hopewell city public schools benefits booklet 2020 by Pierce Group Benefits

EMPLOYEE BENEFITS PLAN HOPEWELL CITY PUBLIC SCHOOLS PLAN YEAR: July 1, 2020 through June 30, 2021

ARRANGED BY:

www.piercegroupbenefits.com

EMPLOYEE BENEFITS GUIDE

TABLE OF CONTENTS Welcome to the Hopewell City Public Schools 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 28, 2020 - MAY 15, 2020 EFFECTIVE DATES: JULY 1, 2020 - JUNE 30, 2021 Benefits Plan Overview

page

Disability Benefits

page

Online Enrollment Instructions

page

Accident Benefits

page

Health Benefits

page

Medical Bridge Benefits

page

Health Rates - 2020-2021

page

Life Insurance

page

Health Savings Account

page

Pre-Paid Legal Plan

page

Dental Benefits

page

Cobra Continuation Of Coverage Rights

page

Vision Benefits

page

Authorization Form

page

Notice Of Insurance Information Practices

page

Continuation Of Coverage for Benefits Form

page

Dependent Care Flexible Spending Account

page

Cancer Benefits

page

Critical Care Benefits

page

29 Rev. 11/20/2020

PRE-TAX & POST-TAX BENEFITS

HOPEWELL CITY PUBLIC SCHOOLS ENROLLMENT PERIOD: APRIL 28, 2020 - MAY 15, 2020 EFFECTIVE DATES: JULY 1, 2020 - JUNE 30, 2021

PRE-TAX BENEFITS Dental Insurance*

Health Insurance*

Sun Life

Anthem

Vision Insurance*

UnitedHealthcare

Health Savings Accounts*

Anthem • Employee Maximum $3,550/year • Family Maximum $7,100/year HSA plans can only be established in conjunction with a qualified High-Deductible Health Plan (HDHP) Hopewell City Public Schools will contribute $1,800 per benefit year to an HSA per employee enrolled in the High-Deductible Health Plan (HDHP)

Dependent Care Flexible Spending Account

Flex Facts • Dependent Care Reimbursement FSA Maximum: $5,000/year You will need to re-sign for the Flexible Spending Account if you want them to continue next year. IF YOU DO NOT RE-SIGN, YOUR CONTRIBUTION WILL STOP EFFECTIVE JUNE 30, 2020.

Cancer Benefits

Colonial Life

Accident Benefits

Colonial Life

Medical Bridge Benefits Colonial Life

POST-TAX BENEFITS Disability Benefits Colonial Life

Critical Care Benefits Colonial Life

Life Insurance

Colonial Life • Term Life Insurance • Whole Life Insurance

Pre-Paid Legal Plan

Legal Resources *EMPLOYEES WILL NEED TO RE-ENROLL IN HEALTH, DENTAL, VISION & HEALTH SAVINGS ACCOUNTS IN ORDER TO CONTINUE COVERAGE FOR THE NEW PLAN YEAR BEGINNING JULY 1, 2020. Please note other insurance products will remain in effect unless you see a representative to change them.

QUALIFICATIONS & IMPORTANT INFO

THINGS YOU NEED TO KNOW QUALIFICATIONS: • Employees must work at least 20 hours a week to be eligible for benefits.

IMPORTANT FACTS: • The plan year for Anthem Health, Sun Life Dental, UnitedHealthcare Vision, Health Savings Accounts, Dependent Care Flexible Spending Accounts, Colonial Insurance products and Legal Resources Pre-Paid Legal Plan lasts from July 1, 2020 through June 30, 2021. • Deductions for Anthem Health, Sun Life Dental, UnitedHealthcare Vision and Dependent Care Flexible Spending Accounts will begin June 2020. Deductions for Health Savings Accounts, Colonial Insurance products and Legal Resources Pre-Paid Legal Plan 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. • Dependent Care 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 Health Screening Rider on 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.

EMPLOYEE BENEFITS GUIDE

HOPEWELL CITY PUBLIC SCHOOLS 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 28, 2020 - MAY 15, 2020 YOU CAN MAKE THE FOLLOWING BENEFIT ELECTIONS ONLINE DURING THE ENROLLMENT PERIOD: • • • • • • •

Enroll in your Health Insurance*. Enroll in your Dental Insurance*. Enroll in your Vision Insurance*. Enroll in your Health Savings Account (HSA)*. Re-enroll in Flexible Spending Account (Dependent Care). Enroll, change or cancel your Pre-Paid Legal. Enroll, change or cancel your Colonial products (see the following pages for changes that can be completed online).

*EMPLOYEES WILL NEED TO RE-ENROLL IN HEALTH, DENTAL, VISION & HEALTH SAVINGS ACCOUNTS IN ORDER TO CONTINUE COVERAGE FOR THE NEW PLAN YEAR BEGINNING JULY 1, 2020.

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/hopewellcitypublicschools 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.

BENSELECT ONLINE ENROLLMENT:

BenSelect

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 the Benefits Representative assigned to your location.

Go to https://harmony.benselect.com/hopewell • 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)

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

Choose a security question and enter answer [______________________________________].

Confirm (or enter) an email address

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

From the welcome screen click “Next”.

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’.

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’.

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 SAVINGS ACCOUNT* Enter annual amount. EMPLOYEE MAX $3,550/year FAMILY MAX $7,100/year HSA plans can only be established in conjunction with a qualified High Deductible Health Plan (HDHP) Hopewell City Public Schools will contribute $1,800 per benefit year to an HSA per employee enrolled in the High-Deductible Health Plan (HDHP)

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

BENSELECT ONLINE ENROLLMENT CONT.:

BenSelect

• DEPENDENT CARE FSA: Enter annual amount. MAX $5,000/year • PRE-PAID LEGAL: You may enroll online in Pre-Paid Legal coverage. • DISABILITY - EDUCATOR 1.0: You may enroll online in Educator 1.0 coverage. • 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. • 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. *EMPLOYEES WILL NEED TO RE-ENROLL IN HEALTH, DENTAL, VISION & HEALTH SAVINGS ACCOUNTS IN ORDER TO CONTINUE COVERAGE FOR THE NEW PLAN YEAR BEGINNING JULY 1, 2020.

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’.

Hopewell City Public Schools July 1, 2020 - June 30, 2021 HealthKeepers POS OA 25/1500/30%/5000

Plan Year Deductible (applies as indicated) One Person Family (two or more people)

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

HealthKeepers HSA 3000/20%/5000

KeyCare HSA

3000/20%/4000

In-Network

Out-of-Network

In-Network

Out-of-Network

In-Network

Out-of-Network

$1,500 $3,000

$3,000 $6,000

$6,000 $12,000

$3,000 $6,000

$6,000 $12,000

In-Network

Out-of-Network

In-Network

Out-of-Network

In-Network

Out-of-Network

$5,000 $10,000

$10,000 $20,000

$5,000 $10,000

$10,000 $20,000

$4,000 $8,000

$10,000 $20,000

Deductible then 30%

Unlimited for all plans

Lifetime Maximum Covered Services Doctor's Visits (outpatient or in-office) Primary Care Physician Visits

$25 copay 100% Coverage (No Charge) $50 copay 100% Coverage (No Charge) Deductible then 30% $25 copay

Deductible then 30% Deductible then 20% 100% Coverage Deductible then 30% (No Charge) Deductible then 30% Deductible then 20%

Deductible then 30%

Deductible then 20% 100% Coverage (No Charge) Deductible then 20%

Deductible then 30% Deductible then 20%

Deductible then 30%

Deductible then 20%

Deductible then 30%

Deductible then 30% Deductible then 20% Deductible then 30% Deductible then 20%

Deductible then 30% Deductible then 30%

Deductible then 20% Deductible then 20%

Deductible then 30% Deductible then 30%

Deductible then 30%

Deductible then 30% Deductible then 20%

Deductible then 20%

Deductible then 30% $15 copay $50 copay

Deductible then 30% Deductible then 20% Deductible then 30% Deductible then 20% Deductible then 30% Deductible then 20%

Deductible then 20% Deductible then 30% Deductible then 30%

Deductible then 20% Deductible then 20% Deductible then 20%

Deductible then 20% Deductible then 30% Deductible then 30%

Deductible then 30% Deductible then 30% Deductible then 30% Deductible then 30% Deductible then 30%

Deductible then 20% Deductible then 20% Deductible then 20% Deductible then 20% Deductible then 20%

Deductible then 30% Deductible then 30% Deductible then 20% Deductible then 30% Deductible then 30%

Deductible then 20% Deductible then 20% Deductible then 20% Deductible then 20% Deductible then 20%

Deductible then 30% Deductible then 30% Deductible then 20% Deductible then 30% Deductible then 30%

Pre-natal & Post-natal Physican Services- Office

Deductible then $450 copay

Deductible then 30% Deductible then 20%

Deductible then 30%

Deductible then 20%

Deductible then 30%

Hospital Services for Delivery (Including Labs, Diagnostic Tests, and X-Rays)

Deductible then 30%

Deductible then 30% Deductible then 20%

Deductible then 30%

Deductible then 20%

Deductible then 30%

Deductible then 30% $25 copay

Deductible then 30% Deductible then 20% Deductible then 30% Deductible then 20%

Deductible then 30% Deductible then 30%

Deductible then 20% Deductible then 20%

Deductible then 30% Deductible then 30%

Preventative Care Specialist Diagnostic Lab in office Diagnostic X-ray in office Chiropractic Services Emergency Room Facility Charge Emergency Physicians and Other Services Telehealth Urgent Care

Deductible then 30%

Deductible then 30% Deductible then 30%

Hospital and Other Covered Services Pre-certification may be required

Inpatient Hospital Services Inpatient Physician and Other Services Ambulance Services Outpatient Hospital and Diagnostic Advanced Diagnostic Services - Office

Maternity

Behavioral Health Inpatient Treatment/Residential Treatment/Day Program Outpatient Professional Provider Visits

Hopewell City Public Schools July 1, 2020 - June 30, 2021 Prescription Drug Benefit *See SPD for out of network Rx benefits Tier 1 Tier 2 Tier 3

HealthKeepers HSA 3000/20%/5000

In Network

$10 copay $40 copay $60 copay

$10 copay after deductible is met $40 copay after deductible is met $60 copay after deductible is met 20% coinsurance up to $250 per prescription after deductible is met

Tier 1- $25 copay after deductible is met Tier 2- $100 copay after deductible is met Tier 3- $150 copay after deductible is met Tier 4 - 20% coinsurance up to $250 after deductible is met

20% coinsurance up to $250 per prescription

Tier 4

Home Delivery Services (Mail Order) SPD for out of network Rx benefits

HealthKeepers POS OA 25/1500/30%/5000

See

Tier 1- $25 copay Tier 2- $100 copay Tier 3- $150 copay Tier 4 - 20% coinsurance up to $250 per prescription

KeyCare HSA

This is a brief highlight of services only. This policy has exclusions and limitations, please refer to your full Summary Plan Description for all plan details.

3000/20%/4000

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

Hopewell City Public Schools July 1, 2020- June 30, 2021 Full-Time Employees - Contribution Schedule (30 hours or more)

Health Keepers 3000 - High Deductible Health Plan Employer provides $1,800 in HSA Contribution

Total Monthly Premium Employer Monthly Contribution Employee Monthly Contribution

Employee Only

Employee + Children

Employee + Spouse

Employee + Family

$494.70

$821.20

$1,043.82

$1,498.94

$444.70

$625.20

$803.82

$1,158.94

$50.00

$196.00

$240.00

$340.00

Health Keepers 1500 Copay Plan

Total Monthly Premium Employer Monthly Contribution Employee Monthly Contribution

Employee Only

Employee + Children

Employee + Spouse

Employee + Family

$609.11

$1,011.13

$1,285.22

$1,845.60

$334.11

$364.13

$418.22

$550.60

$275.00

$647.00

$867.00

$1,295.00

Out of Area Plan Plans- Key Care 3000 High Deductible Health Plan Employer provides $1,800 in HSA Contribution

Total Monthly Premium Employer Monthly Contribution Employee Monthly Contribution

Employee Only

Employee + Children

Employee + Spouse

Employee + Family

$527.37

$875.44

$1,112.75

$1,597.93

$234.37

$360.44

$466.75

$703.93

$293.00

$515.00

$646.00

$894.00

Hopewell City Public Schools July 1, 2020- June 30, 2021 Part-Time Employees - Contribution Schedule (20 hours or more) Health Keepers 3000 - High Deductible Health Plan Employer provides $1,800 in HSA Contribution

Total Monthly Premium Employer Monthly Contribution Employee Monthly Contribution

Employee Only

Employee + Children

Employee + Spouse

Employee + Family

$494.70

$821.20

$1,043.82

$1,498.94

$229.70

$325.20

$419.32

$602.44

$265.00

$496.00

$624.50

$896.50

Health Keepers 1500 Copay Plan

Total Monthly Premium Employer Monthly Contribution Employee Monthly Contribution

Employee Only

Employee + Children

Employee + Spouse

Employee + Family

$609.11

$1,011.13

$1,285.22

$1,845.60

$167.11

$182.13

$209.22

$275.60

$442.00

$829.00

$1,076.00

$1,570.00

Out of Area Plan Plans- Key Care 3000 High Deductible Health Plan Employer provides $1,800 in HSA Contribution

Total Monthly Premium Employer Monthly Contribution Employee Monthly Contribution

Employee Only

Employee + Children

Employee + Spouse

Employee + Family

$527.37

$875.44

$1,112.75

$1,597.93

$79.37

$118.94

$155.25

$237.93

$448.00

$756.50

$957.50

$1,360.00

Using your Health Savings Account (HSA) Learn how to make the most of your benefi ts

A health plan with a Health Savings Account (HSA) gives you access to many doctors and hospitals in your plan and helps pay for your costs when you need care. This plan also comes with a spending account and debit card you can use to pay for certain medical expenses. Let’s take a closer look at how your HSA works and how to make the most of it.

HSA ACCOUNT

Activate your debit card Your debit card will arrive in the mail. Once you activate it, use your debit card to pay for medical expenses like copays, lab tests, deductibles, prescriptions, hospital visits, urgent and emergency care, your percentage of the costs (coinsurance). See a full list of qualified medical and dental expenses at irs.gov/pub502.

View all your plan benefits, account balance and review your claims.



Set your account preferences and keep your email address updated so we can send you plan information. You’ll also want to opt in to receive eStatements and avoid paying a monthly paper statement fee.



Set up one-time or reoccurring tax-free contributions to your account. Transfer money from your personal bank account or automatically deduct funds from your paycheck if offered by your employer. Visit irs.gov/pub969 to see the maximum amount you’re allowed to add to your HSA this year.



Check out the How it all Works tab to learn more about all the benefits your HSA offers. Get tips, watch a video or use a spending account calculator to help manage your expenses for the year.

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.

108286VAMENBVA VPOD 6/18

More perks of your HSA 

The money you put into your HSA, the interest you earn, and even the money you take out to pay for health care costs is all tax-free.



All the money in your HSA rolls over from year to year, and it’s yours even if you change health plans, jobs or retire.



You can earn rewards by taking certain steps to improve your health.



If you’re 55 or older you can contribute an extra $1,000 a year.

Check out how it all works Learn about all the benefits your plan offers and the tools that will help you manage your health care expenses. Just log in at anthem.com and select Spending Accounts under the Menu tab.

Questions about your HSA? Contact Member Services anytime at the number on the back of your ID card or HSA debit card.

Ü»²¬¿´ ×²-«®¿²½»

ÐÎÑÌÛÝÌÍ ÇÑËÎ ÍÓ×ÔÛò

Ç±« ½¿² º»»´ ³±®» ½±²º·¼»²¬ ©·¬¸ ¼»²¬¿´ ·²-«®¿²½» ¬¸¿¬ »²½±«®¿¹»- ®±«¬·²» ½´»¿²·²¹- ¿²¼ ½¸»½µ«°-ò Ü»²¬¿´ ·²-«®¿²½» ¸»´°- °®±¬»½¬ §±«® ¬»»¬¸ º±® ¿ ´·º»¬·³»ò ÐÎÛÊÛÒÌÍ ÑÌØÛÎ ØÛßÔÌØ ×ÍÍËÛÍò ÝÑÓÓÑÒÔÇ ÝÑÊÛÎÛÜ

Û¨¿³- ¿²¼ ½´»¿²·²¹Èó®¿§Ú·´´·²¹Ì±±¬¸ »¨¬®¿½¬·±²-

Ö«-¬ ¿²²«¿´ °®»ª»²¬·ª» ½¿®» ¿´±²» ½¿² ¸»´° °®»ª»²¬ ±¬¸»® ¸»¿´¬¸ ·--«»- -«½¸ ¿- ¸»¿®¬ ¼·-»¿-» ¿²¼ ¼·¿¾»¬»-ò Ó¿²§ °´¿²- ½±ª»® °®»ª»²¬·ª» -»®ª·½»- ¿¬ ±® ²»¿® ïððû ¬± ³¿µ» ·¬ »¿-§ º±® §±« ¬± «-» §±«® ¼»²¬¿´ ¾»²»º·¬-ò ÔÑÉÛÎÍ ÑËÌóÑÚóÐÑÝÕÛÌ ÛÈÐÛÒÍÛÍò

Í»»·²¹ ¿² ·²ó²»¬©±®µ ¼»²¬·-¬ ½¿² ®»¼«½» §±«® º»»¿°°®±¨·³¿¬»´§ íðû º®±³ ¬¸»·® -¬¿²¼¿®¼ º»»-ò ß¼¼ ¬¸» ¾»²»º·¬- ±º §±«® ½±·²-«®¿²½» ¬± ¬¸¿¬ ¿²¼ ¬¸·²¹- ¿®» ´±±µ·²¹ ¹±±¼ º±® §±«® ©¿´´»¬ò

Ý¸·´¼ ¾®¿½»-

ÜÛÒÌßÔ ÚßÍÌ ÚßÝÌÍ

ØÑÐÛÉÛÔÔ Ý×ÌÇ ÐËÞÔ×Ý ÍÝØÑÑÔÍ

Ð»®·±¼±²¬¿´ ¼·-»¿-» ½¿² ´»¿¼ ¬± ®»½»¼·²¹ ¹«³-ô ¾±²» ¼¿³¿¹»ô ´±-- ±º ¬»»¬¸ô ¿²¼ ½¿² ·²½®»¿-» ¬¸» ®·-µ ±º ±¬¸»® ¸»¿´¬¸ °®±¾´»³- -«½¸ ¿- ¸»¿®¬ ¼·-»¿-» ¿²¼ ¼·¿¾»¬»-òï

Ì®»¿¬³»²¬ ±º ¹«³ ¼·-»¿-» ·² °»±°´» ©·¬¸ ¬§°» î ¼·¿¾»¬»- ½¿² ´±©»® ¾´±±¼ -«¹¿® ±ª»® ¬·³»òî

ß´´ Û´·¹·¾´» Û³°´±§»»ÐÑÔ×ÝÇ ý çðèçðé Í«² Ô·º» ß--«®¿²½» Ý±³°¿²§ ±º Ý¿²¿¼¿

ïììëêïî ÜÛÒê ÝÔï ðíñíðñîðîð ðèæðíæëè

èððóîìéóêèéë ‹ -«²´·º»ò½±³ñ«-

Ü»²¬¿´ ×²-«®¿²½»

Ù±±¼ ²»©-ÿ Ç±«® °´¿² ½±ª»®- ®±«¬·²» -»®ª·½»-

É¸¿¬Ž- ½±ª»®»¼

´·µ» ½´»¿²·²¹- ¿²¼ »¨¿³- ¿¬ ïððûò

×ÒóÒÛÌÉÑÎÕ

ÑËÌóÑÚóÒÛÌÉÑÎÕ

üîôððð °»® °»®-±²

üîôððð ´·º»¬·³» °»® ½¸·´¼

ÐÔßÒ ÇÛßÎ ÓßÈ×ÓËÓ Ì§°» ××ô ××× øÞ¿-·½ ¿²¼ Ó¿¶±® Í»®ª·½»-÷ Ì§°» ×Ê Ñ®¬¸± Í»®ª·½»

Ì§°» × Ð®»ª»²¬·ª» Í»®ª·½»- ¼± ²±¬ ½±«²¬ ¬±©¿®¼ §±«® Ð´¿² Ç»¿® ³¿¨·³«³

ÐÔßÒ ÇÛßÎ ÜÛÜËÝÌ×ÞÔÛ

×ÒóÒÛÌÉÑÎÕ

ÑËÌóÑÚóÒÛÌÉÑÎÕ

Òñß

üð ·²¼·ª·¼«¿´ñüð º¿³·´§

üëð ·²¼·ª·¼«¿´ñüïëð º¿³·´§

Òñß

ÐÎÑÝÛÜËÎÛ Ì§°» × Ð®»ª»²¬·ª» Í»®ª·½»Ì§°» ××ô ××× øÞ¿-·½ ¿²¼ Ó¿¶±® Í»®ª·½»-÷ Ì§°» ×Ê Ñ®¬¸± Í»®ª·½»-

ÌØÛ ÐÔßÒ ÐßÇÍ ÌØÛ ÚÑÔÔÑÉ×ÒÙ ÐÛÎÝÛÒÌßÙÛ ÚÑÎ ÐÎÑÝÛÜËÎÛÍ

×ÒóÒÛÌÉÑÎÕ

ÑËÌóÑÚóÒÛÌÉÑÎÕ

Ì§°» × Ð®»ª»²¬·ª» Í»®ª·½»-

ïððû

Ì§°» ×× Þ¿-·½ Í»®ª·½»-

ïððû

èðû

Ì§°» ××× Ó¿¶±® Í»®ª·½»-

êðû

ëðû

Ì§°» ×Ê Ñ®¬¸± Í»®ª·½»-

ëðû

ÐÎÑÝÛÜËÎÛ

ÍÛÎÊ×ÝÛÍ Ì§°» × Ð®»ª»²¬·ª» Ü»²¬¿´ Í»®ª·½»-ô ·²½´«¼·²¹æ ‹ Ñ®¿´ »ª¿´«¿¬·±²- Š î ·² ¿²§ ¾»²»º·¬ §»¿® ‹ Î±«¬·²» ¼»²¬¿´ ½´»¿²·²¹- Š î ·² ¿²§ ¾»²»º·¬ §»¿® ‹ Ú´«±®·¼» ¬®»¿¬³»²¬ Š ï ·² ¿²§ ê ³±²¬¸ °»®·±¼ò Ñ²´§ º±® ½¸·´¼®»² «²¼»® ¿¹» ïç ‹ Í»¿´¿²¬- Š ²± ³±®» ¬¸¿² ï °»® ¬±±¬¸ ·² ¿²§ íê ³±²¬¸ °»®·±¼ô ±²´§ º±® °»®³¿²»²¬ ³±´¿® ¬»»¬¸ò Ñ²´§ º±® ½¸·´¼®»² «²¼»® ¿¹» ïê ‹ Í°¿½» ³¿·²¬¿·²»®- Š ±²´§ º±® ½¸·´¼®»² «²¼»® ¿¹» ïç ‹ Þ·¬»©·²¹ ¨ó®¿§- Š ï ·² ¿²§ ïî ³±²¬¸ °»®·±¼ ‹ ×²¬®¿±®¿´ ½±³°´»¬» -»®·»- ¨ó®¿§- Š ï ·² ¿²§ íê ³±²¬¸ °»®·±¼ ‹ Ù»²»¬·½ ¬»-¬ º±® -«-½»°¬·¾·´·¬§ ¬± ±®¿´ ¼·-»¿-»-

‹ Ô±½¿´·¦»¼ ¼»´·ª»®§ ±º ¿²¬·³·½®±¾·¿´ ¿¹»²¬‹ Í¬¿·²´»-- -¬»»´ ½®±©²- Š ±²´§ º±® ½¸·´¼®»² «²¼»® ¿¹» ïç ‹ Ó¿¶±® ¹«³ ¼·-»¿-» ø-«®¹·½¿´ °»®·±¼±²¬·½-÷

Ì§°» ×× Þ¿-·½ Ü»²¬¿´ Í»®ª·½»-ô ·²½´«¼·²¹æ ‹ Ò»© º·´´·²¹‹ Í·³°´» »¨¬®¿½¬·±²-ô ·²½·-·±² ¿²¼ ¼®¿·²¿¹» ‹ Í«®¹·½¿´ »¨¬®¿½¬·±²- ±º »®«°¬»¼ ¬»»¬¸ô ·³°¿½¬»¼ ¬»»¬¸ô ±® »¨°±-»¼ ®±±¬ ‹ Þ·±°-§ ø·²½´«¼·²¹ ¾®«-¸ ¾·±°-§÷ ‹ Û²¼±¼±²¬·½- ø·²½´«¼»- ®±±¬ ½¿²¿´ ¬¸»®¿°§÷ Š ï °»® ¬±±¬¸ ·² ¿²§ îì ³±²¬¸ °»®·±¼ ‹ Ù»²»®¿´ ¿²»-¬¸»-·¿ñ×Ê -»¼¿¬·±² Š ³»¼·½¿´´§ ®»¯«·®»¼ ‹ Ó·²±® ¹«³ ¼·-»¿-» ø²±²ó-«®¹·½¿´ °»®·±¼±²¬·½-÷ ‹ Í½¿´·²¹ ¿²¼ ®±±¬ °´¿²·²¹ Š ï ·² ¿²§ îì ³±²¬¸ °»®·±¼ °»® ¿®»¿ ‹ Ð»®·±¼±²¬¿´ ³¿·²¬»²¿²½» Š î ·² ¿²§ ¾»²»º·¬ §»¿®

Ú±® ¿ ½±³°´»¬» ¼»-½®·°¬·±² ±º -»®ª·½»- ¿²¼ ©¿·¬·²¹ °»®·±¼-ô °´»¿-» ®»ª·»© §±«® ½»®¬·º·½¿¬» ±º ·²-«®¿²½»ò ×º §±« ©»®» ½±ª»®»¼ «²¼»® §±«® »³°´±§»®Ž- °®·±® °´¿² ¬¸» ©¿·¬ ©·´´ ¾» ©¿·ª»¼ º±® ¿²§ ¬§°» ±º -»®ª·½» ½±ª»®»¼ «²¼»® ¬¸» °®·±® °´¿² ¿²¼ ¬¸·- °´¿²ò

Ì§°» ××× Ó¿¶±® Ü»²¬¿´ Í»®ª·½»-ô ·²½´«¼·²¹æ ‹ Ü»²¬«®»- ¿²¼ ¾®·¼¹»- Š -«¾¶»½¬ ¬± ë §»¿® ®»°´¿½»³»²¬ ´·³·¬ ‹ ×²´¿§ô ±²´¿§ô ¿²¼ ½®±©² ®»-¬±®¿¬·±²- Š ï °»® ¬±±¬¸ ·² ¿²§ ë §»¿® °»®·±¼ ‹ Ü»²¬¿´ ·³°´¿²¬- Š -«¾¶»½¬ ¬± ë §»¿® ®»°´¿½»³»²¬ ´·³·¬ Ì§°» ×Ê Ñ®¬¸± Í»®ª·½»-ô ·²½´«¼·²¹æ ‹ Ñ®¬¸±¼±²¬·½ ¬®»¿¬³»²¬ ·- ´·³·¬»¼ ¬± ¬¸» ¼»°»²¼»²¬ ½¸·´¼®»² ±® -¬«¼»²¬ ¿¹» ´·-¬»¼ ¿¾±ª» É¿·¬·²¹ Ð»®·±¼-

‹ Ò± ©¿·¬·²¹ °»®·±¼ º±® °®»ª»²¬·ª»ô ¾¿-·½ ±® ³¿¶±® -»®ª·½»‹ Ò± ©¿·¬·²¹ °»®·±¼ º±® ±®¬¸±¼±²¬·½ -»®ª·½»-

Ú®»¯«»²¬´§ ¿-µ»¼ ¯«»-¬·±²Ø±© ¼±»- ¿ ÐÐÑ ©±®µá ÐÐÑ -¬¿²¼- º±® Ð¿®¬·½·°¿¬·²¹ Ð®±ª·¼»® Ñ®¹¿²·¦¿¬·±²ò É·¬¸ ¿ ¼»²¬¿´ ÐÐÑ °´¿²ô ¼»²¬¿´ °®±ª·¼»®- ¿¹®»» ¬± °¿®¬·½·°¿¬» ·² ¿ ¼»²¬¿´ ²»¬©±®µ ¾§ ±ºº»®·²¹ ¼·-½±«²¬»¼ º»»- ±² ³±-¬ ¼»²¬¿´ °®±½»¼«®»-ò É¸»² §±« ª·-·¬ ¿ °®±ª·¼»® ·² ¬¸» ²»¬©±®µô §±« ½±«´¼ -»» ´±©»® ±«¬ó±ºó°±½µ»¬ ½±-¬¾»½¿«-» °®±ª·¼»®- ·² ¬¸» ²»¬©±®µ ¿¹®»» ¬± ¬¸»-» °®»ó ²»¹±¬·¿¬»¼ ¼·-½±«²¬»¼ º»»- ±² »´·¹·¾´» ½´¿·³-ò Ø±© ¼± × º·²¼ ¿ ¼»²¬·-¬á Í·³°´§ ª·-·¬ ©©©ò-«²´·º»ò½±³ñº·²¼¿¼»²¬·-¬ò Ú±´´±© ¬¸» °®±³°¬- ¬± º·²¼ ¿ ¼»²¬·-¬ ·² §±«® ¿®»¿ ©¸± °¿®¬·½·°¿¬»- ·² ¬¸» ÐÐÑ ²»¬©±®µò Ç±« ¼± ²±¬ ²»»¼ ¬± -»´»½¬ ¿ ¼»²¬·-¬ ·² ¿¼ª¿²½»ò Ì¸» ÐÐÑ ²»¬©±®µ º±® §±«® °´¿² ·- ¬¸» Í«² Ô·º» Ü»²¬¿´ Ò»¬©±®µr ©·¬¸ ïíðôðððõ «²·¯«» ¼»²¬·-¬-ò

½±³³±² ¯«»-¬·±²- ©¸»² ·¬Ž- ½±²ª»²·»²¬ º±® §±«ò É¸¿¬ ª¿´«» ¿¼¼»¼ ¾»²»º·¬- ¼±»- ³§ °´¿² ·²½´«¼»á Ç±«® °´¿² ·²½´«¼»- ±«® Ô·º»¬·³» ±º Í³·´»-r °®±¹®¿³ô ©·¬¸ ¾»²»º·¬- ³¿²§ °»±°´» °®»º»®ô -«½¸ ¿- ¾®«-¸ ¾·±°-·»- º±® ¬¸» »¿®´§ ¼»¬»½¬·±² ±º ±®¿´ ½¿²½»®ò Ç±«® °´¿² ¿´-± ·²½´«¼»- Ð®»ª»²¬·ª» Ó¿¨ É¿·ª»®r ©¸·½¸ ¿´´±©- ½±ª»®»¼ ¼»²¬¿´ »¨°»²-»- º±® °®»ª»²¬·ª» -»®ª·½»- ¬± ²±¬ ¿°°´§ ¬± ¬¸» ¿²²«¿´ ³¿¨·³«³ò

Sun Life Dental (12 month) Employee Only Employee + Spouse Employee + Child(ren) Employee + Family

Ü± × ¸¿ª» ¬± ½¸±±-» ¿ ¼»²¬·-¬ ·² ¬¸» ÐÐÑ ²»¬©±®µá Ò±ò Ç±« ½¿² ª·-·¬ ¿²§ ´·½»²-»¼ ¼»²¬·-¬ º±® -»®ª·½»-ò Ø±©»ª»®ô §±« ½±«´¼ -»» ´±©»® ±«¬ó±ºó°±½µ»¬- ½±-¬- ©¸»² §±« ª·-·¬ ¿ ¼»²¬·-¬ ·² ¬¸» ²»¬©±®µò ß®» ³§ ¼»°»²¼»²¬- »´·¹·¾´» º±® ½±ª»®¿¹»á Ç»-ò Ç±«® °´¿² ±ºº»®- ½±ª»®¿¹» º±® §±«® -°±«-»í ¿²¼ ¼»°»²¼»²¬ ½¸·´¼®»²ò ß² »´·¹·¾´» ½¸·´¼ ·- ¼»º·²»¼ ¿- ¿ ½¸·´¼ ¬± ¿¹» îêòì

$18.92 $44.16 $44.16 $81.17

Sun Life Dental (12 month) Part Time

É¸¿¬ ·º × ¸¿ª» ¿´®»¿¼§ -¬¿®¬»¼ ¼»²¬¿´ ©±®µô ´·µ» ¿ ®±±¬ ½¿²¿´ ±® ¾®¿½»-ô ¬¸¿¬ ®»¯«·®»- -»ª»®¿´ ª·-·¬-á Ç±«® ½±ª»®¿¹» ©·¬¸ «- ³¿§ ¸¿²¼´» ¬¸»-» °®±½»¼«®»¼·ºº»®»²¬´§ ¬¸¿² §±«® °®·±® °´¿²ò Ì± »²-«®» ¿ -³±±¬¸ ¬®¿²-·¬·±² º±® ©±®µ ·² °®±¹®»--ô ½¿´´ ±«® ¼»²¬¿´ ½´¿·³»¨°»®¬- ¾»º±®» §±«® ²»¨¬ ª·-·¬ ¿¬ èððóììîóééìîò

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

EE Paid ER Paid Total $30.16 $38.39 $38.39 $53.81

$49.08 $82.55 $82.55 $134.98

EE Paid ER Paid Total $30.80 $57.97 $57.97 $99.27

$18.28 $24.58 $24.58 $35.71

$49.08 $82.55 $82.55 $134.98

Ü± × ¸¿ª» ¬± º·´» ¬¸» ½´¿·³á Ó¿²§ ¼»²¬·-¬- ©·´´ º·´» ½´¿·³- º±® §±«ò ×º ¿ ¼»²¬·-¬ ©·´´ ²±¬ º·´» §±«® ½´¿·³ô -·³°´§ ¿-µ §±«® ¼»²¬·-¬ ¬± ½±³°´»¬» ¿ -¬¿²¼¿®¼ ß³»®·½¿² Ü»²¬¿´ ß--±½·¿¬·±² øßÜß÷ ½´¿·³ º±®³ ¿²¼ ³¿·´ ·¬ ¬±æ Í«² Ô·º» ÐòÑò Þ±¨ îçìð Ý´·²¬±²ô ×ß ëîéíí

ÝÑÒÍ×ÜÛÎ ß ÐÎÛóÜÛÌÛÎÓ×ÒßÌ×ÑÒ ÑÚ ÞÛÒÛÚ×ÌÍ

Ø±© ½¿² × ¹»¬ ³±®» ·²º±®³¿¬·±² ¿¾±«¬ ³§ ½±ª»®¿¹» ±® º·²¼ ³§ ¼»²¬¿´ ×Ü ½¿®¼á ßº¬»® ¬¸» »ºº»½¬·ª» ¼¿¬» ±º §±«® ½±ª»®¿¹»ô §±« ½¿² ª·»© ¾»²»º·¬ ·²º±®³¿¬·±² ±²´·²» ¿¬ §±«® ½±²ª»²·»²½» ¬¸®±«¹¸ §±«® Í«² Ô·º» ¿½½±«²¬ò Ì± ½®»¿¬» ¿² ¿½½±«²¬ ¹± ¬± ©©©ò-«²´·º»ò½±³ñ¿½½±«²¬ ¿²¼ ®»¹·-¬»®ò Ç±« ½¿² ¿´-± ¿½½»-- ¬¸·- ·²º±®³¿¬·±² º®±³ ±«® ³±¾·´» ¿°°‰Þ»²»º·¬ Ì±±´-ô ©¸·½¸ ·- ¿ª¿·´¿¾´» º±® ß°°´» ¿²¼ ß²¼®±·¼ ¼»ª·½»-ò Ñ® §±« ½¿² ½¿´´ Í«² Ô·º»Ž- Ü»²¬¿´ Ý«-¬±³»® Í»®ª·½» ¿¬ èððó ììîóééìîò Ç±« ½¿² ¿´-± ½¿´´ ¿²§ ¬·³»ô ¼¿§ ±® ²·¹¸¬ô ¬± ¿½½»-- ±«® ¿«¬±³¿¬»¼ -§-¬»³ ¿²¼ ¹»¬ ¿²-©»®- ¬±

Ì¸»§ ¿´´±© «- ¬± ®»ª·»© §±«® °®±ª·¼»®Ž- ¬®»¿¬³»²¬ °´¿² ¬± ´»¬ §±« µ²±© ¾»º±®» ¬®»¿¬³»²¬ ·-¬¿®¬»¼ ¸±© ³«½¸ ±º ¬¸» ©±®µ -¸±«´¼ ¾» ½±ª»®»¼ ¾§ ¬¸» °´¿²ô ¿²¼ ¸±© ³«½¸ §±« ³¿§ ²»»¼ ¬± ½±ª»®ò É» ®»½±³³»²¼ ¬¸»³ º±® ¿²§ ¼»²¬¿´ ¬®»¿¬³»²¬ »¨°»½¬»¼ ¬± »¨½»»¼ üíððò

ïò ß³»®·½¿² ß½¿¼»³§ ±º Ð»®·±¼±²¬±´±¹§ ¸¬¬°æññ©©©ò°»®·±ò±®¹ñ½±²-«³»®ñ´±ª»Á¬¸»Á¹«³-Á§±«ûîé®»Á©·¬¸ò ø¿½½»--»¼ ±² ðêñðêñïç÷ îò ¸¬¬°-æññ©©©ò½¼½ò¹±ªñ¼·¿¾»¬»-ñ²¼»°ñ°¼º-ñïëðóØ»¿´¬¸§ó¬»»¬¸ó³¿¬¬»®ò°¼º ø¿½½»--»¼ ðêñðêñïç÷ íò ×º °»®³·¬¬»¼ ¾§ ¬¸» Û³°´±§»®Ž- »³°´±§»» ¾»²»º·¬ °´¿² ¿²¼ ²±¬ °®±¸·¾·¬»¼ ¾§ -¬¿¬» ´¿©ô ¬¸» ¬»®³ •-°±«-»Œ ·² ¬¸·- ¾»²»º·¬ ·²½´«¼»- ¿²§ ·²¼·ª·¼«¿´ ©¸± ·- »·¬¸»® ®»½±¹²·¦»¼ ¿- ¿ -°±«-»ô ¿ ®»¹·-¬»®»¼ ¼±³»-¬·½ °¿®¬²»®ô ±® ¿ °¿®¬²»® ·² ¿ ½·ª·´ «²·±²ô ±® ±¬¸»®©·-» ¿½½±®¼»¼ ¬¸» -¿³» ®·¹¸¬- ¿- ¿ -°±«-»ò ìò Ð´»¿-» -»» §±«® »³°´±§»® º±® ³±®» -°»½·º·½ ·²º±®³¿¬·±²ò

Î»¿¼ ¬¸» ×³°±®¬¿²¬ ·²º±®³¿¬·±² -»½¬·±² º±® ³±®» ¼»¬¿·´- ·²½´«¼·²¹ ´·³·¬¿¬·±²- ¿²¼ »¨½´«-·±²èððóîìéóêèéë ‹ -«²´·º»ò½±³ñ«-

Ü»²¬¿´ ×²-«®¿²½»

×³°±®¬¿²¬ ·²º±®³¿¬·±²

Þ»²»º·¬ ¿¼¶«-¬³»²¬Þ»²»º·¬- ©·´´ ¾» ½±±®¼·²¿¬»¼ ©·¬¸ ¿²§ ±¬¸»® ¼»²¬¿´ ½±ª»®¿¹»ò Ë²¼»® ¬¸» ß´¬»®²¿¬·ª» Ì®»¿¬³»²¬ °®±ª·-·±²ô ¾»²»º·¬- ©·´´ ¾» °¿§¿¾´» º±® ¬¸» ³±-¬ »½±²±³·½¿´ -»®ª·½»- ±® -«°°´·»- ³»»¬·²¹ ¾®±¿¼´§ ¿½½»°¬»¼ -¬¿²¼¿®¼- ±º ¼»²¬¿´ ½¿®»ò Ô¿¬» »²¬®¿²¬ ×º §±« ±® ¿ ¼»°»²¼»²¬ ¿°°´§ º±® ¼»²¬¿´ ·²-«®¿²½» ³±®» ¬¸¿² íï ¼¿§- ¿º¬»® §±« ¾»½±³» »´·¹·¾´»ô §±« ±® §±«® ¼»°»²¼»²¬ ¿®» ¿ ´¿¬» »²¬®¿²¬ò Ì¸» ¾»²»º·¬- º±® ¬¸» º·®-¬ ïî ³±²¬¸- º±® ´¿¬» »²¬®¿²¬- ©·´´ ¾» ´·³·¬»¼ ¿- º±´´±©-æ Ì×ÓÛ ×ÒÍËÎÛÜ ÝÑÒÌ×ÒËÑËÍÔÇ ËÒÜÛÎ ÌØÛ ÐÑÔ×ÝÇ

ÞÛÒÛÚ×ÌÍ ÐÎÑÊ×ÜÛÜ ÚÑÎ ÑÒÔÇ ÌØÛÍÛ ÍÛÎÊ×ÝÛÍ

Ô»-- ¬¸¿² ê ³±²¬¸-

Ð®»ª»²¬·ª» Í»®ª·½»-

ß¬ ´»¿-¬ ê ³±²¬¸- ¾«¬ ´»-- ¬¸¿² ïî ³±²¬¸-

Ð®»ª»²¬·ª» Í»®ª·½»- ¿²¼ º·´´·²¹- «²¼»® Þ¿-·½ Í»®ª·½»-

ß¬ ´»¿-¬ ïî ³±²¬¸-

Ð®»ª»²¬·ª»ô Þ¿-·½ô Ó¿¶±® ¿²¼ Ñ®¬¸± Í»®ª·½»-

É» ©·´´ ²±¬ °¿§ º±® ¬®»¿¬³»²¬- -«¾¶»½¬ ¬± ¬¸» ´¿¬» »²¬®¿²¬ ´·³·¬¿¬·±²ô ¿²¼ -¬¿®¬»¼ ±® ½±³°´»¬»¼ ¼«®·²¹ ¬¸» ´¿¬» »²¬®¿²¬ ´·³·¬¿¬·±² °»®·±¼ò Ì± ¾»½±³» ·²-«®»¼ô §±« ³«-¬ ³»»¬ ¬¸» »´·¹·¾·´·¬§ ®»¯«·®»³»²¬- -»¬ º±®¬¸ ¾§ §±«® »³°´±§»®ò Ç±«® ½±ª»®¿¹» »ºº»½¬·ª» ¼¿¬» ©·´´ ¾» ¼»¬»®³·²»¼ ¾§ ¬¸» Ð±´·½§ ¿²¼ ³¿§ ¾» ¼»´¿§»¼ ·º §±« ¿®» ²±¬ ¿½¬·ª»´§ ¿¬ ©±®µ ±² ¬¸» ¼¿¬» §±«® ½±ª»®¿¹» ©±«´¼ ±¬¸»®©·-» ¹± ·²¬± »ºº»½¬ò Í·³·´¿®´§ô ¼»°»²¼»²¬ ½±ª»®¿¹»ô ·º ±ºº»®»¼ô ³¿§ ¾» ¼»´¿§»¼ ·º §±«® ¼»°»²¼»²¬- ¿®» ·² ¬¸» ¸±-°·¬¿´ ø»¨½»°¬ º±® ²»©¾±®²-÷ ±² ¬¸» ¼¿¬» ½±ª»®¿¹» ©±«´¼ ±¬¸»®©·-» ¾»½±³» »ºº»½¬·ª»ò Î»º»® ¬± §±«® Ý»®¬·º·½¿¬» º±® ¼»¬¿·´-ò Ô·³·¬¿¬·±²- ¿²¼ »¨½´«-·±²Ì¸» ¾»´±© »¨½´«-·±²- ¿²¼ ´·³·¬¿¬·±²- ³¿§ ª¿®§ ¾§ -¬¿¬» ´¿© ¿²¼ ®»¹«´¿¬·±²-ò Ì¸·- ´·-¬ ³¿§ ²±¬ ¾» ½±³°®»¸»²-·ª»ò Ð´»¿-» -»» §±«® Ý»®¬·º·½¿¬» ±® ¿-µ §±«® ¾»²»º·¬- ¿¼³·²·-¬®¿¬±® º±® ¼»¬¿·´-ò Ü»²¬¿´ É» ©·´´ ²±¬ °¿§ ¿ ¾»²»º·¬ º±® ¿²§ Ü»²¬¿´ °®±½»¼«®»ô ©¸·½¸ ·- ²±¬ ´·-¬»¼ ¿- ¿ ½±ª»®»¼ ¼»²¬¿´ »¨°»²-»ò ß²§ ¼»²¬¿´ -»®ª·½» ·²½«®®»¼ °®·±® ¬± ¬¸» Ûºº»½¬·ª» ¼¿¬» ±® ¿º¬»® ¬¸» ¬»®³·²¿¬·±² ¼¿¬» ·- ²±¬ ½±ª»®»¼ô «²´»-- -°»½·º·½¿´´§ ´·-¬»¼ ·² ¬¸» ½»®¬·º·½¿¬»ò ß ³»³¾»® ³«-¬ ¾» ¿ ½±ª»®»¼ ¼»²¬¿´ ³»³¾»® «²¼»® ¬¸» Ð´¿² ¬± ®»½»·ª» ¼»²¬¿´ ¾»²»º·¬-ò Ì¸» Ð´¿² ¸¿º®»¯«»²½§ ´·³·¬¿¬·±²- ±² ½»®¬¿·² °®»ª»²¬·ª» ¿²¼ ¼·¿¹²±-¬·½ -»®ª·½»-ô ®»-¬±®¿¬·±²- øº·´´·²¹-÷ô °»®·±¼±²¬¿´ -»®ª·½»-ô »²¼±¼±²¬·½ -»®ª·½»-ô ¿²¼ ®»°´¿½»³»²¬ ±º ¼»²¬«®»-ô ¾®·¼¹»- ¿²¼ ½®±©²-ò ß´´ -»®ª·½»- ³«-¬ ¾» ²»½»--¿®§ ¿²¼ °®±ª·¼»¼ ¿½½±®¼·²¹ ¬± ¿½½»°¬¿¾´» ¼»²¬¿´ ¬®»¿¬³»²¬ -¬¿²¼¿®¼-ò Ì®»¿¬³»²¬ °»®º±®³»¼ ±«¬-·¼» ¬¸» Ë²·¬»¼ Í¬¿¬»- ·- ²±¬ ½±ª»®»¼ô »¨½»°¬ º±® »³»®¹»²½§ ¼»²¬¿´ ¬®»¿¬³»²¬ô -«¾¶»½¬ ¬± ¿ ³¿¨·³«³ ¾»²»º·¬ò Ü»²¬¿´ °®±½»¼«®»- º±® Ñ®¬¸±¼±²¬·½-å ÌÓÖå ®»°´¿½·²¹ ¿ ¬±±¬¸ ³·--·²¹ °®·±® ¬¸» »ºº»½¬·ª» ¼¿¬»å ·³°´¿²¬- ¿²¼ ·³°´¿²¬ ®»´¿¬»¼ -»®ª·½»-å ±® ±½½´«-¿´ ¹«¿®¼- º±® ¾®«¨·-³ ¿®» ²±¬ ½±ª»®»¼ «²´»-- ½±ª»®¿¹» ·- »´»½¬»¼ ±® ³¿²¼¿¬»¼ ¾§ ¬¸» -¬¿¬»ò Ì¸·- Ñª»®ª·»© ·- °®»´·³·²¿®§ ¬± ¬¸» ·--«¿²½» ±º ¬¸» Ð±´·½§ò Î»º»® ¬± §±«® Ý»®¬·º·½¿¬» º±® ¼»¬¿·´-ò Î»½»·°¬ ±º ¬¸·Ñª»®ª·»© ¼±»- ²±¬ ½±²-¬·¬«¬» ¿°°®±ª¿´ ±º ½±ª»®¿¹» «²¼»® ¬¸» Ð±´·½§ò ×² ¬¸» »ª»²¬ ±º ¿ ¼·-½®»°¿²½§ ¾»¬©»»² ¬¸·Ñª»®ª·»©ô ¬¸» Ý»®¬·º·½¿¬» ¿²¼ ¬¸» Ð±´·½§ô ¬¸» ¬»®³- ±º ¬¸» Ð±´·½§ ©·´´ ¹±ª»®²ò Ð®±¼«½¬ ±ºº»®·²¹- ³¿§ ²±¬ ¾» ¿ª¿·´¿¾´» ·² ¿´´ -¬¿¬»- ¿²¼ ³¿§ ª¿®§ ¼»°»²¼·²¹ ±² -¬¿¬» ´¿©- ¿²¼ ®»¹«´¿¬·±²-ò

Ì¸·- °´¿² ¼±»- ²±¬ °®±ª·¼» ½±ª»®¿¹» º±® °»¼·¿¬®·½ ±®¿´ ¸»¿´¬¸ -»®ª·½»- ¬¸¿¬ -¿¬·-º·»- ¬¸» ®»¯«·®»³»²¬- º±® •³·²·³«³ »--»²¬·¿´ ½±ª»®¿¹»Œ ¿¼»º·²»¼ ¾§ Ì¸» Ð¿¬·»²¬ Ð®±¬»½¬·±² ¿²¼ ßºº±®¼¿¾´» Ý¿®» ß½¬ øÐÐßÝß÷ò Í«² Ô·º» ½±³°¿²·»- ·²½´«¼» Í«² Ô·º» ¿²¼ Ø»¿´¬¸ ×²-«®¿²½» Ý±³°¿²§ øËòÍò÷ ¿²¼ Í«² Ô·º» ß--«®¿²½» Ý±³°¿²§ ±º Ý¿²¿¼¿ ø½±´´»½¬·ª»´§ô •Í«² Ô·º»Œ÷ò Ù®±«° ·²-«®¿²½» °±´·½·»- ¿®» «²¼»®©®·¬¬»² ¾§ Í«² Ô·º» ß--«®¿²½» Ý±³°¿²§ ±º Ý¿²¿¼¿ øÉ»´´»-´»§ Ø·´´-ô Óß÷ ·² ¿´´ -¬¿¬»-ô »¨½»°¬ Ò»© Ç±®µô «²¼»® Ð±´·½§ Ú±®³ Í»®·»- ïëóÙÐóðï ¿²¼ ïêóÜÛÒóÝóðïò w îðïç Í«² Ô·º» ß--«®¿²½» Ý±³°¿²§ ±º Ý¿²¿¼¿ô É»´´»-´»§ Ø·´´-ô Óß ðîìèïò ß´´ ®·¹¸¬- ®»-»®ª»¼ò Í«² Ô·º» ¿²¼ ¬¸» ¹´±¾» -§³¾±´ ¿®» ¬®¿¼»³¿®µ±º Í«² Ô·º» ß--«®¿²½» Ý±³°¿²§ ±º Ý¿²¿¼¿ò Ê·-·¬ «- ¿¬ ©©©ò-«²´·º»ò½±³ñ«-ò ÙÊÞØóÛÛóèíèì

ÍÔÐÝ îçëéç

èððóîìéóêèéë ‹ -«²´·º»ò½±³ñ«-

Ü»²¬¿´ ×²-«®¿²½»

Hopewell City Public Schools

Vision Benefit Summary Powered by Spectera Eyecare Networks Customer Service and Provider Locator: (800) 638-3120 myuhcvision.com

UnitedHealthcare vision has been trusted for more than 50 years to deliver affordable, innovative vision care solutions to the nation’s leading employers through experienced, customer-focused people and the nation’s most accessible, diversified vision care network. Exam with Materials Benefit Frequency Comprehensive Exam(s) Eyeglass Lenses Frames Contact Lenses instead of Eyeglasses

Once every 12 months Once every 12 months Once every 24 months Once every 12 months In-Network Services

Copays $ 10.00 Exam(s) Eyeglasses (lenses and frame) $ 25.00 $ 25.00 Contact lenses instead of Eyeglasses Frame Benefit (for frames that exceed the allowance, an additional 30% discount may be applied to the overage)¹ Private Practice Provider $130.00 retail frame allowance Retail Chain Provider $130.00 retail frame allowance Lens Options Standard Scratch-resistant Coating, Polycarbonate Lenses for Dependent Children (up to age 19) - covered in full. Contact Lens Benefit² Elective contact lenses Allowance is applied toward the purchase of contact lenses. Contact lens copay is waived. Elective contact lens fitting and evaluation Allowance is applied toward the contact lens fitting/evaluation fees. 3 Necessary contact lenses Children's and Maternity Eye Care Benefit

$130.00 $60.00 Covered in full after copay (if applicable).

Members age 0-12 and members pregnant or breastfeeding are eligible for a 2nd exam. Members age 0-12 and members pregnant or breastfeeding are also eligible for a replacement frame and lenses if they have a prescription change of 0.5 diopter or more. The 2nd exam and replacement benefits are the same as the initial exam, frame and lens benefits. Out-of-Network Reimbursements (Copays do not apply) Exam(s) Up to $40.00 Frames Up to $45.00 Single Vision Lenses Up to $40.00 Lined Bifocal and Progressive Lenses Up to $60.00 Lined Trifocal Lenses Up to $80.00 Lenticular Lenses Up to $80.00 Elective Contacts instead of Eyeglasses² Up to $105.00 Contact Lens Fitting and Evaluation Up to $0.00 3 Necessary Contacts instead of Eyeglasses Up to $210.00

United Healthcare Vision Employee Only Employee + Spouse Employee + Child(ren) Employee + Family

12-month $6.46 $11.05 $11.58 $17.34

Discounts Laser vision UnitedHealthcare has partnered with QualSight LASIK, the largest LASIK manager in the United States, to provide our members with access to discounted laser vision correction providers. Member savings represent up to 35% off the national average price of Traditional LASIK. Contracted prices start at $945 per eye for Traditional LASIK and $1,395 per eye for Custom LASIK. Discounts are also provided on newer technologies such as Custom Bladeless (all laser) LASIK. For more information, visit myuhcvision.com. Additional Material At a participating in-network provider you will receive up to a 20% discount on an additional pair of eyeglasses or contact lenses. This program is available after your vision benefits have been exhausted. Please note that this discount shall not be considered insurance, and that UnitedHealthcare shall neither pay nor reimburse the provider or member for any funds owed or spent. Additional materials do not have to be purchased at the time of initial material purchase. Hearing Aids As a UnitedHealthcare vision plan member, you can save on custom-programmed hearing aids when you buy them from UnitedHealthcare Hearing. To find out more go to UHCHearing.com. When placing your order use promo code MYVISION to get the special price discount. ¹30% discount available at most participating in-network provider locations. May exclude certain frame manufacturers. Please verify all discounts with your provider. ²Contact lenses are instead of eyeglass lenses and/or eyeglass frames. ³Necessary contact lenses are determined at the provider's discretion for one or more of the following conditions: Following cataract surgery without intraocular lens implant; to correct extreme vision problems that cannot be corrected with eyeglass lenses and/or frames; with certain conditions such as anisometropia, keratoconus, irregular corneal/astigmatism, aphakia, pathological myopia, aniseikonia, aniridia, facial deformity, or corneal deformity. If your provider considers your contacts necessary, you should ask your provider to contact UnitedHealthcare vision confirming the reimbursement that UnitedHealthcare will make before you purchase such contacts.

Important to Remember: In-Network • Always identify yourself as a UnitedHealthcare vision member when making your appointment. This will assist the provider in obtaining your benefit information. • Patient lens options which are not covered-in-full may be available at a discount at participating providers. Based on state guidelines, lens materials and options may not be available at these discounted prices at all provider locations. Please ask your provider for details. The Lens Options list can be found at myuhcvision.com. Choice and Access of Vision Care Providers UnitedHealthcare offers its vision program through a national network including both private practice and retail chain providers. To access the Provider Locator service or for a printed directory, visit our website myuhcvision.com or call (800) 638-3120, 24 hours a day, seven days a week. You may also view your benefits, search for a provider or print an ID card online at myuhcvision.com. Retain this UnitedHealthcare vision benefit summary which includes detailed benefit information and instructions on how to use the program. Please refer to your Certificate of Coverage for a full explanation of benefits. In-Network Provider - Copays and non-covered patient options are paid to provider by program participant at the time of service. Out-of-Network Provider - Participant pays all billed charges to the provider, and UnitedHealthcare reimburses the participant for services rendered up to the maximum allowance. Copays do not apply to out-of-network benefits. Receipts for payments should be submitted within 90 days after the date of service to the following address: UnitedHealthcare Vision, Attn. Claims Department, P.O. Box 30978, Salt Lake City, UT 84130. If it was not reasonably possible to give written proof in the time required, the Company will not reduce or deny the claim for this reason. However, proof must be filed as soon as reasonably possible, but no later than 1 year after the date of service unless the Covered Person was legally incapacitated. Customer Service is available toll-free at (800) 638-3120 from 8:00 a.m. to 11:00 p.m. Eastern Time Monday through Friday, and 9:00 a.m. to 6:30 p.m. Eastern Time on Saturday. This Benefit Summary is intended only to highlight your benefits and should not be relied upon to fully determine coverage. This benefit plan may not cover all of your healthcare expenses. More complete descriptions of benefits and the terms under which they are provided are contained in the certificate of coverage that you will receive upon enrolling in the plan. If this Benefit Summary conflicts in any way with the Policy issued to your employer, the Policy shall prevail.

UnitedHealthcare vision coverage provided by or through UnitedHealthcare Insurance Company, located in Hartford, Connecticut, UnitedHealthcare Insurance Company of New York, located in Islandia, New York, or its affiliates. Administrative services provided by Spectera, Inc., United HealthCare Services, Inc. or their affiliates Plans sold in Texas use policy form number VPOL.18.TX and associated COC form number VCOC.INT.18.TX or VCOC.CER.18.TX. Plans sold in Virginia use policy form number VPOL.18.VA and associated COC form number VCOC.INT.18.VA or VCOC.CER.18.VA. If you opt to receive vision care services or vision care materials that are not covered benefits under this plan, a participating vision care provider may charge you their normal fee for such services or materials. Prior to providing you with vision care services or vision care materials that are not covered benefits, the vision care provider will provide you with an estimated cost for each service or material upon your request. This cost may be higher than if you had received only covered vision services and you may incur additional out-of-pocket expenses. Eyewear materials may be ordered through the Spectera Eyecare Networks lab network with which UnitedHealthcare has a business relationship. 02/20 © 2020 United HealthCare Services, Inc. NCA-03C (v4.0)

Dependent Care FSA

Save up to $1,500 on dependent care expenses this year! a ti i ati i a e e e t a e e i le s e i a (DCA) is li e e ei i a is u t u a e i e

u t

How does a dependent care FSA work? A dependent care FSA is a flexible spending account that allows you to set aside pre-tax dollars for dependent care expenses, such as daycare, that allow you to work or look for work. You choose an annual election amount, up to $5,000 per family. The money is placed in your account via payroll deduction, in equal installments, and then used to pay for eligible dependent care expenses incurred during the plan year.

Why should I enroll in a dependent care FSA? Child and dependent care is a large expense for many families. Millions of people rely on child care to be able to work, while others are responsible for older parents or disabled family members. If you pay for care of dependents in order to work, youâ&#x20AC;&#x2122;ll want to take advantage of the savings this plan offers. Money contributed to a dependent care account is free from federal and most state taxes and remains tax-free when it is spent on eligible expenses. On average, participants enjoy a 30% tax savings on their annual contribution. This means you could be saving up to $1,500 per year on dependent care expenses!

Qualifying Dependents* y Your qualifying child under the age of 13 y Your spouse or qualifying adult child or relative who is physically or mentally

incapable of self-care

*additional restrictions may apply. See Internal Revenue Code Section 152.

How do I use my DCA to pay for dependent care expenses? You can use your Flex Facts Debit Card to pay your provider for eligible dependent care expenses, or pay with your personal funds and submit a claim for reimbursement.

Qualifying expenses What qualifies?

What doesn’t qualify?

Dependent care FSA funds can cover costs for: y

Certain expenses are not eligible, for instance:

efore school or after school care for children 12 and younger

y Expenses incurred in a prior plan year y Expenses for non-disabled children 13 and older

y Custodial care for dependent adults

y Educational expenses including kindergarten or private school tuition fees

y Licensed day care centers y Nanny Au Pair

y Food, clothing, sports lessons, field trips, and entertainment

y Nursery schools or preschools

y Overnight camp expenses

y Late pick-up fees

y Late payment fees for child care

y Summer or holiday day camps

A comprehensive list of eligible expenses can be found at flexfacts.com.

Online & mobile access Get instant access to your account with the Flex Facts Portal and Mobile App. y View your account balance and transaction history

y View important alerts and communications

y Submit and view claims

y Sign up for direct deposit

y Upload and store receipts

y Sign up for text message alerts

Download the Flex Facts Mobile App on the App Store or Google Play store

Helpful hints y

You must have funds in your dependent care FSA before you can spend them.

You can’t change your election amount during the plan year, unless you experience a change in status or

qualifying event. y y

eep your receipts, as you will need an itemized invoice for all reimbursement requests. If your employment terminates before the end of the plan year, your account will be terminated.

y Any unused funds that remain in your account at the end of the year will be forfeited (also known as the use-it-or-lose-it rule).

www.FlexFacts.com • 1200 River Ave Suite 10E • Lakewood, NJ 08701 • 877-943-2287

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

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

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

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.

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

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.

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.

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.

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.

Group Critical Care 1.0 Plan 3 Full

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.

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

ÂŠ 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.

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

ÂŠ 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.

100355-1 11/12

100355-1

Educator Disability Income Insurance

How long could you afford to go without a paycheck? Help protect your paycheck with Colonial Life’s short-term disability insurance. You use your paycheck mainly to pay for your home, your car, groceries, medical bills and utilities. What if you couldn’t go to work due to an accident or sickness? Monthly Expenses:

$_________________

$_________________ Total $_________________

My Coverage Worksheet (For use with your Colonial Life Benefits Counselor) Who’s being covered?

You only You and your spouse You and your dependent children You, your spouse and your dependent children

How much coverage do I need? On-Job Accident/On-Job Sickness $______________ Off-Job Accident/Off-Job Sickness $______________ Select One Benefit Period Option:

On-Job

Off-Job

First 3 months

$_____________/month

Next 9 months

$_____________/month

First 6 months

$_____________/month

Next 6 months

$_____________/month

= Total Disability

Educator Disability 1.0-VA

Option A Option B = Partial Disability Up to 3 months

When will my benefits start? After an Accident: ___________ days

After a Sickness: ___________ days

How much will it cost? Your cost will vary based on the level of coverage you select.

Employee Coverage In addition to disability coverage, this plan also provides employees with benefits for medical fees related to accidents, hospital confinement, accidental death and dismemberment, as well as fractures and dislocations. Even if youâ&#x20AC;&#x2122;re not disabled, the following benefits are payable for covered accidental injuries:

Medical Fees for Accidents Only Doctorâ&#x20AC;&#x2122;s Office or Urgent Care Facility Visit (Once per covered accident)...................................................................$75 X-Ray and Other Diagnostic Imaging (Once per covered accident)..............................................................................$75 Emergency Room Visit (Once per covered accident)....................................................................................................... $150

Hospital Confinement Benefit for Accident or Sickness Pays in addition to disability benefit. l

Benefits begin on the first day of confinement in a hospital for a covered accident or sickness. Up to 3 months..................................................................................................................... $1,200/month ($40/day) The Hospital Confinement benefit increases to $6,000/month ($200/day) when the Total Disability benefit ends at age 70

Accidental Death and Dismemberment Benefits Benefits payable for death or dismemberment. l l

Accidental Death............................................................................................................................................................... $25,000 Loss of a Finger or Toe Single Dismemberment.................................................................................................................................................. $750 Double Dismemberment.............................................................................................................................................$1,500 Loss of a Hand, Foot or Sight of an Eye Single Dismemberment...............................................................................................................................................$7,500 Double Dismemberment.......................................................................................................................................... $15,000 Accidental Death Common Carrier ........................................................................................................................... $50,000

Complete Fractures Complete Fractures requiring closed reduction Hip, Thigh .....................................................................................................................................................................................$1,500 Vertebrae . ...................................................................................................................................................................................... 1,350 Pelvis ................................................................................................................................................................................................ 1,200 Skull (depressed) ......................................................................................................................................................................... 1,125 Leg ........................................................................................................................................................................................................900 Foot, Ankle, Kneecap .....................................................................................................................................................................750 Forearm, Hand, Wrist . ....................................................................................................................................................................750 Lower Jaw ..........................................................................................................................................................................................600 Shoulder Blade, Collarbone .........................................................................................................................................................600 Skull (simple) . ...................................................................................................................................................................................525 Upper Arm, Upper Jaw ..................................................................................................................................................................525 Facial Bones .......................................................................................................................................................................................450 Vertebral Processes . .......................................................................................................................................................................300 Coccyx, Rib, Finger, Toe .................................................................................................................................................................120

Complete Dislocations .Complete Dislocations requiring closed reduction with anesthesia Hip ..................................................................................................................................................................................................$1,350 Knee .....................................................................................................................................................................................................975 Collarbone - sternoclavicular.......................................................................................................................................................750 Shoulder .............................................................................................................................................................................................750 Collarbone - acromioclavicular separation.............................................................................................................................675 Ankle, Foot .........................................................................................................................................................................................600 Hand . ...................................................................................................................................................................................................525 Lower Jaw ..........................................................................................................................................................................................450 Wrist .....................................................................................................................................................................................................375 Elbow ...................................................................................................................................................................................................300 One Finger, Toe . ...............................................................................................................................................................................120 For a fracture or dislocation requiring an open reduction, your benefit would be 11/2 times the amount shown.

Additional Features l

Waiver of Premium

Worldwide Coverage

Optional Spouse and Dependent Coverage You may cover one or all of the eligible dependent members of your family for an additional premium.

Medical Fees for Accidents Only Doctorâ&#x20AC;&#x2122;s Office or Urgent Care Facility Visit (Once per covered accident)...........................................................$75 X-Ray and Other Diagnostic Imaging (Once per covered accident)......................................................................$75 Emergency Room Visit (Once per covered accident)............................................................................................... $150

Hospital Confinement Benefit for Accident or Sickness l

Up to 3 months........................................................................................................................ $1,200/month ($40/day)

Accidental Death and Dismemberment Benefits l

Accidental Death..................................................................................................................................... Spouse $10,000 Child(ren) $5,000 Loss of a Finger or Toe Single Dismemberment............................................................................................................................................$75 Double Dismemberment...................................................................................................................................... $150

Loss of a Hand, Foot or Sight of an Eye Single Dismemberment......................................................................................................................................... $750 Double Dismemberment...................................................................................................................................$1,500

Accidental Death Common Carrier . ................................................................................................Spouse $20,000 Child(ren) $10,000

Here are some

Colonial Life’s frequently asked questions about disability insurance: Will my disability income payment be reduced if I have other insurance?

What if I change employers?

You’re paid regardless of any other insurance you may have with other insurance companies. Benefits are paid directly to you (unless you specify otherwise).

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 continue to pay your premiums when they are due.

When am I considered totally disabled?

Can my premium change? You may choose the amount of coverage to meet your needs (subject to your income). You can elect more or less coverage which will change your premium. 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.

Totally disabled means you are: l

Unable to perform the material and substantial duties of your job; Not, in fact, engaged in any employment or occupation for wage or profit for which you are qualified by reason of education, training or experience; and

What is a covered accident or a covered sickness?

Under the regular and appropriate care of a doctor.

A covered accident is an accident. A covered sickness means an illness, infection, disease or any other abnormal physical condition, not caused by an injury.

What if I want to return to work part-time after I am totally disabled? You may be able to return to work part-time and still receive benefits. We call this “Partial Disability.” This means you may be eligible for coverage if: l You are unable to perform the material and substantial duties of your job for more than 20 hours per week, l You are able to work at your job or your place of employment for 20 hours or less per week, l Your employer will allow you to return to your job or place of employment for 20 hours or less per week; and l You are under the regular and appropriate care of a doctor. The total disability benefit must have been paid for at least one full month immediately prior to your being partially disabled.

A covered accident or covered sickness: l Occurs after the effective date of the policy; l Occurs while the policy is in force; l Is of a type listed on the Policy Schedule; and l Is not excluded by name or specific description in the policy. EXCLUSIONS We will not pay benefits for injuries received in accidents or sicknesses which are caused by or are the result of: alcoholism or drug addiction; flying; giving birth within the first nine months after the effective date of the policy; felonies or illegal occupations; having a pre-existing condition as described and limited by the policy; psychiatric or psychological condition; committing or trying to commit suicide or injuring yourself intentionally; being exposed to war or any act of war or serving in the armed forces of any country or authority.

When do disability benefits end? The Total Disability Benefit will end on the policy anniversary date on or after your 70th birthday. The Hospital Confinement benefit increases when the Total Disability Benefit ends. A pre-existing condition is when you have a sickness or physical condition for which you were treated, had medical testing, received medical advice, or had taken medication within 12 months testing, or before the effective date of your policy. If you become disabled because of a pre-existing condition, Colonial Life will not pay for any disability period if it begins during the first 12 months the policy is in force. Colonial Life 1200 Colonial Life Boulevard Columbia, South Carolina 29210 coloniallife.com 6/11

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

Colonial Life and Making benefits count are registered service marks of Colonial Life &71381-1 Accident Insurance Company. 100252

Educator Disability 1.0-VA

For cost and complete details, see your Colonial Life benefits counselor. Applicable to policy form ED DIS 1.0-VA. 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.

What is a pre-existing condition?

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?

Sports-related accidental injury Broken bone Burn Concussion Laceration

Back or knee injuries

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

Portable

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.

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

Initial Care l

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

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

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

Coma..............................................................................................................................................................$10,000

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

Tendon/Ligament/Rotator Cuff...........................................................$500 - one, $1,000 - two or more

Ruptured Disc...................................................................................................................................................$500

Torn Knee Cartilage........................................................................................................................................$500

Surgical Care l

Surgery (cranial, open abdominal or thoracic)................................................................................. $1,500

Surgery (hernia)...............................................................................................................................................$150

Surgery (arthroscopic or exploratory).....................................................................................................$200

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

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

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

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)

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

Appliances ........................................................................................... $100 (such as wheelchair, crutches)

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

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

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

Loss of the sight of both eyes

Loss of both hands or both feet

Loss of the hearing of both ears

Loss or loss of use of one arm and one leg or

Loss of the ability to speak

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

Named Insured

$25,000

$100,000

Spouse

$25,000

$100,000

Child(ren)

$5,000

$20,000

Health Screening Benefit

$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

Hemoccult stool analysis

Bone marrow testing

Mammography

Breast ultrasound

Pap smear

CA 15-3 (blood test for breast cancer)

PSA (blood test for prostate cancer)

CA125 (blood test for ovarian cancer)

Carotid doppler

Serum cholesterol test to determine level of HDL and LDL

CEA (blood test for colon cancer)

Chest x-ray

Serum protein electrophoresis (blood test for myeloma)

Colonoscopy

Stress test on a bicycle or treadmill

Echocardiogram (ECHO)

Skin cancer biopsy

Electrocardiogram (EKG, ECG)

Thermography

Fasting blood glucose test

ThinPrep pap test

Flexible sigmoidoscopy

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.

74231-2

Accident 1.0-Preferred with Health Screening Benefit-VA

One-Parent Family, with Employee

One Child Only

Hospital Confinement Indemnity Insurance Plan 1 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

Health savings account (HSA) compatible

For more information, talk with your benefits counselor.

ColonialLife.com

This plan is compatible with HSA guidelines. This plan may also be offered to employees who do not have HSAs. Colonial Life & Accident Insurance Company’s Individual Medical Bridge offers an HSA compatible plan in most states.

THIS POLICY PROVIDES LIMITED BENEFITS. 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.

IMB7000 – PLAN 1 | 5-16 | 101576-1

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)

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 n Breast

n Gynecological

n Cardiac

n Liver

n Digestive

n 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

n Skin

– Laparoscopic hernia repair – Skin grafting

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

Tier 2 outpatient surgical procedures n Breast

n Gynecological

n Cardiac

n Musculoskeletal system

– Breast reconstruction – Breast reduction

– Hysterectomy – Myomectomy

– Angioplasty – Cardiac catheterization

n Digestive

– Exploratory laparoscopy – Laparoscopic appendectomy – Laparoscopic cholecystectomy

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

n Thyroid

– Excision of a mass

n 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

n 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.

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

n Blood test for triglycerides n Bone marrow testing n Breast ultrasound n CA 15-3 (blood test for breast cancer) n CA 125 (blood test for ovarian cancer) n CEA (blood test for colon cancer) n Carotid Doppler

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

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

For more information, talk with your benefits counselor.

n Hemoccult stool analysis n Mammography n Pap smear n PSA (blood test for prostate cancer) n 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.

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

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

Term Life Insurance Life insurance protection when you need it most Life insurance needs change as life circumstances change. You may need different coverage if you’re getting married, buying a home or having a child. Term life insurance from Colonial Life provides protection for a specified period of time, typically offering the greatest amount of coverage for the lowest initial premium. This fact makes term life insurance a good choice for supplementing cash value coverage during life stages when obligations are higher, such as while children are younger. It’s also a good option for families on a tight budget — especially since you can convert it to a permanent cash value plan later.

With this coverage: n A beneficiary can receive a benefit that is typically free from income tax. n The policy’s accelerated death benefit can pay a percentage of the death benefit if the covered person is diagnosed with a terminal illness. n You can convert it to a Colonial Life cash value insurance plan, with no proof of good health, to age 75. n Coverage is guaranteed renewable up to age 95 as long as premiums are paid when due. n Portability allows you to take it with you if you change jobs or retire.

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

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: n Life insurance benefits for the beneficiary are typically tax-free. n 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. n 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 n 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

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

n 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

COMPREHENSIVE, AFFORDABLE

AND

IN DEMAND

OUR MISSION. OUR CLIENTS. OUR SERVICES. >> For more than 25 years, Legal Resources has been a group legal plan provider to employers. >> Today, over 700 employer groups offer the Legal Resources plan. >> Our benefit is designed to provide 100% coverage for the most often utilized legal services and covers the participating employee, spouse, and qualifying dependent children.

100% COVERED SERVICES INCLUDE: Wills and Estate Planning

Consultation and Advice

Criminal Law

Real Estate Transactions

Billing Disputes

Preparation of Legal Documents

Traffic Court Representation

Elder Law

Identity Theft Assistance

Family Law

Civil Actions

And Much More...

OUR PROVIDER NETWORK >> Our members have access to a network of top-rated full service law firms in their area, with over 13,000 attorneys nationwide. >> Members choose their law firm from our industry-leading provider network.

PLAN HIGHLIGHTS

Voluntary or employer paid benefit for employees. Nationwide 800.728.5768

Virginia Beach, VA. v080818

757.498.1220

Plan canâ&#x20AC;&#x2122;t be used against the employer.

Dedicated Account Management Team provides ongoing, on-site support year-round.

PUT THE LEGAL RESOURCES PLAN To Work for You and Your Employees 48

ADD-ON pro-active identity theft monitoring also available. Richmond, VA. 804.897.1700

Bethesda, MD. 301.354.9490

FULLY COVERED SERVICES LEGAL RESOURCES COVERS 100% OF THE ATTORNEY FEES FOR FULLY COVERED LEGAL SERVICES General Advice and Consultation

Wills and Estate Planning

• Unlimited in-person or telephone advice and consultation for fully covered services

• Will preparation and periodic updates • Advance medical directive • Financial powers of attorney • Contingent trust for minor children

Family Law • Uncontested domestic adoption • Uncontested divorce • Uncontested name change

Elder Law • Estate advice • Powers of attorney for members’ parents

Preparation and Review of Routine Legal Documents • Unlimited pages and occurrences

Real Estate • Purchase, sale, or refinance of primary residence • Deed preparation • Tenant-Landlord matters • Landlord-Tenant consultation

Traffic Violations • Traffic infractions and misdemeanors • Speeding • Reckless driving • Driving under the influence

Consumer Relations and Credit Protection • Warranty disputes • Billing disputes • Collection agency harassment

1st Offense

Criminal Matters

Civil Actions

• Defense of misdemeanor • Misdemeanor defense of juveniles

• Representation as defendant • Representation as plaintiff • Insurance matters • Initial administrative hearing • Small Claims Court advice

Fully covered for first offense involving alcohol or illegal drugs

Identity Theft • Prevention assistance • Education services • Identity recovery assistance

Don’t see your legal need listed?

You’re still covered!¹

The Legal Resources Plan offers a 25% discount on less common legal needs, such as...

Immigration

Tax Law Issues

Small Business Matters

Bankruptcy

Felonies

Including pre-existing legal matters and much more... Legal Resources Employee + Family

Per Month $17.00

This SUMMARY OF COVERAGE is intended to provide a broad general overview of plan coverage and is not a contract. Coverage may vary by organization. For specific coverage questions, please call Member Services at 800.728.5768. Member is responsible for all non-attorney costs such as filing fees, court costs, fines, etc. 1 Since your employer is the participating sponsor, you may not use the Plan in a dispute with your employer.

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 Hopewell City Public Schools, 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: Missy Shores at Hopewell City Public Schools. Applicable documentation will be required i.e. court order, certificate of coverage etc.

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 Hopewell City Public Schools Attn: Missy Shores, Human Resources 103 N 12th Street Hopewell, VA 23860 Phone: 804-541-6400 COBRA Administrator for Health, Dental and Vision Coverage PO Box 269009 Plano, TX 75026

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)

___________ (Date Signed)

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. 10-16

18514-16

CONTACT INFORMATION: ANTHEM - HEALTH INSURANCE • • • •

Customer Service: 1-800-582-6941 LiveHealthOnline: www.livehealthonline.com or 1-844-784-8409 24/7 NurseLine: 1-800-337-4770 Website: www.anthem.com

ANTHEM - HEALTH SAVINGS ACCOUNT

FLEX FACTS - DEPENDENT CARE FLEXIBLE SPENDING ACCOUNT • Customer Service: 1-877-943-2287 • Website: www.FlexFacts.com • Claims Mailing Address: 1200 River Avenue, Suite 10E Lakewood, NJ 08701

MANAGE YOUR ACCOUNT ONLINE OR DOWNLOAD THE FLEX FACTS MOBILE APP

Contact Member Services anytime at the number on the back of your ID card or HSA debit card.

• • • •

SUN LIFE - DENTAL INSURANCE • Customer Service: 1-800-247-6875 • Website: www.sunlife.com/us

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

LEGAL RESOURCES - PRE-PAID LEGAL

UNITEDHEALTHCARE - VISION INSURANCE

• Customer Service: 1-800-728-5768 • Website: www.legalresources.com

• Customer Service: 1-800-638-3120 • Website: www.myuhcvision.com

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.

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

hopewellcitypublicschools

For additional information concerning plans offered to employees of Hopewell City Public Schools, please contact our Pierce Group Benefits Service Center at 1-800-387-5955