2021 Benefit Guide by Senestech Site

2021

SenesTech Inc

Benefits Guide | 1

Your company partners with Amplify HR Management to provide comprehensive Human Resource services such as processing your company's payroll, issuing W-2 Forms, access to group benefit plans and much more. This booklet contains information about the employee benefits available to you. Please note that all benefits in this booklet are subject to change. This booklet is a guide and not a contract. For more detailed information about each benefit plan, you should refer to the plan document issued by the insurance carrier. Amplify's Benefits Specialists are here to assist you from 8:00 a.m. until 5:00 p.m. Central Time Monday through Friday at (224) 424-5400 or email us at Benefits@AmplifyHRM.com.

Enrollment is easy! Simply log into the Amplify employee web portal at: https://whr.prismhr.com/whr.amp/auth/#/login?lang=en If you have not created a user name and password, click on "Register". If you have forgotten your username and/or password, click on the "Forgot Username" or "Forgot Password" link. If you need assistance with your login, please call us at (224) 424-5400.

Navigating the Enrollment Portal Once logged in, your primary screen is the Employee Self Service dashboard. The dashboard menu is located on the left side of the screen. Each of these menus have sub-menus associated with them. These options will allow you to manage your personal information, view your time off balances (only available if we are tracking your policy), view your active benefit enrollments, and view pay details and print check stubs. To access the benefits enrollment portal, select "Benefits" and then "Benefits Enrollment". • Before you begin selecting your benefits, enter your dependents (if any) by clicking on "Dependents from the menu on the left. • Select the coverage type from the menu on the left to begin choosing the benefit plans you wish to enroll in. • Click "Next" on each screen to move to the next coverage type. Note that you will need to elect or waive each coverage type in order to complete your enrollment. • For each plan, click "view" to see more details about the plan. You can also view each plan summary by selecting "SBC". • Don't forget to add your dependents to each plan! • When you are finished, click "Submit". You will need to confirm your elections by checking the box next to the acknowledgment statement and type your name exactly as it appears in the upper right-hand side of your screen. • Once you have submitted your enrollment, you will not be able to make any changes online and will need to call the Benefits Department at (224) 424-5400 or email Benefits@AmplifyHRM.com. • Be sure to keep a copy of your confirmation for your records. If you have any questions about the available benefits or if you need help enrolling, please contact the Benefits Department at (224) 424-5400 or email us at Benefits@AmplifyHRM.com. 2

Who is Eligible? Full-time employees working a minimum of 30 hours per week are eligible to enroll for coverage under your company's medical plan and Amplify's dental, vision, and voluntary benefit plans. Coverage for certain benefits may depend on rules specific to each individual insurance company.

Dependents You may cover your dependents under the plans that offer dependent coverage. Generally, eligible dependents are: • Your legal spouse • Your unmarried or married dependent children, up to age 26. Depending on your medical plan, you may also be able to cover your domestic partner. Amplify's dental, vision, as well as certain voluntary benefit plans allow you to cover your domestic partner.

When to Enroll If you are a newly hired employee, you should receive an auto-generated email notifying you of the eligibility and the deadline to enroll. If you do not receive the enrollment notification email, please contact the Amplify Benefits Department PRIOR TO YOUR ELIGIBILITY DA TE at Benefits@Amplifyhrm.com or (224) 424-5400. You may also enroll at open enrollment. The open enrollment period will be announced each year 30-45 days prior to the open enrollment period.

1.Know your Benefits Benefits are a big part of your total compensation, so it's important that you get the maximum value from your benefit plans. Be sure to review all benefits carefully and make the elections that fit your personal or family's needs. If you have any questions about any of the benefits available to you, please call or email Amplify's Benefits Department at (224) 424-5400 or Benefits@AmplifyHRM.com.

2.Choose your Benefits Carefully Your elections will remain in effect until the next open enrollment period, unless you experience a qualifying status change event (see below for more information on status change events). The specific open enrollment dates are announced each year prior to the open enrollment period beginning.

3.Social Security Numbers Health insurers are required to report certain information about health plan members and their insurance coverage to the IRS each year, including member social security numbers. Be sure you have entered the Social Security number for each dependent you are enrolling in coverage.

4.Flexible Spending Accounts Flexible Spending Account elections must be made each year. If you are a new hire, your election is valid from your benefits effective date through December 31st of each year. You must make a new election for the subsequent year during the open enrollment period prior to January 1st.

5. Health Savings Accounts Health Savings Account contributions can be started or stopped at any time during the year (at the beginning/end of a month), however, they are processed as an annualized amount. HSA deductions will end at the end of each year and a new annualized amount must be elected for the subsequent year during the open enrollment period prior to January 1st.

6. Qualifying Life Events/Status Changes Your elections under the plan are generally irrevocable for the plan year under Internal Revenue Code Section 125. However, the IRS provides specific instances when an employee can make mid-year election changes. Note that the regulations require that if a change in status occurs, the change in election must be consistent with that event. For example, if an employee divorces, the employee may drop coverage for the spouse but not for themselves or other covered dependents. Other examples of status changes events are marriage, loss of certain other health coverage, entitlement to Medicare or Medicaid, HIPAA special enrollment rights, etc.

If you experience a status change event and want to change your benefit plan election(s), you must make the change within 30 days of the event. Note that for changes to your health plan, the insurance carrier has the final determination as to the validity of the status change. For questions about status change, please contact Amplify's Benefits Department at (224) 424- 5400 or Benefits@AmplifyHRM.com.

United HealthCare All Savers Choice Plus UHC’s All Savers Choice Plus plans allow members to choose network providers or providers who are not part of UHC’s network. Keep in mind that when you see providers who are not in network, your outof-pocket costs can be considerably higher than when you see a network provider.

United HealthCare All Savers Choice Plus HSA This plan is a Health Savings Account (HSA) qualified plan, which allows member to contribute pretax dollars to an HSA account. Because it is HSA-qualified, there are certain requirements of the plan design. One of those requires that the deductible be met before any benefits are payable. This means you will pay out-of-pocket any time you seek care under the plan, including doctor visits and prescriptions until you have reached your deductible.

Seeking Services For all plan types, members can manage their care through a primary care physician (PCP), although designating a PCP is generally not required for most plans. Providers both in- and out-of-network can be accessed without a referral. Note that some plans do not provide out-of network coverage. Your available plans may or may not provide out-of-network coverage, depending on the plans your employer is offering. The plan side-by-side comparison on the following pages will indicate which plans, if any, do not provide out-of-network coverage. When seeing an in-network provider, you can expect to pay a copay, coinsurance, and/or a deductible depending on the provider or type of service you are seeking. For example, you may have to pay a copay for a visit to your PCP. If you have in-patient surgery, you may be responsible for a deductible and coinsurance. "Virtual visits" provide live consultation with board-certified doctors, via online video, for many non-emergency medical and behavioral health needs. This provides added convenience 24 hour a day, seven days a week, generally at a reduced or no copay. As always, check your plan Summary of Benefits and Coverage (SBC) for your specific coverage. See the plan side-by-side comparison on the following page(s) or the plan Summary of Benefits and Coverage (SBC) for more detailed information.

Medical Plans

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Important Reminder:

Get trusted support for medical issues… every step of the way Dealing with a serious health issue—or getting a diagnosis you don’t understand—can be hard on you and your family. Health Advocate’s team of healthcare experts is here to help you get the care you need, and peace of mind knowing your diagnosis and treatment are on target.

An entire team by your side—at no cost to you Call anytime for support from our team of medical directors, registered nurses and other experts—professionals with extensive experience working with leading institutions and supporting complicated medical issues. They can: • H elp you understand diagnoses and evaluate treatment options • R esearch and identify the most advanced approaches to care • A rrange appointments with physicians and specialists, anywhere in the U.S.

Available to the whole family You, your spouse or domestic partner, dependents, parents and parents-in-law can all take advantage of our personalized services. Your medical and personal information will be kept completely confidential.

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• H elp coordinate care and services during and after a hospital stay • P rovide end-to-end support during all phases of care

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Support for every type of medical condition

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• Explain health conditions, diagnoses and treatments; research treatment options • Arrange second opinions and transfer medical records; coordinate care and services

Take the hassle out of healthcare • Find the right in-network doctors and make appointments • Review medical bills to find errors or duplicate charges; resolve complicated claims and billing issues

Navigating the healthcare system and dealing with personal problems can be a challenge. Our experts will answer your questions and take on virtually any healthcare or administrative issue so you get to the right care at the right time. We’ll also provide confidential counseling and the right support to help you work through personal issues. All at no cost to you.

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• Work through relationship issues, stress, depression, substance abuse and more • Build coping skills to manage life’s challenges and gain control of your life

Work/life resources to make life easier and find balance

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Available at no cost to employees, spouses, dependents, parents and parents-in-law. Completely confidential.

• Locate childcare, eldercare, summer camps, special needs services and relocation support • Easy access to legal/financial experts and information, saving you time, money and worry

We’re not an insurance company. Health Advocate is not a direct medical care provider, and is not affiliated with any insurance company or third party provider. ©2018 Health Advocate HA-CEM-1801024-13FLY

Confidential support for personal problems

Dental Plans MetLife Dental PPO plans are designed to help you get the dental care you need and help lower your costs. The plans cover a wide range of services both in and out of network. By using an in- network dentist, you can expect to pay less out-of-pocket for covered services than when using a non-network dentist. Benefits are payable immediately from the start date of an individual?s benefits. Plan benefits for in-network covered services are based on a percentage of the negotiated fee ? the fee that participating dentists have agreed to accept as payment in full for covered services, subject to the deductibles, copayments, cost sharing and benefit maximums. Negotiated fees are subject to change.

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Dental Discount Plan

Plan Highlights And Advantages Save an average of 60% on all dental expenses Over 392,000 dentists nationally to select from Unlimited benefits each year (use as much as you like) No waiting periods on any procedures after enrollment Orthodontics (braces) for children and adults Includes cosmetic dentistry No forms to complete or age limits No exclusions for any pre-existing dental conditions

See plan summary for details about the provider network and Fee Schedule by logging into the Enrollment Portal at www.amplifyhrm.com.

Monthly Cost: Employee: $12.76 Employee + 1: $22.76 Employee + 2 or more: $32.78

The MetLife Vision PPO plan, you have the flexibility choose one of the many in-network providers or any vision provider outside of the network. Remember, however that you'll find more savings by seeing an in-network provider.

There are two basic types of Flexible Spending Accounts (FSA): Medical FSA and Dependent Care FSA. A Medical FSA allows employees enrolled in a medical plan to deposit pre-tax funds into an account that can be used to pay for out-of-pocket medical expenses such as copayments, coinsurance, and deductibles. It can also be used to pay for dental and vision expenses. The money in the account must be used; otherwise any money left in the account over $500 for 2020 or $550 for 2021 must be forfeited. Amounts left in the account of $500 for 2020 or $550 for 2021or less can be rolled over into the next plan year. If your company offers a High Deductible Health Plan (HDHP) and you are contributing to a Health Savings Account (HSA), you cannot enroll in the standard Medical FSA. However, you can enroll in a Limited Benefit Medical FSA, which reimburses only for vision and dental expenses until you have reached your plan's deductible. Once you have reached your deductible, the Limited Benefit FSA can reimburse for all eligible medical expenses. A Dependent Care FSA allows employees to deposit pre-tax dollars to use for day care expenses. Unused Dependent Care FSA funds must be forfeited; there is no roll-over provision.

Transit & Parking If you ride the subway, bus, train, or vanpool; or if you pay for parking at your place of employment, you can use pre-tax dollars to help pay for the cost of your commute and/ or parking by contributing to a Transit & Parking plan. The IRS allows employees to set aside up to $270 per month for transit expenses and $270 per month for parking.

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Life and AD&D To provide employees and their families with financial protection, your employer provides all eligible employees with the Unum life insurance coverage below, with the ability to purchase additional coverage.

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Disability For additional financial protection in the event of an extended illness or accident, the company provides the Unum disability coverage listed below.

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We offer an array of additional benefits to help satisfy the individual needs of employees. See the following pages for information on: • • • • • • •

Voluntary Short and Long Term Disability Accident Coverage Critical Illness Coverage Hospital Indemnity Coverage Pet Insurance MetLaw Legal Plan Auto & Home Insurance

Legal experts on your side for less than a dollar a day Quality legal assistance can be pricey. And it can be hard to know where to turn to find an attorney you trust. But for a low monthly fee, you can have a team of top attorneys ready to help you take care of life’s planned and unplanned legal events. With MetLaw, a group legal plan available through Hyatt Legal Plans, you get access to experts who can assist you with a broad range of personal legal needs you might face throughout your life. This could be when you’re buying or selling a home, starting a family, dealing with identity theft, or caring for aging parents. You may be thinking—why would top attorneys need or want to join a legal plan network. But even experienced attorneys need to grow their practice. By providing exceptional service to you and other plan members, they can gain more clients through your referrals. That’s how we’ve established a large network of highly experienced attorneys, averaging 25 years of experience.

Reduce the cost of legal services with MetLaw.

Apply today! For questions, please call MetLife at 1 800 GET-MET8 (1-800-438-6388) Our attorneys are here to help when you’re:

How it works Our service is tailored to your needs. With network attorneys available in person, by phone, or by email and online tools to do-it-yourself or plan your next move—we make it easy to get legal help. And for certain legal matters, your attorney can represent you in court without you having to make an appearance. Best of all, you have unlimited access to our attorneys for all legal matters covered under the plan. For a low monthly premium conveniently paid through payroll deduction, an expert is on your side as long as you need them.

• •

Getting married Buying or selling a home

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Starting a family Dealing with identity theft Sending kids off to college

• •

Whatever you need to protect your family, MetLaw is here to make life a little easier. •

For added peace of mind, your spouse and dependent children are also covered.

Caregiving for aging parents And more

MetLaw helps you navigate life’s planned and unplanned events.

You get legal assistance for some of the most frequently needed personal legal matters—with no waiting periods, no deductibles and no claim forms. And, if you have a trusted attorney who does not participate in our network, that’s OK. You can be 1 reimbursed for some of the costs. MetLaw covers some of the most frequently needed personal legal matters:

Money Matters

Home & Real Estate

Estate Planning

Family & Personal

Civil Lawsuits

Elder-Care Issues

Vehicle & Driving

• Identity Theft Defense • Personal Bankruptcy • Negotiations with Creditors • • • •

Foreclosure Tenant Negotiations Boundary & Title Disputes Deeds

• Simple Wills • Complex Wills • Revocable & Irrevocable Trusts • Adoption • Guardianship • Conservatorship • Prenuptial Agreement • Name Change • Review of ANY Personal Legal Document • Civil Litigation Defense • Disputes Over Consumer Goods & Services Consultation & Document Review for issues related to your parents: • Medicare • Medicaid • Repossession • Defense of Traffic Tickets3

• Tax Audit Representation • Debt Collection Defense

• Tax Collection Defense • Promissory Notes

• Sale or Purchase of Primary and Vacation Home • Eviction Defense • Property Tax Assessments • Mortgages

• Refinancing & Home Equity Loan of Primary and Vacation Home • Security Deposit Assistance • Zoning applications

• Powers of Attorney (Healthcare, Financial, Childcare, Immigration) • Healthcare Proxies • Juvenile Court Defense Including Criminal Matters • Parental Responsibility Matters • School Hearings • Demand Letters • Personal Property Issues • Small Claims Assistance • Administrative Hearings • • • •

Prescription Plans Nursing Home Agreements Leases Notes

• Driving Privileges Restoration

• Living Wills • Codicils

82% of those enrolled in a legal plan through an employer agreed that they worry less about unexpected issues because of their employer benefits.2

• Affidavits • Garnishment Defense • Protection from Domestic Violence • Review of Immigration Documents • Incompetency Defense • Pet Liabilities • Deeds • Wills • Powers of Attorney • License Suspension Due to DUI

1. You will be responsible to pay the difference, if any, between the Plan’s payment and the non-Plan Attorney’s charge for services. 2. Harris Poll on behalf of Hyatt Legal Plans, a MetLife Company, Improving Employee Wellness through Legal Benefits (February 2016). 3. Does not cover DUI. Group legal plans provided by Hyatt Legal Plans, Inc., a MetLife company, Cleveland, Ohio. In certain states, group legal plans are provided through insurance coverage underwritten by Metropolitan Property and Casualty Insurance Company and affiliates, 700 Quaker Lane, Warwick, RI 02886. No service, including consultations, will be provided for: 1) employment-related matters, including company or statutory benefits; 2) matters involving the employer, MetLife, its affiliates, or plan attorneys; 3) matters in which there is a conflict of interest between the employee and spouse/civil union partner or dependents, in which case services are excluded for the spouse/civil union partner and dependents; 4) appeals and class actions; 5) farm and business matters, including rental issues when the participant is the landlord; 6) patent, trademark, and copyright matters; 7) costs and fines; 8) frivolous or unethical matters; 9) matters for which an attorney-client relationship exists prior to the participant becoming eligible for MetLaw. For all other personal legal matters, an advice and consultation benefit is provided. Additional representation is also included for certain matters. Please see your plan description for details. MetLaw and MetLife® are registered trademarks of Metropolitan Life Insurance Company, New York, NY.

Discover the greatest pet insurance plans ever offered. Exclusively for employees. Only from Nationwide®. You care about your pets and consider them members of your family. So whether your family includes kids with two feet or kids with four paws—or both—you know what responsibility looks like. So why not give your pets the best health care available? The My Pet Protection suite of pet insurance plans is composed of the only plans specifically designed for employees and gives you superior protection at an unbeatable price, featuring: SM

    

90% back on vet bills1 Exclusivity—unavailable to the general public One set price, regardless of the pet’s age The best deal anywhere: an average savings of 40% over similar plans from other pet insurers2 A wellness plan option that includes spay/neuter3, preventive dental cleaning and more

Easy enrollment

Select the species (dog or cat)*

Provide your zip code

Pick between two plans

Get a fast, no-obligation quote today at

Metlife.com/mybenefits • 1-800-GET-MET8 *To enroll your bird, rabbit, reptile or other exotic pet, please call 888-899-4874. 28

Choose a plan that’s as unique as your pet. Get back 90% of the vet bill for these items and more.1

Accidents, including poisonings and allergic reactions Injuries, including cuts, sprains and broken bones Common illnesses, including ear infections, vomiting and diarrhea Serious/chronic illnesses5, including cancer and diabetes Hereditary and congenital conditions5 Surgeries and hospitalization X-rays, MRIs and CT scans Prescription medications and therapeutic diets Wellness exams Preventive dental cleaning Vaccinations Spay/neuter Flea and tick prevention Heartworm testing and prevention Routine blood tests

              

Visit any vet, anywhere

       

Just like all other pet insurers, we don’t cover pre-existing conditions. However, we go above and beyond with extra features such as emergency boarding, lost pet advertising and more. Plus, both plans have a low $250 annual deductible and a generous $7,500 maximum annual benefit.

® Free service available to all pet insurance members. Unlimited, 24/7 access to a veterinary professional ($150 value). Only from Nationwide.

My Pet Protection plans are available exclusively through your employer. Get a quote today. Metlife.com/mybenefits • 1-800-GET-MET8 1

Some exclusions may apply. Certain coverages may be subject to pre-existing exclusion. See policy documents for a complete list of exclusions. 2 Average based on similar plans from top competitors’ websites for a 4-year-old Labrador retriever in Calif., 94550. Data provided using information available as of March 2016. 3 Spay/neuter coverage is available with My Pet Protection with Wellness. 4 Pet owners receive a 5% multiple pet discount by insuring two to three pets or a 10% discount on each policy for four or more pets. 5 Excludes pre-existing conditions. Metropolitan Life Insurance Company is the program administrator for pet insurance fulfilled by Nationwide®. Insurance terms, definitions and explanations are intended for informational purposes only and do not in any way replace or modify the definitions and information contained in individual insurance contracts, policies or declaration pages, which are controlling. Such terms and availability may vary by state and exclusions may apply. Insurance plans are offered and administered by Nationwide through its subsidiaries and affiliates. Underwritten by Veterinary Pet Insurance Company (CA), Brea, CA, an A.M. Best A+ rated company (2016); National Casualty Company (all other states), Columbus, OH, an A.M. Best A+ rated company (2016). Nationwide, the Nationwide N and Eagle, and Nationwide is on your side are service marks of Nationwide Mutual Insurance Company. ©2017 Nationwide. ©2017 METLIFE, INC. 17GRP4771 17GRPMETMPPFLYR

Why is having quality auto and home insurance so important? Because you need to protect your possessions, but you don’t need to pay too much or settle for coverage that’s less than the best. Auto and home insurance should meet your specific needs. That’s why insurance from MetLife Auto & Home® is designed so that you’re not surprised by coverage gaps or unexpected costs. We offer simplicity in our insurance packages and professional advice. Auto MetLife Auto & Home provides insurance coverage that eliminates gaps and surprises. Our Auto AdvantageSM features go beyond basic liability and collision coverage to offer you more complete coverage and benefits, including: •

Convenient payment options

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24/7/365 claim service

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Identity Theft Protection Services

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Replacement costs for Total Loss1

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Enhanced rental car damage coverage2

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Towing/roadside assistance

Replacement costs for Special Parts2

•

Deductible Savings Benefit3

•

Windshield repair without a deductible

For 40 years, MetLife Auto & Home has been protecting drivers with outstanding coverage.

Home* Our homeowners products offer uncommon protection called Coverage A Plus, which is an optional benefit with any Standard or Platinum Homeowners Policy. This coverage is designed so that in the event of a loss, your home would be fully replaced without you incurring extra costs. Additional benefits include: •

Maximum coverage equal to the replacement cost at the time the repair is made.

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Materials of “like kind and quality” for rebuilding your house.

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An insurance benefit amount that meets the current construction costs to rebuild it — even if costs exceed your dwelling limit, which is currently a unique benefit in the Homeowners Insurance industry.

We also offer replacement cost on home contents, so there are no surprises with unexpected out-of-pocket expenses. In the event of a covered loss, it replaces personal property without deduction for depreciation. Switching auto and home insurance carriers has never been easier. Call us today and we’ll take care of the rest, regardless of when your current policy expires. Don’t wait — others have saved up to $536.4 See how much you could save by switching your auto insurance to MetLife Auto & Home.

Apply today! For questions, please call MetLife at 1 800 GET-MET8 (1-800-438-6388) Why should I apply now? •

Employee discounts

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Superior insurance coverage that protects you from gaps and surprises

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Extra savings and convenience with payroll deduction/ monthly bank account deduction

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Don’t wait until your current policy is about to expire — we can help you switch and save now.

How can having MetLife Auto & Home Insurance benefit you? We can provide you with the coverage you need and the savings and service you deserve for your valuable property. You will have access to generous discounts and unique features, all the while keeping your personal insurance information private from your employer, and allowing you to take the policy with you if you switch employers.

Even if you change jobs, retire, or your employment status changes, your coverage doesn’t have to end. You can keep your MetLife Auto & Home Insurance policy, as long as you pay the premiums due.

Trust MetLife Auto & Home for other value-added products. MetLife Auto & Home is here to provide the personal touch you expect when addressing your insurance needs. • • • •

Automobile Renters Personal Excess Liability Landlord’s Rental Dwelling

• • • •

Motorcycle Motorhome Homeowners Condominium

• •

Boat Scheduled Personal Property

•

Snowmobile

For added convenience, MetLife Auto & Home’s mobile application is now available on your App Store. After downloading this app,6 you can use it to submit an auto claim, pay your auto and home bill, and view account information.

And don’t forget about our discounts for multi-policy, good student, safe driver, anti-theft devices and more.5

*Home Insurance is not part of MetLife Auto & Home’s benefit offering in MA & FL. 1. Does not apply to leased, substitute, or non-owned autos. Applies within the first 12 months you own or the first 15,000 miles you drive a new auto, whichever comes first. See policy for restrictions. Subject to deductible. 2. See policy for restrictions. Subject to deductible. Not available in all states, such as NC. 3. Not available in all states. In New York, drivers must pay a state required minimum deductible before using this benefit. Benefit can be earned for up to 5 years. Depending on your policy form, the benefit could be up to $250 or $500. 4. Average annual savings based on our 2017 countrywide research of new call center customers’ annual average savings in 2016. 5. Available in most states to those who qualify. 6. Before using the MetLife Mobile app, you must register at www.metlife.com/mybenefits from a computer. Registration cannot be done from your mobile device. MetLife Auto & Home is a brand of Metropolitan Property and Casualty Insurance Company and its affiliates: Economy Preferred Insurance Company, Metropolitan Casualty Insurance Company, Metropolitan Direct Property and Casualty Insurance Company, Metropolitan General Insurance Company, Metropolitan Group Property and Casualty Insurance Company, and Metropolitan Lloyds Insurance Company of Texas, all with administrative home offices in Warwick, RI. Coverage, rates, discounts and policy features vary by state and product, and are available in most states to those who qualify. Met P&C®, MetCasSM, and MetGenSM are licensed in Minnesota.

LEGAL NOTICES

AMPLIFYHRM.COM 32

LEGAL NOTICES AMPLIFY HR MANAGEMENT AND/OR YOUR EMPLOYER RESERVE(S) THE RIGHT TO CHANGE, AMEND OR TERMINATE ANY BENEFITS PLAN AT ANY TIME FOR ANY REASON. PARTICIPATION IN A BENEFIS PLAN IS NOT A PROMISE OR GUARANTEE OF FUTURE EMPLOYMENT. RECEIPT OF BENEFITS DOCUMENTS DOES NOT CONSTITUTE ELIGIBILITY. THESE NOTICES DO NOT APPLY TO ANY BENEFITS YOUR EMPLOYER OFFERS OUTSIDE OF AMPLIFY HR MANAGEMENT. The Benefits eBook, combined with these legal notices, provides an overview of the benefits available to eligible employees and their dependents. In all cases, the official plan documents govern and this Benefits eBook is not, and should not be relied upon as a governing document. In the event of a discrepancy between the information presented in the Benefits Guide and official plan documents, the official plan documents will govern.

STATEMENT OF MATERIAL MODIFICATIONS

This Benefits eBook constitutes a Summary of Material Modifications (SMM) or Summary of Material Reductions (SMR), as applicable. It is meant to supplement and/or replace certain information in the SPD, so retain it for future reference along with your SPD. Please share these materials with your covered family members.

SUMMARY OF BENEFITS COVERAGE

A Summary of Benefits Coverage (SBC) for each of the employer-sponsored medical plans is available by contacting the Amplify HR Management Benefits Department at (224)424-5400.

IMPORTANT NOTICE ABOUT CREDITABLE PRESCRIPTION DRUG COVERAGE AND MEDICARE

The purpose of this notice is to advise you that the prescription drug coverage under your employer’s medical plan is expected to pay out, on average, at least as much as the standard Medicare prescription drug coverage will pay in 2021. This is known as “creditable coverage.”

Why this is important: if you or your covered dependent(s) are enrolled in any prescription drug coverage during 2021 listed in this notice and are or become covered by Medicare, you may decide to enroll in a Medicare prescription drug plan later and not be subject to a late enrollment penalty — as long as you had creditable coverage within 63 days of your Medicare prescription drug plan enrollment. You should keep this notice with your important records. If you or your family members aren’t currently covered by Medicare and won’t become covered by Medicare in the next 12 months, this notice doesn’t apply to you. Please read the notice below carefully. It has information about prescription drug coverage with your employer and prescription drug coverage available for people with Medicare. It also tells you where to find more information to help you make decisions about your prescription drug coverage. NOTICE OF CREDITABLE COVERAGE

You may have heard about Medicare’s prescription drug coverage (called Part D) and wondered how it would affect you. Prescription drug coverage is available to everyone with Medicare through Medicare prescription drug plans. All Medicare prescription drug plans provide at least a standard level of coverage set by Medicare. Some plans also offer more coverage for a higher monthly premium. Individuals can enroll in a Medicare prescription drug plan when they first become eligible, and each year from October 15 through December 7. Individuals leaving employer/union coverage may be eligible for a Medicare Special Enrollment Period. If you are covered by one of your employer’s prescription drug plans, you’ll be interested to know that the prescription drug coverage under the plan is, on average, at least as good as standard Medicare prescription drug coverage for 2021. This is called creditable coverage. Coverage under one of these plans will help you avoid a late Part D enrollment penalty if you are or become eligible for Medicare and later decide to enroll in a Medicare prescription drug plan.

If you decide to enroll in a Medicare prescription drug plan and you are an active employee or family member of an active employee, you may also continue your employer coverage. In this case, your employer’s plan will continue to pay primary or secondary as it had before you enrolled in a Medicare prescription drug plan. If you waive or drop employer coverage, Medicare will be your only payer. You can re-enroll in the employer plan at annual enrollment or if you have a special enrollment event for the employer plan, assuming you remain eligible. You should know that if you waive or leave coverage with your employer’s plan and you go 63 days or longer without creditable prescription drug coverage (once your applicable Medicare enrollment period ends), your monthly Part D premium will go up at least 1% per month for every month that you did not have creditable coverage. For example, if you go 19 months without coverage, your Medicare prescription drug plan premium will always be at least 19% higher than what most other people pay. You’ll have to pay this higher premium as long as you have Medicare prescription drug coverage. In addition, you may have to wait until the following October to enroll in Part D. You may receive this notice at other times in the future — such as before the next period you can enroll in Medicare prescription drug coverage, if your employer plan coverage changes, or upon your request. FOR MORE INFORMATION ABOUT YOUR OPTIONS UNDER MEDICARE PRESCRIPTION DRUG COVERAGE

More detailed information about Medicare plans that offer prescription drug coverage is in the Medicare & You handbook. Medicare participants will get a copy of the handbook in the mail every year from Medicare. You may also be contacted directly by Medicare prescription drug plans. Here’s how to get more information about Medicare prescription drug plans: • • •

Visit www.medicare.gov for personalized help. Call your State Health Insurance Assistance Program (see a copy of the Medicare & You handbook for the telephone number). Call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048.

For people with limited income and resources, extra help paying for a Medicare prescription drug plan is available. Information about this extra help is available from the Social Security Administration (SSA). For more information about this extra help, visit SSA online at www.socialsecurity.gov or call 1-800-772-1213 (TTY 1-800-325-0778). Remember: Keep this notice. If you enroll in a Medicare prescription drug plan after your applicable Medicare enrollment period ends, you may need to provide a copy of this notice when you join a Part D plan to show that you are not required to pay a higher Part D premium amount. For more information about this notice or your prescription drug coverage, contact: Anthony Quinn Executive Vice President, Benefits & HR 1 Overlook Point, Suite 550 Lincolnshire, IL 60069 (224) 424-5400

HIPAA SPECIAL ENROLLMENT NOTICE NOTICE OF SPECIAL ENROLLMENT RIGHTS FOR HEALTH PLAN

If you have declined enrollment in your employer’s healthplan for you or your dependents (including your spouse) because of other health insurance coverage, you or your dependents may be able to enroll in some coverages under these plans without waiting for the next Open Enrollment period, provided you request enrollment within 30 days after your other coverage ends. In addition, if you have a new dependent as a result of marriage, birth, adoption or placement for adoption, you may be able to enroll yourself and your eligible dependents, provided that you request enrollment within 30 days after the marriage, birth, adoption or placement for adoption. Your employer’s plan will also allow a special enrollment opportunity if you or your eligible dependents either: • •

Lose Medicaid or Children’s Health Insurance Program (CHIP) coverage because you are no longer eligible, or Become eligible for a state’s premium assistance program under Medicaid or CHIP.

Note: If your dependent becomes eligible for special enrollment rights, you may add the dependent to your current coverage or change to another medical plan.

WOMEN’S HEALTH AND CANCER RIGHTS ACT (WHCRA) NOTICE If you have had or are going to have a mastectomy, you may be entitled to certain benefits under the Women’s Health and Cancer Rights Act of 1998 (WHCRA). For individuals receiving mastectomy-related benefits, coverage will be provided in a manner determined in consultation with the attending physician and the patient, for: • • • •

All stages of reconstruction of the breast on which the mastectomy was performed; Surgery and reconstruction of the other breast to produce a symmetrical appearance; Prostheses; and Treatment of physical complications of the mastectomy, including lymphedema.

These benefits will be provided subject to the same deductibles and coinsurance applicable to other medical and surgical benefits provided under this plan. If you would like more information on WHCRA benefits, call your medical carrier at the phone number listed on the back of your ID card.

NEWBORNS’ AND MOTHERS’ HEALTH PROTECTION ACT NOTICE Group health plans and health insurance issuers generally may not, under Federal law, restrict benefits for any hospital length of stay in connection with childbirth for the mother or newborn child to less than 48 hours following a vaginal delivery, or less than 96 hours following a cesarean section. However, Federal law generally does not prohibit the mother’s or newborn’s attending provider, after consulting with the mother, from discharging the mother or her newborn earlier than 48 hours (or 96 hours as applicable). In any case, plans and issuers may not, under Federal law, require that a provider obtain authorization from the plan or the insurance issuer for prescribing a length of stay not in excess of 48 hours (or 96 hours). If you would like more information on maternity benefits, call your medical carrier at the phone number listed on the back of your ID card.

MICHELLE’S LAW NOTICE EXTENDED DEPENDENT MEDICAL COVERAGE DURING STUDENT MEDICAL LEAVES

Your employer’s plan may extend medical coverage for dependent children if they lose eligibility for coverage because of a medically necessary leave of absence from a post-secondary educational institution (including a college or university). Coverage may continue for up to a year, unless the child’s eligibility would end earlier for another reason. Extended coverage is available if a child’s leave of absence from school — or change in school enrollment status (for example, switching from full-time to part-time status) — starts while the child has a serious illness or injury, is medically necessary, and otherwise causes eligibility for student coverage under the plan to end. Written certification from the child’s physician stating that the child suffers from a serious illness or injury and the leave of absence is medically necessary may be required. If the coverage provided by the plan is changed during this one-year period, the plan will provide the changed coverage for the remainder of the leave of absence.

TAXATION OF BENEFITS

The taxation of certain benefits may vary at the local, state and federal level. You should consult your tax advisor if you have any questions about the proper treatment of any benefits.

Premium Assistance Under Medicaid and the Children’s Health Insurance Program (CHIP) If you or your children are eligible for Medicaid or CHIP and you’re eligible for health coverage from your employer, your state may have a premium assistance program that can help pay for coverage, using funds from their Medicaid or CHIP programs. If you or your children aren’t eligible for Medicaid or CHIP, you won’t be eligible for these premium assistance programs but you may be able to buy individual insurance coverage through the Health Insurance Marketplace. For more information, visit www.healthcare.gov. If you or your dependents are already enrolled in Medicaid or CHIP and you live in a State listed below, contact your State Medicaid or CHIP office to find out if premium assistance is available. If you or your dependents are NOT currently enrolled in Medicaid or CHIP, and you think you or any of your dependents might be eligible for either of these programs, contact your State Medicaid or CHIP office or dial 1-877KIDS NOW or www.insurekidsnow.gov to find out how to apply. If you qualify, ask your state if it has a program that might help you pay the premiums for an employer-sponsored plan. If you or your dependents are eligible for premium assistance under Medicaid or CHIP, as well as eligible under your employer plan, your employer must allow you to enroll in your employer plan if you aren’t already enrolled. This is called a “special enrollment” opportunity, and you must request coverage within 60 days of being determined eligible for premium assistance. If you have questions about enrolling in your employer plan, contact the Department of Labor at www.askebsa.dol.gov or call 1-866-444-EBSA (3272). If you live in one of the following states, you may be eligible for assistance paying your employer health plan premiums. The following list of states is current as of July 31, 2020. Contact your State for more information on eligibility –

ALABAMA – Medicaid

CALIFORNIA – Medicaid

Website: http://myalhipp.com/ Phone: 1-855-692-5447

Website: https://www.dhcs.ca.gov/services/Pages/TPLRD_CAU_c ont.aspx Phone: 916-440-5676

ALASKA – Medicaid

COLORADO – Health First Colorado (Colorado’s Medicaid Program) & Child Health Plan Plus (CHP+)

The AK Health Insurance Premium Payment Program Website: http://myakhipp.com/ Phone: 1-866-251-4861 Email: CustomerService@MyAKHIPP.com Medicaid Eligibility: http://dhss.alaska.gov/dpa/Pages/medicaid/default.aspx

Health First Colorado Website: https://www.healthfirstcolorado.com/ Health First Colorado Member Contact Center: 1-800-221-3943/ State Relay 711 CHP+: https://www.colorado.gov/pacific/hcpf/childhealth-plan-plus CHP+ Customer Service: 1-800-359-1991/ State Relay 711 Health Insurance Buy-In Program (HIBI): https://www.colorado.gov/pacific/hcpf/health-insurancebuy-program HIBI Customer Service: 1-855-692-6442

ARKANSAS – Medicaid

FLORIDA – Medicaid

Website: http://myarhipp.com/ Phone: 1-855-MyARHIPP (855-692-7447)

Website: https://www.flmedicaidtplrecovery.com/flmedicaidtplrec overy.com/hipp/index.html Phone: 1-877-357-3268

2 GEORGIA – Medicaid Website: https://medicaid.georgia.gov/health-insurancepremium-payment-program-hipp Phone: 678-564-1162 ext 2131

MASSACHUSETTS – Medicaid and CHIP Website: http://www.mass.gov/eohhs/gov/departments/masshealth/ Phone: 1-800-862-4840

INDIANA – Medicaid Healthy Indiana Plan for low-income adults 19-64 Website: http://www.in.gov/fssa/hip/ Phone: 1-877-438-4479 All other Medicaid Website: https://www.in.gov/medicaid/ Phone 1-800-457-4584

MINNESOTA – Medicaid Website: https://mn.gov/dhs/people-we-serve/children-andfamilies/health-care/health-care-programs/programsand-services/other-insurance.jsp Phone: 1-800-657-3739

MISSOURI – Medicaid

IOWA – Medicaid and CHIP (Hawki) Medicaid Website: https://dhs.iowa.gov/ime/members Medicaid Phone: 1-800-338-8366 Hawki Website: http://dhs.iowa.gov/Hawki Hawki Phone: 1-800-257-8563

Website: http://www.dss.mo.gov/mhd/participants/pages/hipp.htm Phone: 573-751-2005

KANSAS – Medicaid Website: http://www.kdheks.gov/hcf/default.htm Phone: 1-800-792-4884

KENTUCKY – Medicaid

Kentucky Integrated Health Insurance Premium Payment Program (KI-HIPP) Website: https://chfs.ky.gov/agencies/dms/member/Pages/kihipp.aspx Phone: 1-855-459-6328 Email: KIHIPP.PROGRAM@ky.gov

MONTANA – Medicaid Website: http://dphhs.mt.gov/MontanaHealthcarePrograms/HIPP Phone: 1-800-694-3084

NEBRASKA – Medicaid

Website: http://www.ACCESSNebraska.ne.gov Phone: 1-855-632-7633 Lincoln: 402-473-7000 Omaha: 402-595-1178

KCHIP Website: https://kidshealth.ky.gov/Pages/index.aspx Phone: 1-877-524-4718 Kentucky Medicaid Website: https://chfs.ky.gov

LOUISIANA – Medicaid

Website: www.medicaid.la.gov or www.ldh.la.gov/lahipp Phone: 1-888-342-6207 (Medicaid hotline) or 1-855-6185488 (LaHIPP)

MAINE – Medicaid

Enrollment Website: https://www.maine.gov/dhhs/ofi/applications-forms Phone: 1-800-442-6003 TTY: Maine relay 711

NEVADA – Medicaid

Medicaid Website: http://dhcfp.nv.gov Medicaid Phone: 1-800-992-0900

NEW HAMPSHIRE – Medicaid

Website: https://www.dhhs.nh.gov/oii/hipp.htm Phone: 603-271-5218 Toll free number for the HIPP program: 1-800-8523345, ext 5218

Private Health Insurance Premium Webpage: https://www.maine.gov/dhhs/ofi/applications-forms Phone: 1-800-977-6740. TTY: Maine relay 711

3 NEW JERSEY – Medicaid and CHIP

Medicaid Website: http://www.state.nj.us/humanservices/ dmahs/clients/medicaid/ Medicaid Phone: 609-631-2392 CHIP Website: http://www.njfamilycare.org/index.html CHIP Phone: 1-800-701-0710

NEW YORK – Medicaid

Website: https://www.health.ny.gov/health_care/medicaid/ Phone: 1-800-541-2831

NORTH CAROLINA – Medicaid

Website: https://medicaid.ncdhhs.gov/ Phone: 919-855-4100

NORTH DAKOTA – Medicaid

SOUTH DAKOTA - Medicaid

Website: http://dss.sd.gov Phone: 1-888-828-0059

TEXAS – Medicaid

Website: http://gethipptexas.com/ Phone: 1-800-440-0493

UTAH – Medicaid and CHIP

Medicaid Website: https://medicaid.utah.gov/ CHIP Website: http://health.utah.gov/chip Phone: 1-877-543-7669

VERMONT– Medicaid

Website: http://www.nd.gov/dhs/services/medicalserv/medicaid/ Phone: 1-844-854-4825

Website: http://www.greenmountaincare.org/ Phone: 1-800-250-8427

Website: http://www.insureoklahoma.org Phone: 1-888-365-3742

Website: https://www.coverva.org/hipp/ Medicaid Phone: 1-800-432-5924 CHIP Phone: 1-855-242-8282

OKLAHOMA – Medicaid and CHIP

VIRGINIA – Medicaid and CHIP

OREGON – Medicaid Website: http://healthcare.oregon.gov/Pages/index.aspx http://www.oregonhealthcare.gov/index-es.html Phone: 1-800-699-9075

WASHINGTON – Medicaid Website: https://www.hca.wa.gov/ Phone: 1-800-562-3022

PENNSYLVANIA – Medicaid Website: https://www.dhs.pa.gov/providers/Providers/Pages/Medical/ HIPP-Program.aspx Phone: 1-800-692-7462

WEST VIRGINIA – Medicaid Website: http://mywvhipp.com/ Toll-free phone: 1-855-MyWVHIPP (1-855-699-8447)

RHODE ISLAND – Medicaid and CHIP Website: http://www.eohhs.ri.gov/ Phone: 1-855-697-4347, or 401-462-0311 (Direct RIte Share Line)

WISCONSIN–Medicaid and CHIP Website: https://www.dhs.wisconsin.gov/badgercareplus/p-10095.htm Phone: 1-800-362-3002

SOUTH CAROLINA – Medicaid Website: https://www.scdhhs.gov Phone: 1-888-549-0820

WYOMING – Medicaid Website: https://health.wyo.gov/healthcarefin/medicaid/programs-andeligibility/ Phone: 1-800-251-1269

To see if any other states have added a premium assistance program since July 31, 2020, or for more information on special enrollment rights, contact either: U.S. Department of Labor Employee Benefits Security Administration www.dol.gov/agencies/ebsa 1-866-444-EBSA (3272)

U.S. Department of Health and Human Services Centers for Medicare & Medicaid Services www.cms.hhs.gov 1-877-267-2323, Menu Option 4, Ext. 61565

Paperwork Reduction Act Statement According to the Paperwork Reduction Act of 1995 (Pub. L. 104-13) (PRA), no persons are required to respond to a collection of information unless such collection displays a valid Office of Management and Budget (OMB) control number. The Department notes that a Federal agency cannot conduct or sponsor a collection of information unless it is approved by OMB under the PRA, and displays a currently valid OMB control number, and the public is not required to respond to a collection of information unless it displays a currently valid OMB control number. See 44 U.S.C. 3507. Also, notwithstanding any other provisions of law, no person shall be subject to penalty for failing to comply with a collection of information if the collection of information does not display a currently valid OMB control number. See 44 U.S.C. 3512. The public reporting burden for this collection of information is estimated to average approximately seven minutes per respondent. Interested parties are encouraged to send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the U.S. Department of Labor, Employee Benefits Security Administration, Office of Policy and Research, Attention: PRA Clearance Officer, 200 Constitution Avenue, N.W., Room N-5718, Washington, DC 20210 or email ebsa.opr@dol.gov and reference the OMB Control Number 1210-0137. OMB Control Number 1210-0137 (expires 1/31/2023)

HIPAA NOTICE OF PRIVACY PRACTICES THIS NOTICE APPLIES TO FULL-TIME EMPLOYEES WHO ELECT TO PARTICIPATE IN AMPLIFY HR MANAGEMENT’S HEALTH BENEFITS PLANS. IT DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW THIS NOTICE CAREFULLY. This Notice of Privacy Practices (“Notice”) applies to Protected Health Information (defined below) associated with Group Health Plans (defined below) provided by Amplify HR Management to its client company worksite employees and their dependents. This Notice describes how Amplify HR Management, collectively we, us, or our, may use and disclose Protected Health Information to carry out payment and health care operations, and for other purposes that are permitted or required by law. We are required by the privacy regulations issued under the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”) to maintain the privacy of Protected Health Information and to provide individuals covered under our group health plan with notice of our legal duties and privacy practices concerning Protected Health Information. We are required to abide by the terms of this Notice so long as it remains in effect. We reserve the right to change the terms of this Notice of Privacy Practices as necessary and to make the new Notice effective for all Protected Health Information maintained by us. If we make material changes to our privacy practices, copies of revised notices will be mailed to all policyholders then covered by the Group Health Plan. DEFINITIONS Group Health Plan means, for purposes of this Notice, the following employee benefits that we provide to our employees and their dependents, to include medical coverage, dental coverage and vision coverage. Protected Health Information (“PHI”) means individually identifiable health information, as defined by HIPAA, that is created or received by us and that relates to the past, present, or future physical or mental health or condition of an individual; the provision of health care to an individual; or the past, present, or future payment for the provision of health care to an individual; and that identifies the individual or for which there is a reasonable basis to believe the information can be used to identify the individual. PHI includes information of persons living or deceased. USES AND DISCLOSURES OF YOUR PROTECTED HEALTH INFORMATION The following categories describe different ways that we use and disclose PHI. For each category of uses and disclosures we will explain what we mean and, where appropriate, provide examples for illustrative purposes. Not every use or disclosure in a category will be listed. However, all of the ways we are permitted or required to use and disclose PHI will fall within one of the categories. Your Authorization – Except as outlined below, we will not use or disclose your PHI unless you have signed a form authorizing the use or disclosure. You have the right to revoke that authorization in

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writing except to the extent that we have taken action in reliance upon the authorization or that the authorization was obtained as a condition of obtaining coverage under the group health plan, and we have the right, under other law, to contest a claim under the coverage or the coverage itself. Uses and Disclosures for Payment – We may make requests, uses, and disclosures of your PHI as necessary for payment purposes. For example, we may use information regarding your medical procedures and treatment to process and pay claims. We may also disclose your PHI for the payment purposes of a health care provider or a health plan. Uses and Disclosures for Health Care Operations – We may use and disclose your PHI as necessary for our health care operations. Examples of health care operations include activities relating to the creation, renewal, or replacement of your Group Health Plan coverage, reinsurance, compliance, auditing, rating, business management, quality improvement and assurance, and other functions related to your Group Health Plan. Family and Friends Involved in Your Care – If you are available and do not object, we may disclose your PHI to your family, friends, and others who are involved in your care or payment of a claim. If you are unavailable or incapacitated and we determine that a limited disclosure is in your best interest, we may share limited PHI with such individuals. For example, we may use our professional judgment to disclose PHI to your spouse concerning the processing of a claim. Other Products and Services – We may contact you to provide information about other health-related products and services that may be of interest to you. For example, we may use and disclose your PHI for the purpose of communicating to you about our health insurance products that could enhance or substitute for existing Group Health Plan coverage, and about health-related products and services that may add value to your Group Health Plan. Other Uses and Disclosures – We may make certain other uses and disclosures of your PHI without your authorization. • We may use or disclose your PHI for any purpose required by law. For example, we may be required by law to use or disclose your PHI to respond to a court order. • We may disclose your PHI for public health activities, such as reporting of disease, injury, birth and death, and for public health investigations. • We may disclose your PHI to the proper authorities if we suspect child abuse or neglect; we may also disclose your PHI if we believe you to be a victim of abuse, neglect, or domestic violence. • We may disclose your PHI if authorized by law to a government oversight agency (e.g., a state insurance department) conducting audits, investigations, or civil or criminal proceedings. • We may disclose your PHI in the course of a judicial or administrative proceeding (e.g., to respond to a subpoena or discovery request). • We may disclose your PHI to the proper authorities for law enforcement purposes. • We may disclose your PHI to coroners, medical examiners, and/or funeral directors consistent with law. • We may use or disclose your PHI for cadaveric organ, eye or tissue donation.

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• • • • •

We may use or disclose your PHI for research purposes, but only as permitted by law. We may use or disclose PHI to avert a serious threat to health or safety. We may use or disclose your PHI if you are a member of the military as required by armed forces services, and we may also disclose your PHI for other specialized government functions such as national security or intelligence activities. We may disclose your PHI to workers' compensation agencies for your workers' compensation benefit determination. We will, if required by law, release your PHI to the Secretary of the Department of Health and Human Services for enforcement of HIPAA.

In the event applicable law, other than HIPAA, prohibits or materially limits our uses and disclosures of Protected Health Information, as described above, we will restrict our uses or disclosure of your Protected Health Information in accordance with the more stringent standard.

RIGHTS THAT YOU HAVE Access to Your PHI – You have the right of access to copy and/or inspect your PHI that we maintain in designated record sets. Certain requests for access to your PHI must be in writing, must state that you want access to your PHI and must be signed by you or your representative (e.g., requests for medical records provided to us directly from your health care provider). Access request forms are available from [Insert company name] at the address below. We may charge you a fee for copying and postage. Amendments to Your PHI – You have the right to request that PHI that we maintain about you be amended or corrected. We are not obligated to make all requested amendments but will give each request careful consideration. To be considered, your amendment request must be in writing, must be signed by you or your representative, and must state the reasons for the amendment/correction request. Amendment request forms are available from us at the address below. Accounting for Disclosures of Your PHI – You have the right to receive an accounting of certain disclosures made by us of your PHI. Examples of disclosures that we are required to account for include those to state insurance departments, pursuant to valid legal process, or for law enforcement purposes. To be considered, your accounting requests must be in writing and signed by you or your representative. Accounting request forms are available from us at the address below. The first accounting in any 12month period is free; however, we may charge you a fee for each subsequent accounting you request within the same 12-month period. Restrictions on Use and Disclosure of Your PHI – You have the right to request restrictions on certain of our uses and disclosures of your PHI for insurance payment or health care operations, disclosures made to persons involved in your care, and disclosures for disaster relief purposes. For example, you may request that we not disclose your PHI to your spouse. Your request must describe in detail the restriction you are requesting. We are not required to agree to your request but will attempt to accommodate reasonable requests when appropriate. We retain the right to terminate an agreed-to restriction if we believe such termination is appropriate. In the event of a termination by us, we will notify you of such termination. You also have the right to terminate, in writing or orally, any agreed-to

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restriction. You may make a request for a restriction (or termination of an existing restriction) by contacting us at the telephone number or address below. Request for Confidential Communications – You have the right to request that communications regarding your PHI be made by alternative means or at alternative locations. For example, you may request that messages not be left on voice mail or sent to a particular address. We are required to accommodate reasonable requests if you inform us that disclosure of all or part of your information could place you in danger. Requests for confidential communications must be in writing, signed by you or your representative, and sent to us at the address below. Right to a Copy of the Notice – You have the right to a paper copy of this Notice upon request by contacting us at the telephone number or address below. Complaints – If you believe your privacy rights have been violated, you can file a complaint with us in writing at the address below. You may also file a complaint in writing with the Secretary of the U.S. Department of Health and Human Services in Washington, D.C., within 180 days of a violation of your rights. There will be no retaliation for filing a complaint. FOR FURTHER INFORMATION If you have questions or need further assistance regarding this Notice, you may contact: Anthony Quinn, Executive Vice President of Employee Benefits and Human Resources for Amplify HR Management 1 Overlook Pt Suite 550 Lincolnshire IL 60069 (224) 424-5400, AQuinn@AmplifyHRM.com EFFECTIVE DATE This Notice is effective January 1, 2021.

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