catheterization

Digestive

– Exploratory laparoscopy – Laparoscopic appendectomy – Laparoscopic cholecystectomy

Ear, nose, throat, mouth – Ethmoidectomy – Mastoidectomy – Septoplasty – Stapedectomy – Tympanoplasty

Thyroid

– Excision of a mass

Eye

ColonialLife.com

– 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

– Cataract surgery – Corneal surgery (penetrating keratoplasty) – Glaucoma surgery (trabeculectomy) – Vitrectomy

Urologic

– Lithotripsy

EXCLUSIONS 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, war, or giving birth within the first nine months after the effective date of the policy. 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. A pre-existing condition is a sickness or physical condition for which a covered person was treated, had medical testing, received medical advice or had taken medication within the 12 months before the effective date of the policy.

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. ©2016 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.

40

1-16 | 101581-1

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

Serum protein electrophoresis (blood test for myeloma) Skin cancer biopsy Stress test on a bicycle or treadmill Thermography ThinPrep pap test Virtual colonoscopy

Chest X-ray Colonoscopy Echocardiogram (ECHO) Electrocardiogram (EKG, ECG) Fasting blood glucose test Flexible sigmoidoscopy

For more information, talk with your benefits counselor.

Hemoccult stool analysis Mammography Pap smear PSA (blood test for prostate cancer) Serum cholesterol test for HDL and LDL levels

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. ©2016 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.

41

IMB7000 – HEALTH SCREENING BENEFIT | 5-16 | 101579-1

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 cannot be paired with Plan 1.

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

For more information, talk with your benefits counselor.

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

THIS POLICY PROVIDES LIMITED BENEFITS.

ColonialLife.com

EXCLUSIONS 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.

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

©2016 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.

42

IMB7000 – MEDICAL TREATMENT PACKAGE | 9-16 | 101596-VA

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 ................................................................. $100 per day Per covered person per day of hospital confinement Maximum of 365 days per covered person per confinement

Enhanced intensive care unit confinement rider .............................................. $500 per day 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.

For more information, talk with your benefits counselor.

EXCLUSIONS

ColonialLife.com

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, war, or giving birth within the first nine months after the effective date of the rider. 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. A pre-existing condition is a sickness or physical condition for which a covered person was treated, had medical testing, received medical advice or had taken medication within the 12 months before the effective date of the rider.

For cost and complete details, see your Colonial Life benefits counselor. Applicable to rider numbers R-DHC7000 and R-EIC7000 (including state abbreviations where used, for example: R-DHC7000-TX and R-EIC7000-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 or rider provisions will control. ©2016 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.

IMB7000 – DAILY HOSPITAL CONFINEMENT AND ENHANCED INTENSIVE CARE UNIT CONFINEMENT RIDERS | 6-16 | 101582-1

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

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

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

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

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

Talk with your Colonial Life benefits counselor to learn more.

ColonialLife.com

Spouse coverage options

Dependent coverage options

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.

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).

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.

7-19 | NS-16570-1

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Whole Life Insurance Life insurance that comes with guarantees — because life doesn’t You can’t predict the future, but you can rest easier knowing you have life insurance with lifelong guarantees.

Whole life insurance provides guaranteed features – cash value accumulation, premium rates and a death benefit (minus any loans and loan interest) – that help ensure those benefits will be there to help protect your family’s way of life.

With this coverage: Life insurance benefits for the beneficiary are typically tax-free.

You have three opportunities to purchase additional coverage with no proof of good health required if you are 50 or younger with the Guaranteed Purchase Option Rider.

The policy’s built-in terminal illness accelerated death benefit provides up to 75% of the policy’s death benefit (up to $150,000) if you’re diagnosed with a terminal illness.1 A $3,000 immediate claim payment that can help your designated beneficiary pay for funeral costs or other expenses.

Talk with your Colonial Life benefits counselor to learn more.

ColonialLife.com

You can take the policy with you even if you change jobs or retire; with no increase in premium.

Paid-Up at Age 70 or Paid-Up at Age 100 These two plan options allow you to select what age your premium payments will end. You can choose to have your policy paid up when you reach age 70 or 100.

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.

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.

7-19 | NS-16576-1

45

ADDITIONAL BENEFITS THE FSA STORE Pierce Group Benefits partners with the FSA Store to provide one convenient location for all your FSA-eligible purchases. Through our partnership, Pierce Group Benefits and FSA Store can help you shop for FSA eligible items and answer the many questions that come along with having a Flexible Spending Account.

• The largest selection of guaranteed FSA-eligible products • 24/7 support, FREE shipping on orders over $50 • Are your health needs eligible? Easily check with our expansive Eligibility List • Need an Rx? We’ll work with you to make getting one easier • Learning Center - Get daily money-saving info • Use your FSA Card or any major credit card

Accessing FSA Store is easy. Simply visit FSAstore.com/PGBFL for the largest selection of guaranteed FSA-eligible products with zero guesswork.

Get $20 off $200+ with code PGBF20. One use per customer.

For Eligible Hybrid Employees: Virginia Association of Counties Group Self Insurance Risk Pool (VACORP) Short and Long Term Disability Group Short Term Disability (STD) program provided for its participant by the Sponsor and administered by Anthem Life Insurance Company helps provide financial protection for covered members by promising to pay a weekly benefit in the event of a covered disability.

Group Long Term Disability (LTD) insurance from Anthem Life Insurance Company helps provide financial protection for insured members by promising to pay a monthly benefit in the event of a covered disability.

Please refer to the plan summary document and your employee handbook for specific plan details, eligibility definitions, limitations, and exclusions Questions about your VACORP Short and Long Term Disability can be directed to your Human Resource Department.

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General Notice of COBRA Continuation Coverage Rights ** Continuation Coverage Rights Under COBRA** Introduction You are receiving this notice because you recently gained coverage under a group health plan (the Plan). This notice has important information about your right to COBRA continuation coverage, which is a temporary extension of coverage under the Plan. This notice explains COBRA continuation coverage, when it may become available to you and your family, and what you need to do to protect your right to get it. When you become eligible for COBRA, you may also become eligible for other coverage options that may cost less than COBRA continuation coverage.

The right to COBRA continuation coverage was created by a federal law, the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA).

COBRA continuation coverage can become available to you and other members of your family when group health coverage would otherwise end. For more information about your rights and obligations under the Plan and under federal law, you should review the Plan’s Summary Plan Description or contact the Plan Administrator.

You may have other options available to you when you lose group health coverage. For example, you may be eligible to buy an individual plan through the Health Insurance Marketplace. By enrolling in coverage through the Marketplace, you may qualify for lower costs on your monthly premiums and lower out-of-pocket costs. Additionally, you may qualify for a 30-day special enrollment period for another group health plan for which you are eligible (such as a spouse’s plan), even if that plan generally doesn’t accept late enrollees.

What is COBRA continuation coverage?

COBRA continuation coverage is a continuation of Plan coverage when it would otherwise end because of a life event. This is also called a “qualifying event.” Specific qualifying events are listed later in this notice. After a qualifying event, COBRA continuation coverage must be offered to each person who is a “qualified beneficiary.” You, your spouse, and your dependent children could become qualified beneficiaries if coverage under the Plan is lost because of the qualifying event. Under the Plan, qualified beneficiaries who elect COBRA continuation coverage must pay for COBRA continuation coverage.

If you’re an employee, you’ll become a qualified beneficiary if you lose your coverage under the Plan because of the following qualifying events: • Your hours of employment are reduced, or • Your employment ends for any reason other than your gross misconduct.

If you’re the spouse of an employee, you’ll become a qualified beneficiary if you lose your coverage under the Plan because of the following qualifying events: • Your spouse dies; • Your spouse’s hours of employment are reduced; • Your spouse’s employment ends for any reason other than his or her gross misconduct; • Your spouse becomes entitled to Medicare benefits (under Part A, Part B, or both); or • You become divorced or legally separated from your spouse.

Your dependent children will become qualified beneficiaries if they lose coverage under the Plan because of the following qualifying events: • The parent-employee dies; • The parent-employee’s hours of employment are reduced; • The parent-employee’s employment ends for any reason other than his or her gross misconduct; • The parent-employee becomes entitled to Medicare benefits (Part A, Part B, or both); • The parents become divorced or legally separated; or • The child stops being eligible for coverage under the Plan as a “dependent child.”

Sometimes, filing a proceeding in bankruptcy under title 11 of the United States Code can be a qualifying event. If a proceeding in bankruptcy is filed with respect to Henry-Martinsville Social Services, and that bankruptcy results in the loss of coverage of any retired employee covered under the Plan, the retired employee will become a qualified beneficiary. The retired employee’s spouse, surviving spouse, and dependent children will also become qualified beneficiaries if bankruptcy results in the loss of their coverage under the Plan.

When is COBRA continuation coverage available?

The Plan will offer COBRA continuation coverage to qualified beneficiaries only after the Plan Administrator has been notified that a qualifying event has occurred. The employer must notify the Plan Administrator of the following qualifying events: • The end of employment or reduction of hours of employment; • Death of the employee; • Commencement of a proceeding in bankruptcy with respect to the employer; or • The employee’s becoming entitled to Medicare benefits (under Part A, Part B, or both).

For all other qualifying events (divorce or legal separation of the employee and spouse or a dependent child’s losing eligibility for coverage as a dependent child), you must notify the Plan Administrator within 60 days after the qualifying event occurs. You must provide this notice to: Bonnie Covington at Henry-Martinsville Social Services. Applicable documentation will be required i.e. court order, certificate of coverage etc.

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How is COBRA continuation coverage provided?

Once the Plan Administrator receives notice that a qualifying event has occurred, COBRA continuation coverage will be offered to each of the qualified beneficiaries. Each qualified beneficiary will have an independent right to elect COBRA continuation coverage. Covered employees may elect COBRA continuation coverage on behalf of their spouses, and parents may elect COBRA continuation coverage on behalf of their children.

COBRA continuation coverage is a temporary continuation of coverage that generally lasts for 18 months due to employment termination or reduction of hours of work. Certain qualifying events, or a second qualifying event during the initial period of coverage, may permit a beneficiary to receive a maximum of 36 months of coverage.

There are also ways in which this 18-month period of COBRA continuation coverage can be extended: Disability extension of 18-month period of COBRA continuation coverage If you or anyone in your family covered under the Plan is determined by Social Security to be disabled and you notify the Plan Administrator in a timely fashion, you and your entire family may be entitled to get up to an additional 11 months of COBRA continuation coverage, for a maximum of 29 months.

The disability would have to have started at some time before the 60th day of COBRA continuation coverage and must last at least until the end of the 18-month period of COBRA continuation coverage.

Second qualifying event extension of 18-month period of continuation coverage If your family experiences another qualifying event during the 18 months of COBRA continuation coverage, the spouse and dependent children in your family can get up to 18 additional months of COBRA continuation coverage, for a maximum of 36 months, if the Plan is properly notified about the second qualifying event. This extension may be available to the spouse and any dependent children getting COBRA continuation coverage if the employee or former employee dies; becomes entitled to Medicare benefits (under Part A, Part B, or both); gets divorced or legally separated; or if the dependent child stops being eligible under the Plan as a dependent child. This extension is only available if the second qualifying event would have caused the spouse or dependent child to lose coverage under the Plan had the first qualifying event not occurred.

Are there other coverage options besides COBRA Continuation Coverage?

Yes. Instead of enrolling in COBRA continuation coverage, there may be other coverage options for you and your family through the Health Insurance Marketplace, Medicaid, or other group health plan coverage options (such as a spouse’s plan) through what is called a “special enrollment period.”

Some of these options may cost less than COBRA continuation coverage. You can learn more about many of these options at www.healthcare.gov.

If you have questions Questions concerning your Plan or your COBRA continuation coverage rights should be addressed to the contact or contacts identified below. For more information about your rights under the Employee Retirement Income Security Act (ERISA), including COBRA, the Patient Protection and Affordable Care Act, and other laws affecting group health plans, contact the nearest Regional or District Office of the U.S. Department of Labor’s Employee Benefits Security Administration (EBSA) in your area or visit www.dol.gov/ebsa. (Addresses and phone numbers of Regional and District EBSA Offices are available through EBSA’s website.) For more information about the Marketplace, visit www.HealthCare.gov.

Keep your Plan informed of address changes To protect your family’s rights, let the Plan Administrator know about any changes in the addresses of family members. You should also keep a copy, for your records, of any notices you send to the Plan Administrator.

Plan Contact Information Henry County Attn: Michelle Via 3300 Kings Mountain Road Martinsville, VA 24112 mvia@co.henry.va.us

48

Authorization for Colonial Life & Accident Insurance Company For the purpose of evaluating my application(s) for insurance submitted during the current enrollment and eligibility for benefits under any insurance issued including checking for and resolving any issues that may arise regarding incomplete or incorrect information on my application(s), I hereby authorize the disclosure of the following information about me and, if applicable, my dependents, from the sources listed below to Colonial Life & Accident Insurance Company (Colonial) and its duly authorized representatives.

Health information may be disclosed by any health care provider or institution, health plan or health care clearinghouse that has any records or knowledge about me including prescription drug database or pharmacy benefit manager, or ambulance or other medical transport service. Health information may also be disclosed by any insurance company, Medicare or Medicaid agencies or the Medical Information Bureau (MIB). Health information includes my entire medical record, but does not include psychotherapy notes. Non-health information including earnings or employment history deemed appropriate by Colonial to evaluate my application may be disclosed by any person or organization that has these records about me, including my employer, employer representative and compensation sources, insurance company, financial institution or governmental entities including departments of public safety and motor vehicle departments.

Any information Colonial obtains pursuant to this authorization will be used for the purpose of evaluating my application(s) for insurance or eligibility for benefits. Some information obtained may not be protected by certain federal regulations governing the privacy of health information, but the information is protected by state privacy laws and other applicable laws. Colonial will not disclose the information unless permitted or required by those laws.

This authorization is valid for two (2) years from its execution and a copy is as valid as the original. A copy will be included with my contract(s) and I or my authorized representative may request access to this information. This authorization may be revoked by me or my authorized representative at any time except to the extent Colonial has relied on the authorization prior to notice of revocation or has a legal right to contest coverage under the contract(s) or the contract itself. If revoked, Colonial may not be able to evaluate my application(s) for insurance or eligibility for benefits as necessary to issue my contract(s). I may revoke this authorization by sending written notice to: Colonial Life & Accident Insurance Company, Underwriting Department, P.O. Box 1365, Columbia, SC 29202.

You may refuse to sign this form; however, Colonial may not be able to issue your coverage. I am the individual to whom this authorization applies or that personâ&#x20AC;&#x2122;s legal Guardian, Power of Attorney Designee, or Conservator. ________________________ (Printed name of individual subject to this disclosure)

_____________ (Social Security Number)

___________________ (Signature)

________________ (Date Signed)

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

________________________________ (Printed name of legal representative)

_____________________________ (Signature of legal representative)

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___________ (Date Signed)

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YES! I want to keep my Colonial Life Coverage.

My premiums are no longer being payroll-deducted.

Complete this form and mail it today â&#x20AC;&#x201D; along with a check for your premium payment.

Name: ____________________________________ Daytime Telephone Number: (______) ________________________ Mailing Address: ____________________________ Social Security Number or Date of Birth:_____________________ City: ______________________________________ State:_______________________ Zip: _____________________ Policy number(s) to be continued: ______________________,

______________________,

______________________,

______________________,

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

Disability

Hospital Income

Cancer or Critical Illness

Life

Please choose one of the following payment options:

1. Deduct premiums monthly from my bank account.

1st-5th 6th-10th 11th-15th 16th-20th 21st-26th Your draft will occur on one of the dates within the range you have selected. Please include a voided check or Routing #____________________________ and Account #________________________________

_______________________________ Signature of bank account owner

2. Bill me directly. (choose one of the following) Quarterly

(Submit a payment 3 times your monthly premium)

Date: ____________________

Semi-annually

(Submit a payment 6 times your monthly premium)

Annually

(Submit a payment 12 times your monthly premium)

Policy Ownerâ&#x20AC;&#x2122;s Signature:______________________________________________

Return To: Colonial Life & Accident Insurance Company P.O. Box 1365 Columbia, South Carolina 29202 1.800.325.4368 (phone) 1.800.561.3082 (fax)

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

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CONTACT INFORMATION: FLEXIBLE BENEFIT ADMINISTRATORS FLEXIBLE SPENDING ACCOUNTS

ANTHEM - HEALTH INSURANCE • • • •

Customer Service: 1-800-582-6941 LiveHealthOnline: www.livehealthonline or 1-888-548-3432 24/7 NurseLine: 1-800-337-4770 Website: www.anthem.com

• Customer Service: 1-800-437-3539 • Website: www.flex-admin.com • Member Portal: https://fba.wealthcareportal.com

MANAGE YOUR ACCOUNT ONLINE OR DOWNLOAD THE FBA MOBILE APP

DELTA - DENTAL INSURANCE • Customer Service: 1-800-237-6060 • Website: www.DeltaDentalVA.com

• • • •

Check your Balance Submit and View Claims Check Claim Status Upload and Store Receipts

TO VIEW YOUR BENEFITS ONLINE Visit www.piercegroupbenefits.com/

SUPERIOR - VISION INSURANCE • Customer Service: 1-800-507-3800 • Website: www.superiorvision.com

henrycounty For additional information concerning plans offered to employees of Henry County Government & Public Service Authority, please contact our Pierce Group Benefits Service Center at 1-800-387-5955

COLONIAL LIFE VISIT COLONIALLIFE.COM TO SET UP YOUR PERSONAL ACCOUNT • Website: www.coloniallife.com • Claims Fax: 1-800-880-9325

• Customer Service & Wellness Screenings: 1-800-325-4368 • TDD for hearing impaired customers call: 1-800-798-4040

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.

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.