Return to flip book view

This benefit guide only provides a summary of your group’s benefits. All lines of coverage described are subject to the definitions, limitations and exclusions set in each insurance carrier or providers contract. Page l Revolution Energy Systems, Inc Employee Benefits Enrollment Guide Plan Year: January 1, 2024 – December 31, 2024

This benefit guide only provides a summary of your group’s benefits. All lines of coverage described are subject to the definitions, limitations and exclusions set in each insurance carrier or providers contract. Page l 2 We know that your benefits are important to you and your family. Helping you understand the benefits offered by Revolution Energy Systems is important to us. That is why we have created this Benefit Guide. Included in this guide are summary of the benefits, cost information, and contact information for each provider. What’s New in 2024 You asked and we listened! We’ve added a variety of new benefits based on employee feedback. Changes coming in 2024 include: • Medical Benefits with Employer Contribution (see Thatch Enrollment Guide) • Voluntary Dental Benefits (New Provider) • Voluntary Vision Benefits (New Provider) • Employer Paid Group Term Life Insurance • Voluntary Life Insurance • Voluntary Life Coverage • Voluntary Short Term Disability • Voluntary Long Term Disability • Voluntary Accident Insurance • Voluntary Critical Illness Insurance • Voluntary Hospital Indemnity Insurance • Voluntary Pet Insurance It is important to remember that only those benefit programs for which you are eligible and have enrolled in apply to you. We encourage you to review each section and to discuss your benefit options with your family members. Be sure to pay close attention to applicable co-payments and deductibles, along with networks and services that may be limited or not covered (exclusions). This guide is not a contract between you and Revolution Energy Systems. It is not intended to cover all provisions of all plans but rather is a quick reference to help answer most of your questions. Please see each Benefits Summary Plan Description for complete details. We hope this guide will give you a clear explanation of your benefits and help you be better prepared for the enrollment process. Enrollment ............................................................................................ Page 3 Voluntary Dental Benefits ....................................................................... Page 4 Voluntary Vision Benefits ........................................................................ Page 5 Group Term Life Insurance...................................................................... Page 6 Voluntary Life Coverage ......................................................................... Page 7 Voluntary Short Term Disability ............................................................... Page 9 Voluntary Long Term Disability ................................................................ Page 10 Accident Insurance ................................................................................ Page 11 Critical Illness Insurance ......................................................................... Page 12 Hospital Indemnity................................................................................. Page 13 Pet Insurance ........................................................................................ Page 14 Contact Information ............................................................................... Page 15 TABLE OF CONTENTS WELCOME

This benefit guide only provides a summary of your group’s benefits. All lines of coverage described are subject to the definitions, limitations and exclusions set in each insurance carrier or providers contract. Page l 3 HOW TO ENROLL Open Enrollment The first step is to review your current benefit elections. Verify your personal information and make any changes if necessary. Newly Eligible Make your benefit elections and complete the enrollment paperwork. Once you have made your elections, you will not be able to change them until the next open enrollment period unless you have a qualified change in status. WHEN TO ENROLL Open Enrollment Open enrollment period runs from December 11, 2023 through December 15, 2023. You will enroll using the online enrollment portal. The benefits you elect during open enrollment will be effective from January 1, 2024 through December 31, 2024. Newly Eligible You become eligible for coverage on the on the 1st of the month after 60 days. Your current coverages will end if you no longer meet the eligibility requirements, your contributions are discontinued, or the group policy is terminated. Qualifying Events Employees are able to enroll or make changes to their benefits elections during the group’s annual open enrollment period. Once you elect an option you are bound to the decision for the entirety of the plan year unless you have a “qualifying event”. Employees have 30 days from the date of the qualifying event to add or change coverage. These may include, but are not limited to: • Changes in your employment status • Changes in your legal marital status • Change in number of dependents • Taking an unpaid leave of absence • Dependent satisfies or cease to satisfy eligibility requirement • Family Medical Leave Act (FMLA) leave • A COBRA qualifying event • Entitlement to Medicare or Medicaid • A change in the place of residence of the employee, resulting in the current carrier not being available ENROLLMENT

This benefit guide only provides a summary of your group’s benefits. All lines of coverage described are subject to the definitions, limitations and exclusions set in each insurance carrier or providers contract. Page l 4 VOLUNTARY DENTAL BENEFITS MetLife Plan Features Dental Plan IN NETWORK (PDP Plus) Annual Deductible (Individual / Family) $50 / $150 Preventive Care (Exams, Cleanings, X-rays, Fluoride under age 14) 100% Basic Procedures (Sealants, Maintainers, Fillings, Simple Extractions, Periodontal Maintenance) 80% Major Procedures (Root Canal, Periodontal Surgery, Crowns, Dentures, Bridges, Repairs, Implant) 50% Calendar Year Maximum Benefit $1,250 EMPLOYEE COST PER MONTH Employee $30.48 Employee + Spouse $59.27 Employee + Child(ren) $75.85 Employee + Family $110.09 Dependents are covered until age 26. Out of Network benefits pay at the 80th percentile of usual and customary fees.

This benefit guide only provides a summary of your group’s benefits. All lines of coverage described are subject to the definitions, limitations and exclusions set in each insurance carrier or providers contract. Page l 5 VOLUNTARY VISION BENEFITS MetLife / Plan Features Vision Plan IN NETWORK (PPO Network) Vision Exam $10 Copay Lenses Single / Bifocal / Trifocal / Lenticular $25 Copay Frames $150 Allowance Frames Purchased at Costco, Walmart & Sam’s Club $80 Allowance with additional 20% discount Contact Lenses – Elective / Necessary $150 Copay / Covered in full after $25 copay Contact Fitting & Evaluation Not to exceed $60 Frequency (Months) Exam Every 12 Months Lenses Every 12 Months Frames Every 24 Months Contacts Every 12 Months Either glasses or contacts allowed per frequency OUT OF NETWORK Vision Exam $45 Allowance Lenses Single / Bifocal / Trifocal / Lenticular $30 / $50 / $65 / $100 Copay Frames $70 Allowance Contact Lenses – Elective / Necessary $105 Allowance / $210 Allowance EMPLOYEE COST PER MONTH Employee $4.79 Employee + Spouse $9.50 Employee + Child(ren) $9.67 Employee + Family $15.36 Dependents are covered until age 26.

This benefit guide only provides a summary of your group’s benefits. All lines of coverage described are subject to the definitions, limitations and exclusions set in each insurance carrier or providers contract. Page l 6 GROUP TERM LIFE BENEFITS MetLife Plan Features Basic Life Insurance Employee Benefit Amount $20,000 AD&D Benefit $20,000 The following shows how much benefits are reduced at certain ages: Age Band Benefit Reduction 65 35% of original amount 70 50% of original amount As an employee of Revolution Energy Basic Life insurance is provided to you at no cost.

This benefit guide only provides a summary of your group’s benefits. All lines of coverage described are subject to the definitions, limitations and exclusions set in each insurance carrier or providers contract. Page l 7 VOLUNTARY LIFE BENEFITS MetLife Plan Features Voluntary Life Insurance Employee Benefit Amount Employees can elect amounts in increments of $10,000. Minimum Benefit Amount $10,000 Maximum Benefit Amount Lesser of 5x earnings or $500,000 Guaranteed Issue Amount $100,000 Spouse Benefit Amount Spouses can elect amounts in increments of $5,000. Minimum Benefit Amount $5,000 Maximum Benefit Amount Guaranteed Issue Amount $100,000; not to exceed 50% of employees benefit $25,000 Dependent Benefit Amount $1,000, $2,000, $4,000, $5,000 or $10,000 (over 6 months old) Maximum Benefit Amount Guaranteed Issue Amount $10,000 $10,000 Employee, Spouse, Dependent Accidental Death & Dismemberment AD&D Same coverage as elected for Voluntary Life above

This benefit guide only provides a summary of your group’s benefits. All lines of coverage described are subject to the definitions, limitations and exclusions set in each insurance carrier or providers contract. Page l 8 VOLUNTARY LIFE RATES Employee Monthly Premium Life & Accidental Death & Dismemberment Premium combined. • Employee must first elect coverage for spouse or dependent to elect coverage. • Employee and Spouse premiums are calculated separately based on the employees age. • Refer to Program Specifications for your maximum benefit amounts. Employee Cost AGE Monthly RATE Per $1,000 <30 $0.165 30-34 $0.174 35-39 $0.175 40-44 $0.302 45-49 $0.406 50-54 $0.643 55-59 $0.968 60-64 $1.409 65-69 $2.264 70+ $3.409 Spouse Cost AGE Monthly RATE Per $1,000 <30 $0.165 30-34 $0.174 35-39 $0.175 40-44 $0.302 45-49 $0.406 50-54 $0.643 55-59 $0.968 60-64 $1.409 65-69 $2.264 70+ $3.409 Child Cost Monthly RATE Per $1,000 $0.294

This benefit guide only provides a summary of your group’s benefits. All lines of coverage described are subject to the definitions, limitations and exclusions set in each insurance carrier or providers contract. Page l 9 VOLUNTARY SHORT TERM DISABILITY Short-Term disability insurance provides you with short term income protection if you become disabled due to a covered injury, illness or pregnancy. Employee Benefit Amount 60% of Pre-Disability Earnings Maximum Benefit Amount $4,000 Elimination Period (Accident) 7 days Elimination Period (Sickness; includes pregnancy) 7 days Benefit Duration 90 days Voluntary Short-Term Disability Colonial Life / Plan Features

This benefit guide only provides a summary of your group’s benefits. All lines of coverage described are subject to the definitions, limitations and exclusions set in each insurance carrier or providers contract. Page l 10 VOLUNTARY LONG TERM DISABIITY Long-Term disability insurance provides you with long term income protection if you become disabled due to a covered injury, illness for an extended period. Employee Benefit Amount 60% of Pre-Disability Earnings Maximum Benefit Amount $6,000 Elimination Period 90 Days Benefit Period Reducing Benefit Duration Voluntary Long-Term Disability MetLife / Plan Features Age Rate per $100 of Covered Monthly Payroll Less than 35 $0.289 35-39 $0.618 40-44 $0.847 45-49 $1.151 50-54 $1.541 55-59 $1.760 60-64 $1.375 65+ $1.516

This benefit guide only provides a summary of your group’s benefits. All lines of coverage described are subject to the definitions, limitations and exclusions set in each insurance carrier or providers contract. Page l 11 ACCIDENT INSURANCE VOLUNTARY ACCIDENT BENEFITS ARE PROVIDED BY COLONIAL LIFE Accident insurance coverage provides full-time employees with a lump sum benefit based on covered injuries you sustain off the job and the treatment you need. Colonial Life Benefit Type Insurance Pays You INJURIES Fractures $200-$7,500 (depending on bone) Dislocations $200-$6,000 (depending on location) Second – and Third-Degree Burns $1,000-$15,000 (depending on severity) Concussions $375 Cuts/Lacerations $50-$600 MEDICAL SERVICES & TREATMENT Ambulance $300 Emergency Treatment $150 Accident Follow-Up Doctor Visit $50 visit / 4 per accident / 16 per year Therapy Services (including Physical Therapy) $45 day / 10 days max X-Ray $60 HOSPITAL COVERAGE Admission $1,750 Confinement $250 Your insurance company already paid the doctor… this money is paid directly to you.

This benefit guide only provides a summary of your group’s benefits. All lines of coverage described are subject to the definitions, limitations and exclusions set in each insurance carrier or providers contract. Page l 12 CRITICAL ILLNESS INSURANCE VOLUNTARY CRITICAL INSURANCE BENEFITS ARE PROVIDED BY COLONIAL LIFE Critical Illness insurance coverage provides full-time employees with a lump sum benefit based upon the diagnosis of a covered illness. Colonial Life Benefit Type Insurance Pays You COVERAGE FOR AMOUNT Employee $5,000 - $75,000 Spouse & Child(ren) 50% of employee’s amount Covered Conditions Initial Benefit COVERAGE FOR AMOUNT Invasive Cancer 100% Non-Invasive Cancer 25% Heart Attack 100% Stroke 100% Coronary Artery Bypass Graft 25% Kidney Failure 100% Coma 100% Major Organ Transplant Benefit 100% Your insurance company already paid the doctor… this money is paid directly to you.

This benefit guide only provides a summary of your group’s benefits. All lines of coverage described are subject to the definitions, limitations and exclusions set in each insurance carrier or providers contract. Page l 13 HOSPITAL INDEMNITY VOLUNTARY HOSPITAL INDEMNITY INSURANCE BENEFITS ARE PROVIDED BY COLONIAL LIFE Hospital indemnity insurance coverage provides full-time employees with a lump sum benefit based upon the hospitalization and associated treatment. Colonial Life / Hospital Indemnity Plan Benefit Limits Benefit Amounts Hospital Confinement 365 days per calendar year Confinement $100 Ambulance Benefit 1 time(s) per calendar year Air Ambulance Transport $1,000 Ambulance Benefit 1 time(s) per calendar year Ground Ambulance Transport $100 Emergency Care 2 time(s) per calendar year Emergency Room $100 Doctor Visit 3 days per calendar year for 1 person; max 5 days for family Doctor Visit / Telemedicine $25

This benefit guide only provides a summary of your group’s benefits. All lines of coverage described are subject to the definitions, limitations and exclusions set in each insurance carrier or providers contract. Page l 14 PET INSURANCE Please call or go online to get pricing.

This benefit guide only provides a summary of your group’s benefits. All lines of coverage described are subject to the definitions, limitations and exclusions set in each insurance carrier or providers contract. Page l 15 The informaon in this Enrollment Guide is presented for illustrave purposes and is based on informaon provided by the employer. The text contained in this Guide was taken from various summary plan descripons and benet informaon. While every eort was taken to accurately report your benets, dis-crepancies or errors are always possible. In case of discrepancy between the Guide and the actual plan documents the actual plan documents will prevail. All informaon is condenal, pursuant to the Health Insurance Portability and Accountability Act of 1996. If you have any quesons about your Guide, contact Human Resources. MetLife Customer Service 800-438-6388 www.MetLife.com/mybenefits Dental Customer Service 800-ASK-4MET (800-275-4638) www.MetLife.com Vision Customer Service 855-MET-EYE1 (855-638-3931) www.MetLife.com CONTACT INFORMATION Title Name Email Phone Number Agent Klaus Knuth KKnuth@keystoneinsgrp.com 574-231-6516 Senior Account Manager Hillary Thompson HThompson@keystoneinsgrp.com 574-231-6530 Senior Account Coordinator Sandy Woodiwiss SWoodiwiss@keystoneinsgrp.com 574-406-6232 Senior Account Coordinator Regina Burns RBurns@keystoneinsgrp.com 574-231-6586 Partner Shamus Mudron SMudron@mkiins.com 815-744-0111 Copyright © Keystone Benefits - all rights reserved Colonial Life Customer Service 800-325-4368 www.coloniallife.com

This benefit guide only provides a summary of your group’s benefits. All lines of coverage described are subject to the definitions, limitations and exclusions set in each insurance carrier or providers contract. Page l 16 13800 Jackson Rd Mishawaka | IN 46544 keystoneinsgrp.com Copyright © Keystone Benefits - all rights reserved