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2024-2025 EMPLOYEE BENEFIT GUIDEHealth. Wealth. Peace of Mind.

1 of 8Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered ServicesCoverage Period: 05/01/2025 - 01/31/2026SM92067S-LIRIANO MOTORS LLC DBA LOST : Health Benefit PlanCoverage for: Family | Plan Type: PPOThe Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan wouldshare the cost for covered health care services. NOTE: Information about the cost of thisplan (called the premium) will be provided separately.This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, visit TrustmarkSB.com or call 1-800-522-1246, ext. 26300. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or otherunderlined terms, see the Glossary. You can view the Glossary at https://www.healthcare.gov/sbc-glossary or call 1-800-522-1246, ext. 26300 to request a copy.Important Questions Answers Why this Matters:What is the overalldeductible?For in-network:$1,500/individual$3,000/familyFor out-of-network:$5,000/individual$10,000/familyPer Calendar YearGenerally, you must pay all of the costs fromproviders up to the deductible amount before thisplan begins to pay.If you have other family members on theplan, each family member must meet their ownindividualdeductible until the total amount of deductible expenses paid by all family membersmeets the overall familydeductible.Are there servicescovered before you meetyourdeductible?Yes. The following services arecovered before you meet yourdeductible:Preventive Care, PrescriptionDrugs, Primary Care Services,Urgent Care Visits, EmergencyRoom VisitsThisplan covers some items and services even if you haven't yet met the deductible amount. Butacopayment or coinsurance may apply. For example, this plan covers certain preventive serviceswithout cost-sharing and before you meet your deductible. See a list of covered preventiveservices at https://www.healthcare.gov/coverage/preventive-care-benefits/.Are there otherdeductibles for specificservices?Yes, $500/individual for outpatientprescription drug expenses.There are no otherdeductibles.You must pay all the costs for these services up to the specific deductible amount before this planbegins to pay for these services.What is theout-of-pocketlimit for this plan?For in-network:$9,000/individual$18,000/familyFor out-of-network:$25,000/individual$50,000/familyPer Calendar YearThe out-of-pocket limit is the most you could pay in a year for covered services.If you have other family members in thisplan, they have to meet their own out-of-pocket limitsuntil the overall family out-of-pocket limit has been met.

1 of 8Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered ServicesCoverage Period: 05/01/2025 - 01/31/2026SM92067S-LIRIANO MOTORS LLC DBA LOST : Health Benefit PlanCoverage for: Family | Plan Type: PPOThe Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan wouldshare the cost for covered health care services. NOTE: Information about the cost of thisplan (called the premium) will be provided separately.This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, visit TrustmarkSB.com or call 1-800-522-1246, ext. 26300. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or otherunderlined terms, see the Glossary. You can view the Glossary at https://www.healthcare.gov/sbc-glossary or call 1-800-522-1246, ext. 26300 to request a copy.Important Questions Answers Why this Matters:What is the overalldeductible?For in-network:$1,500/individual$3,000/familyFor out-of-network:$5,000/individual$10,000/familyPer Calendar YearGenerally, you must pay all of the costs fromproviders up to the deductible amount before thisplan begins to pay.If you have other family members on theplan, each family member must meet their ownindividualdeductible until the total amount of deductible expenses paid by all family membersmeets the overall familydeductible.Are there servicescovered before you meetyourdeductible?Yes. The following services arecovered before you meet yourdeductible:Preventive Care, PrescriptionDrugs, Primary Care Services,Urgent Care Visits, EmergencyRoom VisitsThisplan covers some items and services even if you haven't yet met the deductible amount. Butacopayment or coinsurance may apply. For example, this plan covers certain preventive serviceswithout cost-sharing and before you meet your deductible. See a list of covered preventiveservices at https://www.healthcare.gov/coverage/preventive-care-benefits/.Are there otherdeductibles for specificservices?Yes, $500/individual for outpatientprescription drug expenses.There are no otherdeductibles.You must pay all the costs for these services up to the specific deductible amount before this planbegins to pay for these services.What is theout-of-pocketlimit for this plan?For in-network:$9,000/individual$18,000/familyFor out-of-network:$25,000/individual$50,000/familyPer Calendar YearThe out-of-pocket limit is the most you could pay in a year for covered services.If you have other family members in thisplan, they have to meet their own out-of-pocket limitsuntil the overall family out-of-pocket limit has been met.

Important Questions Answers Why this Matters:2 of 8What is not included intheout-of-pocket limit?Pre-certification penalties,premiums, balanced-billingcharges, and health care this plandoesn't cover.Even though you pay these expenses, they don't count toward the out-of-pocket limit.Will you pay less if youuse a network provider?Yes. See TrustmarkSB.com or call1-800-522-1246, ext. 26300 for alist ofnetwork providers.This plan uses a provider network. You will pay less if you use a provider in the plan's network.You will pay the most if you use anout-of-network provider, and you might receive a bill from aprovider for the difference between the provider's charge and what your plan pays (balancebilling). Be aware, your network provider might use an out-of-network provider for some services(such as lab work). Check with yourprovider before you get services.Do you need areferral tosee aspecialist?No. You can see the specialist you choose without a referral.All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies.What You Will PayCommon Services You May NeedIn-Network Provider Out-of-Network ProviderLimitations, Exceptions, & Other ImportantMedical Event(You will pay the least) (You will pay the most)InformationPrimary care visit to treatan injury or illness$60copay/office visitand 50%coinsurancefor other outpatientservices.50%coinsuranceYou may have to pay for services that aren'tpreventive. Ask your provider if the services youIf you visit a healthcareprovider’s officeor clinicSpecialist visit$60 copay/office visitand 50%coinsurancefor other outpatientservices.50%coinsuranceneed are preventive. Then check what your plan willpay for.General medical and dermatology telemedicinePreventive care/screening/immunizationNo charge for coveredservices.50%coinsuranceservices via Teladoc® are available for $0 perconsult.If you have a testDiagnostic test (x-ray,blood work)50%coinsurance 50% coinsurance NoneImaging (CT/PET scans,MRIs)50%coinsurance 50% coinsurance $300 penalty for failure to precertify.

Important Questions Answers Why this Matters:2 of 8What is not included intheout-of-pocket limit?Pre-certification penalties,premiums, balanced-billingcharges, and health care this plandoesn't cover.Even though you pay these expenses, they don't count toward the out-of-pocket limit.Will you pay less if youuse a network provider?Yes. See TrustmarkSB.com or call1-800-522-1246, ext. 26300 for alist ofnetwork providers.This plan uses a provider network. You will pay less if you use a provider in the plan's network.You will pay the most if you use anout-of-network provider, and you might receive a bill from aprovider for the difference between the provider's charge and what your plan pays (balancebilling). Be aware, your network provider might use an out-of-network provider for some services(such as lab work). Check with yourprovider before you get services.Do you need areferral tosee aspecialist?No. You can see the specialist you choose without a referral.All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies.What You Will PayCommon Services You May NeedIn-Network Provider Out-of-Network ProviderLimitations, Exceptions, & Other ImportantMedical Event(You will pay the least) (You will pay the most)InformationPrimary care visit to treatan injury or illness$60copay/office visitand 50%coinsurancefor other outpatientservices.50%coinsuranceYou may have to pay for services that aren'tpreventive. Ask your provider if the services youIf you visit a healthcareprovider’s officeor clinicSpecialist visit$60 copay/office visitand 50%coinsurancefor other outpatientservices.50%coinsuranceneed are preventive. Then check what your plan willpay for.General medical and dermatology telemedicinePreventive care/screening/immunizationNo charge for coveredservices.50%coinsuranceservices via Teladoc® are available for $0 perconsult.If you have a testDiagnostic test (x-ray,blood work)50%coinsurance 50% coinsurance NoneImaging (CT/PET scans,MRIs)50%coinsurance 50% coinsurance $300 penalty for failure to precertify.

What You Will PayCommon Services You May NeedIn-Network Provider Out-of-Network ProviderLimitations, Exceptions, & Other ImportantMedical Event(You will pay the least) (You will pay the most)Information3 of 8Generic drugs (Tier 1)$20 copay/prescription(retail), $40copay/prescription (mailorder)$20copay/prescription(retail), $40copay/prescription (mailorder)Covers up to a 30-day supply for a retailprescription; up to a 90 day supply for a mail orderprescription.If you need drugs totreat your illness orconditionPreferred brand drugs(Tier 2)$75copay/prescription(retail), $185copay/prescription (mailorder)$75copay/prescription(retail), $185copay/prescription (mailorder)Covers up to a 30-day supply for a retailprescription; up to a 90 day supply for a mail orderprescription.Separate $500deductible/person.More information aboutprescription drugcoverage is available atNon-preferred brand drugs(Tier 3)$105copay/prescription(retail), $315copay/prescription (mailorder)$105copay/prescription(retail), $315copay/prescription (mailorder)Covers up to a 30-day supply for a retailprescription; up to a 90 day supply for a mail orderprescription.Separate $500deductible/person.TrustmarkSB.comSpecialty drugs (Tier 4)$0^^PrudentRx eligiblemedicines: 30% afterprescription deductibleis met; $0 if enrolled inPrudentRx.Non-eligible medicines:$300 copay/prescription(retail) after prescriptiondeductible is met.Not coveredCovers up to a 30-day supply.For members enrolled in PrudentRx, eligiblespecialty drugs have $0 cost sharing. If you opt outor fail to enroll in PrudentRx, you are responsible forthe 30% coinsurance for PrudentRx eligible drugs.Payments for these medications will not counttoward your deductible or out-of-pocket for non-EHB medications. See plan document for moredetails.Separate $500 deductible/person.If you have outpatientsurgeryFacility fee (e.g.,ambulatory surgery center)$2,500 access fee then50%coinsurance$2,500 access fee then50%coinsuranceNonePhysician/surgeon fees 50% coinsurance 50% coinsuranceEmergency room care $750 copay/visit $750 copay/visitIf you need immediatemedical attentionEmergency medicaltransportation50% coinsurance 50% coinsurance NoneUrgent care $125 copay/visit 50% coinsurance

What You Will PayCommon Services You May NeedIn-Network Provider Out-of-Network ProviderLimitations, Exceptions, & Other ImportantMedical Event(You will pay the least) (You will pay the most)Information3 of 8Generic drugs (Tier 1)$20 copay/prescription(retail), $40copay/prescription (mailorder)$20copay/prescription(retail), $40copay/prescription (mailorder)Covers up to a 30-day supply for a retailprescription; up to a 90 day supply for a mail orderprescription.If you need drugs totreat your illness orconditionPreferred brand drugs(Tier 2)$75copay/prescription(retail), $185copay/prescription (mailorder)$75copay/prescription(retail), $185copay/prescription (mailorder)Covers up to a 30-day supply for a retailprescription; up to a 90 day supply for a mail orderprescription.Separate $500deductible/person.More information aboutprescription drugcoverage is available atNon-preferred brand drugs(Tier 3)$105copay/prescription(retail), $315copay/prescription (mailorder)$105copay/prescription(retail), $315copay/prescription (mailorder)Covers up to a 30-day supply for a retailprescription; up to a 90 day supply for a mail orderprescription.Separate $500deductible/person.TrustmarkSB.comSpecialty drugs (Tier 4)$0^^PrudentRx eligiblemedicines: 30% afterprescription deductibleis met; $0 if enrolled inPrudentRx.Non-eligible medicines:$300 copay/prescription(retail) after prescriptiondeductible is met.Not coveredCovers up to a 30-day supply.For members enrolled in PrudentRx, eligiblespecialty drugs have $0 cost sharing. If you opt outor fail to enroll in PrudentRx, you are responsible forthe 30% coinsurance for PrudentRx eligible drugs.Payments for these medications will not counttoward your deductible or out-of-pocket for non-EHB medications. See plan document for moredetails.Separate $500 deductible/person.If you have outpatientsurgeryFacility fee (e.g.,ambulatory surgery center)$2,500 access fee then50%coinsurance$2,500 access fee then50%coinsuranceNonePhysician/surgeon fees 50% coinsurance 50% coinsuranceEmergency room care $750 copay/visit $750 copay/visitIf you need immediatemedical attentionEmergency medicaltransportation50% coinsurance 50% coinsurance NoneUrgent care $125 copay/visit 50% coinsurance

What You Will PayCommon Services You May NeedIn-Network Provider Out-of-Network ProviderLimitations, Exceptions, & Other ImportantMedical Event(You will pay the least) (You will pay the most)Information4 of 8If you have a hospitalstayFacility fee (e.g., hospitalroom)$2,500 access fee then50%coinsurance$2,500 access fee then50%coinsurance$300 penalty for failure to precertify.Physician/surgeon fees 50%coinsurance 50% coinsurance $300 penalty for failure to precertify.If you need mentalhealth, behavioralhealth, or substanceabuse servicesOutpatient services$60/visit for primarycare/specialist visit,$125/visit for urgentcare, $750copay/visitfor emergency roomservices, $2,500Access Fee then 50%coinsurance foroutpatient surgery, or50%coinsurance forother outpatientservices$750copay/visit foremergency roomservices, $2,500 AccessFee then 50%coinsurance for outpatientsurgery, or 50%coinsurance for otheroutpatient servicesMental health telemedicine services viaTeladoc® are available for $0 per consult.Inpatient services$2,500 Access Feethen 50%coinsurancefor inpatienthospitalization, or 50%coinsurance for otherinpatient services$2,500 Access Fee then50%coinsurance forinpatient hospitalization,or 50%coinsurance forother inpatient services$300 penalty for failure to precertify.Office Visits0% coinsurance routineprenatal visits, 50%coinsurance otherservices50%coinsuranceCost sharing does not apply for preventive services.Depending on the type of services,copayment,coinsurance or deductible may apply. Maternitycare may include tests and services describedelsewhere in the SBC (i.e. ultrasound).

What You Will PayCommon Services You May NeedIn-Network Provider Out-of-Network ProviderLimitations, Exceptions, & Other ImportantMedical Event(You will pay the least) (You will pay the most)Information4 of 8If you have a hospitalstayFacility fee (e.g., hospitalroom)$2,500 access fee then50%coinsurance$2,500 access fee then50%coinsurance$300 penalty for failure to precertify.Physician/surgeon fees 50%coinsurance 50% coinsurance $300 penalty for failure to precertify.If you need mentalhealth, behavioralhealth, or substanceabuse servicesOutpatient services$60/visit for primarycare/specialist visit,$125/visit for urgentcare, $750copay/visitfor emergency roomservices, $2,500Access Fee then 50%coinsurance foroutpatient surgery, or50%coinsurance forother outpatientservices$750copay/visit foremergency roomservices, $2,500 AccessFee then 50%coinsurance for outpatientsurgery, or 50%coinsurance for otheroutpatient servicesMental health telemedicine services viaTeladoc® are available for $0 per consult.Inpatient services$2,500 Access Feethen 50%coinsurancefor inpatienthospitalization, or 50%coinsurance for otherinpatient services$2,500 Access Fee then50%coinsurance forinpatient hospitalization,or 50%coinsurance forother inpatient services$300 penalty for failure to precertify.Office Visits0% coinsurance routineprenatal visits, 50%coinsurance otherservices50%coinsuranceCost sharing does not apply for preventive services.Depending on the type of services,copayment,coinsurance or deductible may apply. Maternitycare may include tests and services describedelsewhere in the SBC (i.e. ultrasound).

What You Will PayCommon Services You May NeedIn-Network Provider Out-of-Network ProviderLimitations, Exceptions, & Other ImportantMedical Event(You will pay the least) (You will pay the most)Information5 of 8If you are pregnantChildbirth/deliveryprofessional services50%coinsurance 50% coinsuranceCost sharing does not apply for preventive services.Depending on the type of services,copayment,coinsurance or deductible may apply. Maternitycare may include tests and services describedelsewhere in the SBC (i.e. ultrasound).Childbirth/delivery facilityservices50%coinsurance 50% coinsurance$300 penalty for failure to precertify.Home health care 50% coinsurance 50% coinsurance 100 days/year. $300 penalty for failure to precertify.Rehabilitation services 50% coinsurance 50% coinsurance60 visits/year. Inpatient rehabilitation: $300 penaltyfor failure to precertify.If you need helprecovering or haveHabilitation services 50% coinsurance 50% coinsurance60 visits/year. Inpatient habilitation: $300 penalty forfailure to precertify.other special healthneedsSkilled nursing care 50% coinsurance 50% coinsurance 81 days/year. $300 penalty for failure to precertify.Durable medicalequipment50% coinsurance 50% coinsurance NoneHospice services 50% coinsurance 50% coinsurance6 months while covered under this plan. $300penalty for failure to precertify.If your child needsdental or eye careChildren’s eye examRoutine visionscreening: No charge.Other services,including routine eyeexam: Not covered.Not covered NoneChildren’s glasses Not covered Not coveredChildren’s dental check-up Not covered Not covered

What You Will PayCommon Services You May NeedIn-Network Provider Out-of-Network ProviderLimitations, Exceptions, & Other ImportantMedical Event(You will pay the least) (You will pay the most)Information5 of 8If you are pregnantChildbirth/deliveryprofessional services50%coinsurance 50% coinsuranceCost sharing does not apply for preventive services.Depending on the type of services,copayment,coinsurance or deductible may apply. Maternitycare may include tests and services describedelsewhere in the SBC (i.e. ultrasound).Childbirth/delivery facilityservices50%coinsurance 50% coinsurance$300 penalty for failure to precertify.Home health care 50% coinsurance 50% coinsurance 100 days/year. $300 penalty for failure to precertify.Rehabilitation services 50% coinsurance 50% coinsurance60 visits/year. Inpatient rehabilitation: $300 penaltyfor failure to precertify.If you need helprecovering or haveHabilitation services 50% coinsurance 50% coinsurance60 visits/year. Inpatient habilitation: $300 penalty forfailure to precertify.other special healthneedsSkilled nursing care 50% coinsurance 50% coinsurance 81 days/year. $300 penalty for failure to precertify.Durable medicalequipment50% coinsurance 50% coinsurance NoneHospice services 50% coinsurance 50% coinsurance6 months while covered under this plan. $300penalty for failure to precertify.If your child needsdental or eye careChildren’s eye examRoutine visionscreening: No charge.Other services,including routine eyeexam: Not covered.Not covered NoneChildren’s glasses Not covered Not coveredChildren’s dental check-up Not covered Not covered

6 of 8Excluded Services & Other Covered Services:Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.)· Bariatric surgery · Cosmetic surgery · Dental care (Adult)· Hearing aids · Infertility treatment · Long-term care· Non-emergency care when traveling outside theU.S.· Routine eye care (Adult) · Routine foot care· Weight loss programsOther Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.)· Acupuncture (if prescribed for rehabilitationpurposes), 12 visits per plan year· Chiropractic care, 20 visits per plan year · Private-duty nursingYour Rights to Continue Coverage: There are agencies that can help if you want to continue your coverage after it ends. The contact information for thoseagencies is: U.S. Department of Labor, Employee Benefits Security Administration at 1-866-444-EBSA (3272) or www.dol.gov/ebsa/healthreform, or the U.S.Department of Health and Human Services, Center for Consumer Information and Insurance Oversight, at 1-877-267-2323 x61565 or www.cciio.cms.gov. Othercoverage options may be available to you too, including buying individual insurance coverage through theHealth Insurance Marketplace. For more information abouttheMarketplace, visit www.HealthCare.gov or call 1-800-318-2596.Your Grievance and Appeals Rights: There are agencies that can help if you have a complaint against your plan for a denial of a claim. This complaint is called agrievance or appeal. For more information about your rights, look at the explanation of benefits you will receive for that medical claim. Your plan documents alsoprovide complete information to submit aclaim, appeal, or a grievance for any reason to your plan. For more information about your rights, this notice, or assistance,contact: 1-800-522-1246, ext. 26300 or the U.S. Department of Labor’s Employee Benefits Security Administration at 1-866-444-EBSA (3272) orwww.dol.gov/ebsa/healthreform.Does this plan provide Minimum Essential Coverage? YesMinimum Essential Coverage generally includes plans, health insurance available through the Marketplace or other individual market policies, Medicare, Medicaid,CHIP, TRICARE, and certain other coverage. If you are eligible for certain types ofMinimum Essential Coverage, you may not be eligible for the premium tax credit.Does this plan meet the Minimum Value Standards? YesIf yourplan doesn’t meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace.

6 of 8Excluded Services & Other Covered Services:Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.)· Bariatric surgery · Cosmetic surgery · Dental care (Adult)· Hearing aids · Infertility treatment · Long-term care· Non-emergency care when traveling outside theU.S.· Routine eye care (Adult) · Routine foot care· Weight loss programsOther Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.)· Acupuncture (if prescribed for rehabilitationpurposes), 12 visits per plan year· Chiropractic care, 20 visits per plan year · Private-duty nursingYour Rights to Continue Coverage: There are agencies that can help if you want to continue your coverage after it ends. The contact information for thoseagencies is: U.S. Department of Labor, Employee Benefits Security Administration at 1-866-444-EBSA (3272) or www.dol.gov/ebsa/healthreform, or the U.S.Department of Health and Human Services, Center for Consumer Information and Insurance Oversight, at 1-877-267-2323 x61565 or www.cciio.cms.gov. Othercoverage options may be available to you too, including buying individual insurance coverage through theHealth Insurance Marketplace. For more information abouttheMarketplace, visit www.HealthCare.gov or call 1-800-318-2596.Your Grievance and Appeals Rights: There are agencies that can help if you have a complaint against your plan for a denial of a claim. This complaint is called agrievance or appeal. For more information about your rights, look at the explanation of benefits you will receive for that medical claim. Your plan documents alsoprovide complete information to submit aclaim, appeal, or a grievance for any reason to your plan. For more information about your rights, this notice, or assistance,contact: 1-800-522-1246, ext. 26300 or the U.S. Department of Labor’s Employee Benefits Security Administration at 1-866-444-EBSA (3272) orwww.dol.gov/ebsa/healthreform.Does this plan provide Minimum Essential Coverage? YesMinimum Essential Coverage generally includes plans, health insurance available through the Marketplace or other individual market policies, Medicare, Medicaid,CHIP, TRICARE, and certain other coverage. If you are eligible for certain types ofMinimum Essential Coverage, you may not be eligible for the premium tax credit.Does this plan meet the Minimum Value Standards? YesIf yourplan doesn’t meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace.

7 of 8Language Access Services:Spanish (Español): Para obtener asistencia en Español, llame al 1-800-522-1246, ext. 26300Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 1-800-522-1246, ext. 26300Chinese (中文): 如果需要中文的帮助，请拨打这个号码 1-800-522-1246, ext. 26300Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 1-800-522-1246, ext. 26300To see examples of how this plan might cover costs for a sample medical situation, see the next section.

7 of 8Language Access Services:Spanish (Español): Para obtener asistencia en Español, llame al 1-800-522-1246, ext. 26300Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 1-800-522-1246, ext. 26300Chinese (中文): 如果需要中文的帮助，请拨打这个号码 1-800-522-1246, ext. 26300Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 1-800-522-1246, ext. 26300To see examples of how this plan might cover costs for a sample medical situation, see the next section.

The plan would be responsible for the other costs of these EXAMPLE covered services.8 of 8About these Coverage Examples:This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be differentdepending on the actual care you receive, the prices yourproviders charge, and many other factors. Focus on the cost sharing amounts(deductibles, copayments and coinsurance) and excluded services under the plan. Use this information to compare the portion of costs you mightpay under different healthplans. Please note these coverage examples are based on self-only coverage.Peg is Having a Baby(9 months of in-network pre-natalcare and a hospital delivery)Managing Joe’s type 2 Diabetes(a year of routine in-network care of awell-controlled condition)Mia’s Simple Fracture(in-network emergency room visit andfollow up care)n The plan’s overall deductible$1,500n The plan’s overall deductible$1,500n The plan’s overall deductible$1,500n Specialist copay$60n Specialist copay$60n Specialist copay$60n Hospital (facility) coinsurance50%n Hospital (facility) coinsurance50%n Hospital (facility) coinsurance50%n Other coinsurance50%n Other coinsurance50%n Other coinsurance50%This EXAMPLE event includes services like: This EXAMPLE event includes services like: This EXAMPLE event includes services like:Specialist office visits (prenatal care) Primary care physician office visits (including Emergency room care (including medicalChildbirth/Delivery Professional Services disease education) supplies)Childbirth/Delivery Facility ServicesDiagnostic tests (blood work) Diagnostic test (x-ray)Diagnostic tests (ultrasounds and blood work)Prescription drugsDurable medical equipment (crutches)Specialist visit (anesthesia) Durable medical equipment (glucose meter) Rehabilitation services (physical therapy)Total Example Cost $12,700 Total Example Cost $5,600 Total Example Cost $2,800In this example, Peg would pay: In this example, Joe would pay: In this example, Mia would pay:Cost Sharing Cost Sharing Cost SharingDeductibles* $4,000 Deductibles* $600 Deductibles* $1,500Copayments $30 Copayments $1,700 Copayments $800Coinsurance $2,900 Coinsurance $0 Coinsurance $100What isn’t covered What isn’t covered What isn’t coveredLimits or exclusions $50 Limits or exclusions $500 Limits or exclusions $0The total Peg would pay is $6,980 The total Joe would pay is $2,800 The total Mia would pay is $2,400* This plan has other deductibles for specific services included in this coverage example. See "Are there other deductibles for specific services?" row above.

The plan would be responsible for the other costs of these EXAMPLE covered services.8 of 8About these Coverage Examples:This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be differentdepending on the actual care you receive, the prices yourproviders charge, and many other factors. Focus on the cost sharing amounts(deductibles, copayments and coinsurance) and excluded services under the plan. Use this information to compare the portion of costs you mightpay under different healthplans. Please note these coverage examples are based on self-only coverage.Peg is Having a Baby(9 months of in-network pre-natalcare and a hospital delivery)Managing Joe’s type 2 Diabetes(a year of routine in-network care of awell-controlled condition)Mia’s Simple Fracture(in-network emergency room visit andfollow up care)n The plan’s overall deductible$1,500n The plan’s overall deductible$1,500n The plan’s overall deductible$1,500n Specialist copay$60n Specialist copay$60n Specialist copay$60n Hospital (facility) coinsurance50%n Hospital (facility) coinsurance50%n Hospital (facility) coinsurance50%n Other coinsurance50%n Other coinsurance50%n Other coinsurance50%This EXAMPLE event includes services like: This EXAMPLE event includes services like: This EXAMPLE event includes services like:Specialist office visits (prenatal care) Primary care physician office visits (including Emergency room care (including medicalChildbirth/Delivery Professional Services disease education) supplies)Childbirth/Delivery Facility ServicesDiagnostic tests (blood work) Diagnostic test (x-ray)Diagnostic tests (ultrasounds and blood work)Prescription drugsDurable medical equipment (crutches)Specialist visit (anesthesia) Durable medical equipment (glucose meter) Rehabilitation services (physical therapy)Total Example Cost $12,700 Total Example Cost $5,600 Total Example Cost $2,800In this example, Peg would pay: In this example, Joe would pay: In this example, Mia would pay:Cost Sharing Cost Sharing Cost SharingDeductibles* $4,000 Deductibles* $600 Deductibles* $1,500Copayments $30 Copayments $1,700 Copayments $800Coinsurance $2,900 Coinsurance $0 Coinsurance $100What isn’t covered What isn’t covered What isn’t coveredLimits or exclusions $50 Limits or exclusions $500 Limits or exclusions $0The total Peg would pay is $6,980 The total Joe would pay is $2,800 The total Mia would pay is $2,400* This plan has other deductibles for specific services included in this coverage example. See "Are there other deductibles for specific services?" row above.

1 of 7Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered ServicesCoverage Period: 05/01/2025 - 01/31/2026SM92067S-LIRIANO MOTORS LLC DBA LOST : Health Benefit PlanCoverage for: Family | Plan Type: High-deductibleThe Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan wouldshare the cost for covered health care services. NOTE: Information about the cost of thisplan (called the premium) will be provided separately.This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, visit TrustmarkSB.com or call 1-800-522-1246, ext. 26300. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or otherunderlined terms, see the Glossary. You can view the Glossary at https://www.healthcare.gov/sbc-glossary or call 1-800-522-1246, ext. 26300 to request a copy.Important Questions Answers Why this Matters:What is the overalldeductible?For in-network:$4,000/individual$8,000/familyFor out-of-network:$10,000/individual$20,000/familyPer Calendar YearGenerally, you must pay all of the costs fromproviders up to the deductible amount before thisplan begins to pay.If you have other family members on theplan, each family member must meet their ownindividualdeductible until the total amount of deductible expenses paid by all family membersmeets the overall familydeductible.Are there servicescovered before you meetyourdeductible?Yes.Preventive care is coveredbefore you meet yourdeductible.Thisplan covers some items and services even if you haven't yet met the deductible amount. Butacopayment or coinsurance may apply. For example, this plan covers certain preventive serviceswithout cost-sharing and before you meet your deductible. See a list of covered preventiveservices at https://www.healthcare.gov/coverage/preventive-care-benefits/.Are there otherdeductibles for specificservices?No. You don't have to meetdeductibles for specific services.What is theout-of-pocketlimit for this plan?For in-network:$6,500/individual$13,000/family+For out-of-network:$20,000/individual$40,000/familyPer Calendar Year+ No individual will have more thana $9,200 individual in-network out-of-pocket expense.The out-of-pocket limit is the most you could pay in a year for covered services.If you have other family members in thisplan, the overall family out-of-pocket limit must be met.

1 of 7Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered ServicesCoverage Period: 05/01/2025 - 01/31/2026SM92067S-LIRIANO MOTORS LLC DBA LOST : Health Benefit PlanCoverage for: Family | Plan Type: High-deductibleThe Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan wouldshare the cost for covered health care services. NOTE: Information about the cost of thisplan (called the premium) will be provided separately.This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, visit TrustmarkSB.com or call 1-800-522-1246, ext. 26300. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or otherunderlined terms, see the Glossary. You can view the Glossary at https://www.healthcare.gov/sbc-glossary or call 1-800-522-1246, ext. 26300 to request a copy.Important Questions Answers Why this Matters:What is the overalldeductible?For in-network:$4,000/individual$8,000/familyFor out-of-network:$10,000/individual$20,000/familyPer Calendar YearGenerally, you must pay all of the costs fromproviders up to the deductible amount before thisplan begins to pay.If you have other family members on theplan, each family member must meet their ownindividualdeductible until the total amount of deductible expenses paid by all family membersmeets the overall familydeductible.Are there servicescovered before you meetyourdeductible?Yes.Preventive care is coveredbefore you meet yourdeductible.Thisplan covers some items and services even if you haven't yet met the deductible amount. Butacopayment or coinsurance may apply. For example, this plan covers certain preventive serviceswithout cost-sharing and before you meet your deductible. See a list of covered preventiveservices at https://www.healthcare.gov/coverage/preventive-care-benefits/.Are there otherdeductibles for specificservices?No. You don't have to meetdeductibles for specific services.What is theout-of-pocketlimit for this plan?For in-network:$6,500/individual$13,000/family+For out-of-network:$20,000/individual$40,000/familyPer Calendar Year+ No individual will have more thana $9,200 individual in-network out-of-pocket expense.The out-of-pocket limit is the most you could pay in a year for covered services.If you have other family members in thisplan, the overall family out-of-pocket limit must be met.

Important Questions Answers Why this Matters:2 of 7What is not included intheout-of-pocket limit?Pre-certification penalties,premiums, balanced-billingcharges, and health care this plandoesn't cover.Even though you pay these expenses, they don't count toward the out-of-pocket limit.Will you pay less if youuse a network provider?Yes. See TrustmarkSB.com or call1-800-522-1246, ext. 26300 for alist ofnetwork providers.This plan uses a provider network. You will pay less if you use a provider in the plan's network.You will pay the most if you use anout-of-network provider, and you might receive a bill from aprovider for the difference between the provider's charge and what your plan pays (balancebilling). Be aware, your network provider might use an out-of-network provider for some services(such as lab work). Check with yourprovider before you get services.Do you need areferral tosee aspecialist?No. You can see the specialist you choose without a referral.All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies.What You Will PayCommon Services You May NeedIn-Network Provider Out-of-Network ProviderLimitations, Exceptions, & Other ImportantMedical Event(You will pay the least) (You will pay the most)InformationPrimary care visit to treatan injury or illness30%coinsurance 50% coinsuranceYou may have to pay for services that aren'tpreventive. Ask your provider if the services youIf you visit a healthcareprovider’s officeSpecialist visit 30% coinsurance 50% coinsuranceneed are preventive. Then check what yourplan will pay for.or clinicPreventive care/screening/immunizationNo charge for coveredservices.50%coinsuranceGeneral medical and dermatology telemedicineservices via Teladoc® are available. A consult feeapplies.If you have a testDiagnostic test (x-ray,blood work)30%coinsurance 50% coinsurance NoneImaging (CT/PET scans,MRIs)30%coinsurance 50% coinsurance $300 penalty for failure to precertify.Generic drugs (Tier 1) 30% coinsurance 30% coinsuranceCovers up to a 30-day supply for a retailprescription; up to a 90 day supply for a mail orderprescription.

Important Questions Answers Why this Matters:2 of 7What is not included intheout-of-pocket limit?Pre-certification penalties,premiums, balanced-billingcharges, and health care this plandoesn't cover.Even though you pay these expenses, they don't count toward the out-of-pocket limit.Will you pay less if youuse a network provider?Yes. See TrustmarkSB.com or call1-800-522-1246, ext. 26300 for alist ofnetwork providers.This plan uses a provider network. You will pay less if you use a provider in the plan's network.You will pay the most if you use anout-of-network provider, and you might receive a bill from aprovider for the difference between the provider's charge and what your plan pays (balancebilling). Be aware, your network provider might use an out-of-network provider for some services(such as lab work). Check with yourprovider before you get services.Do you need areferral tosee aspecialist?No. You can see the specialist you choose without a referral.All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies.What You Will PayCommon Services You May NeedIn-Network Provider Out-of-Network ProviderLimitations, Exceptions, & Other ImportantMedical Event(You will pay the least) (You will pay the most)InformationPrimary care visit to treatan injury or illness30%coinsurance 50% coinsuranceYou may have to pay for services that aren'tpreventive. Ask your provider if the services youIf you visit a healthcareprovider’s officeSpecialist visit 30% coinsurance 50% coinsuranceneed are preventive. Then check what yourplan will pay for.or clinicPreventive care/screening/immunizationNo charge for coveredservices.50%coinsuranceGeneral medical and dermatology telemedicineservices via Teladoc® are available. A consult feeapplies.If you have a testDiagnostic test (x-ray,blood work)30%coinsurance 50% coinsurance NoneImaging (CT/PET scans,MRIs)30%coinsurance 50% coinsurance $300 penalty for failure to precertify.Generic drugs (Tier 1) 30% coinsurance 30% coinsuranceCovers up to a 30-day supply for a retailprescription; up to a 90 day supply for a mail orderprescription.

What You Will PayCommon Services You May NeedIn-Network Provider Out-of-Network ProviderLimitations, Exceptions, & Other ImportantMedical Event(You will pay the least) (You will pay the most)Information3 of 7If you need drugs totreat your illness orconditionPreferred brand drugs(Tier 2)30%coinsurance 30% coinsuranceCovers up to a 30-day supply for a retailprescription; up to a 90 day supply for a mail orderprescription.More information aboutprescription drugcoverage is available atNon-preferred brand drugs(Tier 3)30%coinsurance 30% coinsuranceCovers up to a 30-day supply for a retailprescription; up to a 90 day supply for a mail orderprescription.TrustmarkSB.comSpecialty drugs (Tier 4) 30% coinsurance Not coveredCovers up to a 30-day supply.Use specialty pharmacy for in-network benefit.If you have outpatientsurgeryFacility fee (e.g.,ambulatory surgery center)30%coinsurance 50% coinsuranceNonePhysician/surgeon fees 30%coinsurance 50% coinsuranceEmergency room care 30% coinsurance 30% coinsuranceIf you need immediatemedical attentionEmergency medicaltransportation30% coinsurance 30% coinsurance NoneUrgent care 30% coinsurance 50% coinsuranceIf you have a hospitalstayFacility fee (e.g., hospitalroom)30%coinsurance 50% coinsurance $300 penalty for failure to precertify.Physician/surgeon fees 30% coinsurance 50% coinsurance $300 penalty for failure to precertify.If you need mentalhealth, behavioralhealth, or substanceabuse servicesOutpatient services 30%coinsurance 50% coinsuranceMental health telemedicine services viaTeladoc® are available. A consult fee applies.Inpatient services 30%coinsurance 50% coinsurance $300 penalty for failure to precertify.Office Visits0%coinsurance routineprenatal visits, 30%coinsurance otherservices50%coinsuranceCost sharing does not apply for preventive services.Depending on the type of services,copayment,coinsurance or deductible may apply. Maternitycare may include tests and services describedelsewhere in the SBC (i.e. ultrasound).

What You Will PayCommon Services You May NeedIn-Network Provider Out-of-Network ProviderLimitations, Exceptions, & Other ImportantMedical Event(You will pay the least) (You will pay the most)Information3 of 7If you need drugs totreat your illness orconditionPreferred brand drugs(Tier 2)30%coinsurance 30% coinsuranceCovers up to a 30-day supply for a retailprescription; up to a 90 day supply for a mail orderprescription.More information aboutprescription drugcoverage is available atNon-preferred brand drugs(Tier 3)30%coinsurance 30% coinsuranceCovers up to a 30-day supply for a retailprescription; up to a 90 day supply for a mail orderprescription.TrustmarkSB.comSpecialty drugs (Tier 4) 30% coinsurance Not coveredCovers up to a 30-day supply.Use specialty pharmacy for in-network benefit.If you have outpatientsurgeryFacility fee (e.g.,ambulatory surgery center)30%coinsurance 50% coinsuranceNonePhysician/surgeon fees 30%coinsurance 50% coinsuranceEmergency room care 30% coinsurance 30% coinsuranceIf you need immediatemedical attentionEmergency medicaltransportation30% coinsurance 30% coinsurance NoneUrgent care 30% coinsurance 50% coinsuranceIf you have a hospitalstayFacility fee (e.g., hospitalroom)30%coinsurance 50% coinsurance $300 penalty for failure to precertify.Physician/surgeon fees 30% coinsurance 50% coinsurance $300 penalty for failure to precertify.If you need mentalhealth, behavioralhealth, or substanceabuse servicesOutpatient services 30%coinsurance 50% coinsuranceMental health telemedicine services viaTeladoc® are available. A consult fee applies.Inpatient services 30%coinsurance 50% coinsurance $300 penalty for failure to precertify.Office Visits0%coinsurance routineprenatal visits, 30%coinsurance otherservices50%coinsuranceCost sharing does not apply for preventive services.Depending on the type of services,copayment,coinsurance or deductible may apply. Maternitycare may include tests and services describedelsewhere in the SBC (i.e. ultrasound).

What You Will PayCommon Services You May NeedIn-Network Provider Out-of-Network ProviderLimitations, Exceptions, & Other ImportantMedical Event(You will pay the least) (You will pay the most)Information4 of 7If you are pregnantChildbirth/deliveryprofessional services30%coinsurance 50% coinsuranceCost sharing does not apply for preventive services.Depending on the type of services,copayment,coinsurance or deductible may apply. Maternitycare may include tests and services describedelsewhere in the SBC (i.e. ultrasound).Childbirth/delivery facilityservices30%coinsurance 50% coinsurance$300 penalty for failure to precertify.Home health care 30% coinsurance 50% coinsurance 100 days/year. $300 penalty for failure to precertify.Rehabilitation services 30% coinsurance 50% coinsurance60 visits/year. Inpatient rehabilitation: $300 penaltyfor failure to precertify.If you need helprecovering or haveHabilitation services 30% coinsurance 50% coinsurance60 visits/year. Inpatient habilitation: $300 penalty forfailure to precertify.other special healthneedsSkilled nursing care 30% coinsurance 50% coinsurance 81 days/year. $300 penalty for failure to precertify.Durable medicalequipment30% coinsurance 50% coinsurance NoneHospice services 30% coinsurance 50% coinsurance6 months while covered under this plan. $300penalty for failure to precertify.If your child needsdental or eye careChildren’s eye examRoutine visionscreening: No charge.Other services,including routine eyeexam: Not covered.Not covered NoneChildren’s glasses Not covered Not coveredChildren’s dental check-up Not covered Not covered

What You Will PayCommon Services You May NeedIn-Network Provider Out-of-Network ProviderLimitations, Exceptions, & Other ImportantMedical Event(You will pay the least) (You will pay the most)Information4 of 7If you are pregnantChildbirth/deliveryprofessional services30%coinsurance 50% coinsuranceCost sharing does not apply for preventive services.Depending on the type of services,copayment,coinsurance or deductible may apply. Maternitycare may include tests and services describedelsewhere in the SBC (i.e. ultrasound).Childbirth/delivery facilityservices30%coinsurance 50% coinsurance$300 penalty for failure to precertify.Home health care 30% coinsurance 50% coinsurance 100 days/year. $300 penalty for failure to precertify.Rehabilitation services 30% coinsurance 50% coinsurance60 visits/year. Inpatient rehabilitation: $300 penaltyfor failure to precertify.If you need helprecovering or haveHabilitation services 30% coinsurance 50% coinsurance60 visits/year. Inpatient habilitation: $300 penalty forfailure to precertify.other special healthneedsSkilled nursing care 30% coinsurance 50% coinsurance 81 days/year. $300 penalty for failure to precertify.Durable medicalequipment30% coinsurance 50% coinsurance NoneHospice services 30% coinsurance 50% coinsurance6 months while covered under this plan. $300penalty for failure to precertify.If your child needsdental or eye careChildren’s eye examRoutine visionscreening: No charge.Other services,including routine eyeexam: Not covered.Not covered NoneChildren’s glasses Not covered Not coveredChildren’s dental check-up Not covered Not covered

5 of 7Excluded Services & Other Covered Services:Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.)· Bariatric surgery · Cosmetic surgery · Dental care (Adult)· Hearing aids · Infertility treatment · Long-term care· Non-emergency care when traveling outside theU.S.· Routine eye care (Adult) · Routine foot care· Weight loss programsOther Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.)· Acupuncture (if prescribed for rehabilitationpurposes), 12 visits per plan year· Chiropractic care, 20 visits per plan year · Private-duty nursingYour Rights to Continue Coverage: There are agencies that can help if you want to continue your coverage after it ends. The contact information for thoseagencies is: U.S. Department of Labor, Employee Benefits Security Administration at 1-866-444-EBSA (3272) or www.dol.gov/ebsa/healthreform, or the U.S.Department of Health and Human Services, Center for Consumer Information and Insurance Oversight, at 1-877-267-2323 x61565 or www.cciio.cms.gov. Othercoverage options may be available to you too, including buying individual insurance coverage through theHealth Insurance Marketplace. For more information abouttheMarketplace, visit www.HealthCare.gov or call 1-800-318-2596.Your Grievance and Appeals Rights: There are agencies that can help if you have a complaint against your plan for a denial of a claim. This complaint is called agrievance or appeal. For more information about your rights, look at the explanation of benefits you will receive for that medical claim. Your plan documents alsoprovide complete information to submit aclaim, appeal, or a grievance for any reason to your plan. For more information about your rights, this notice, or assistance,contact: 1-800-522-1246, ext. 26300 or the U.S. Department of Labor’s Employee Benefits Security Administration at 1-866-444-EBSA (3272) orwww.dol.gov/ebsa/healthreform.Does this plan provide Minimum Essential Coverage? YesMinimum Essential Coverage generally includes plans, health insurance available through the Marketplace or other individual market policies, Medicare, Medicaid,CHIP, TRICARE, and certain other coverage. If you are eligible for certain types ofMinimum Essential Coverage, you may not be eligible for the premium tax credit.Does this plan meet the Minimum Value Standards? YesIf yourplan doesn’t meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace.

5 of 7Excluded Services & Other Covered Services:Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.)· Bariatric surgery · Cosmetic surgery · Dental care (Adult)· Hearing aids · Infertility treatment · Long-term care· Non-emergency care when traveling outside theU.S.· Routine eye care (Adult) · Routine foot care· Weight loss programsOther Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.)· Acupuncture (if prescribed for rehabilitationpurposes), 12 visits per plan year· Chiropractic care, 20 visits per plan year · Private-duty nursingYour Rights to Continue Coverage: There are agencies that can help if you want to continue your coverage after it ends. The contact information for thoseagencies is: U.S. Department of Labor, Employee Benefits Security Administration at 1-866-444-EBSA (3272) or www.dol.gov/ebsa/healthreform, or the U.S.Department of Health and Human Services, Center for Consumer Information and Insurance Oversight, at 1-877-267-2323 x61565 or www.cciio.cms.gov. Othercoverage options may be available to you too, including buying individual insurance coverage through theHealth Insurance Marketplace. For more information abouttheMarketplace, visit www.HealthCare.gov or call 1-800-318-2596.Your Grievance and Appeals Rights: There are agencies that can help if you have a complaint against your plan for a denial of a claim. This complaint is called agrievance or appeal. For more information about your rights, look at the explanation of benefits you will receive for that medical claim. Your plan documents alsoprovide complete information to submit aclaim, appeal, or a grievance for any reason to your plan. For more information about your rights, this notice, or assistance,contact: 1-800-522-1246, ext. 26300 or the U.S. Department of Labor’s Employee Benefits Security Administration at 1-866-444-EBSA (3272) orwww.dol.gov/ebsa/healthreform.Does this plan provide Minimum Essential Coverage? YesMinimum Essential Coverage generally includes plans, health insurance available through the Marketplace or other individual market policies, Medicare, Medicaid,CHIP, TRICARE, and certain other coverage. If you are eligible for certain types ofMinimum Essential Coverage, you may not be eligible for the premium tax credit.Does this plan meet the Minimum Value Standards? YesIf yourplan doesn’t meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace.

6 of 7Language Access Services:Spanish (Español): Para obtener asistencia en Español, llame al 1-800-522-1246, ext. 26300Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 1-800-522-1246, ext. 26300Chinese (中文): 如果需要中文的帮助，请拨打这个号码 1-800-522-1246, ext. 26300Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 1-800-522-1246, ext. 26300To see examples of how this plan might cover costs for a sample medical situation, see the next section.

6 of 7Language Access Services:Spanish (Español): Para obtener asistencia en Español, llame al 1-800-522-1246, ext. 26300Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 1-800-522-1246, ext. 26300Chinese (中文): 如果需要中文的帮助，请拨打这个号码 1-800-522-1246, ext. 26300Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 1-800-522-1246, ext. 26300To see examples of how this plan might cover costs for a sample medical situation, see the next section.

The plan would be responsible for the other costs of these EXAMPLE covered services.7 of 7About these Coverage Examples:This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be differentdepending on the actual care you receive, the prices yourproviders charge, and many other factors. Focus on the cost sharing amounts(deductibles, copayments and coinsurance) and excluded services under the plan. Use this information to compare the portion of costs you mightpay under different healthplans. Please note these coverage examples are based on self-only coverage.Peg is Having a Baby(9 months of in-network pre-natalcare and a hospital delivery)Managing Joe’s type 2 Diabetes(a year of routine in-network care of awell-controlled condition)Mia’s Simple Fracture(in-network emergency room visit andfollow up care)n The plan’s overall deductible$4,000n The plan’s overall deductible$4,000n The plan’s overall deductible$4,000n Specialist coinsurance30%n Specialist coinsurance30%n Specialist coinsurance30%n Hospital (facility) coinsurance30%n Hospital (facility) coinsurance30%n Hospital (facility) coinsurance30%n Other coinsurance30%n Other coinsurance30%n Other coinsurance30%This EXAMPLE event includes services like: This EXAMPLE event includes services like: This EXAMPLE event includes services like:Specialist office visits (prenatal care) Primary care physician office visits (including Emergency room care (including medicalChildbirth/Delivery Professional Services disease education) supplies)Childbirth/Delivery Facility ServicesDiagnostic tests (blood work) Diagnostic test (x-ray)Diagnostic tests (ultrasounds and blood work)Prescription drugsDurable medical equipment (crutches)Specialist visit (anesthesia) Durable medical equipment (glucose meter) Rehabilitation services (physical therapy)Total Example Cost $12,700 Total Example Cost $5,600 Total Example Cost $2,800In this example, Peg would pay: In this example, Joe would pay: In this example, Mia would pay:Cost Sharing Cost Sharing Cost SharingDeductibles $4,000 Deductibles $4,000 Deductibles $2,800Copayments $0 Copayments $0 Copayments $0Coinsurance $1,700 Coinsurance $200 Coinsurance $0What isn’t covered What isn’t covered What isn’t coveredLimits or exclusions $50 Limits or exclusions $500 Limits or exclusions $0The total Peg would pay is $5,750 The total Joe would pay is $4,700 The total Mia would pay is $2,800

The plan would be responsible for the other costs of these EXAMPLE covered services.7 of 7About these Coverage Examples:This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be differentdepending on the actual care you receive, the prices yourproviders charge, and many other factors. Focus on the cost sharing amounts(deductibles, copayments and coinsurance) and excluded services under the plan. Use this information to compare the portion of costs you mightpay under different healthplans. Please note these coverage examples are based on self-only coverage.Peg is Having a Baby(9 months of in-network pre-natalcare and a hospital delivery)Managing Joe’s type 2 Diabetes(a year of routine in-network care of awell-controlled condition)Mia’s Simple Fracture(in-network emergency room visit andfollow up care)n The plan’s overall deductible$4,000n The plan’s overall deductible$4,000n The plan’s overall deductible$4,000n Specialist coinsurance30%n Specialist coinsurance30%n Specialist coinsurance30%n Hospital (facility) coinsurance30%n Hospital (facility) coinsurance30%n Hospital (facility) coinsurance30%n Other coinsurance30%n Other coinsurance30%n Other coinsurance30%This EXAMPLE event includes services like: This EXAMPLE event includes services like: This EXAMPLE event includes services like:Specialist office visits (prenatal care) Primary care physician office visits (including Emergency room care (including medicalChildbirth/Delivery Professional Services disease education) supplies)Childbirth/Delivery Facility ServicesDiagnostic tests (blood work) Diagnostic test (x-ray)Diagnostic tests (ultrasounds and blood work)Prescription drugsDurable medical equipment (crutches)Specialist visit (anesthesia) Durable medical equipment (glucose meter) Rehabilitation services (physical therapy)Total Example Cost $12,700 Total Example Cost $5,600 Total Example Cost $2,800In this example, Peg would pay: In this example, Joe would pay: In this example, Mia would pay:Cost Sharing Cost Sharing Cost SharingDeductibles $4,000 Deductibles $4,000 Deductibles $2,800Copayments $0 Copayments $0 Copayments $0Coinsurance $1,700 Coinsurance $200 Coinsurance $0What isn’t covered What isn’t covered What isn’t coveredLimits or exclusions $50 Limits or exclusions $500 Limits or exclusions $0The total Peg would pay is $5,750 The total Joe would pay is $4,700 The total Mia would pay is $2,800

1 of 8Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered ServicesCoverage Period: 05/01/2025 - 01/31/2026SM92067S-LIRIANO MOTORS LLC DBA LOST : Health Benefit PlanCoverage for: Family | Plan Type: PPOThe Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan wouldshare the cost for covered health care services. NOTE: Information about the cost of thisplan (called the premium) will be provided separately.This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, visit TrustmarkSB.com or call 1-800-522-1246, ext. 26300. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or otherunderlined terms, see the Glossary. You can view the Glossary at https://www.healthcare.gov/sbc-glossary or call 1-800-522-1246, ext. 26300 to request a copy.Important Questions Answers Why this Matters:What is the overalldeductible?For in-network:$4,000/individual$8,000/familyFor out-of-network:$10,000/individual$20,000/familyPer Calendar YearGenerally, you must pay all of the costs fromproviders up to the deductible amount before thisplan begins to pay.If you have other family members on theplan, each family member must meet their ownindividualdeductible until the total amount of deductible expenses paid by all family membersmeets the overall familydeductible.Are there servicescovered before you meetyourdeductible?Yes. The following services arecovered before you meet yourdeductible:Preventive Care, PrescriptionDrugs, Primary Care Services,Urgent Care Visits, EmergencyRoom Visits, Speech, Occupationand Physical Therapy Visits,Diagnostic Tests, ImagingServicesThisplan covers some items and services even if you haven't yet met the deductible amount. Butacopayment or coinsurance may apply. For example, this plan covers certain preventive serviceswithout cost-sharing and before you meet your deductible. See a list of covered preventiveservices at https://www.healthcare.gov/coverage/preventive-care-benefits/.Are there otherdeductibles for specificservices?No. You don't have to meetdeductibles for specific services.

1 of 8Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered ServicesCoverage Period: 05/01/2025 - 01/31/2026SM92067S-LIRIANO MOTORS LLC DBA LOST : Health Benefit PlanCoverage for: Family | Plan Type: PPOThe Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan wouldshare the cost for covered health care services. NOTE: Information about the cost of thisplan (called the premium) will be provided separately.This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, visit TrustmarkSB.com or call 1-800-522-1246, ext. 26300. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or otherunderlined terms, see the Glossary. You can view the Glossary at https://www.healthcare.gov/sbc-glossary or call 1-800-522-1246, ext. 26300 to request a copy.Important Questions Answers Why this Matters:What is the overalldeductible?For in-network:$4,000/individual$8,000/familyFor out-of-network:$10,000/individual$20,000/familyPer Calendar YearGenerally, you must pay all of the costs fromproviders up to the deductible amount before thisplan begins to pay.If you have other family members on theplan, each family member must meet their ownindividualdeductible until the total amount of deductible expenses paid by all family membersmeets the overall familydeductible.Are there servicescovered before you meetyourdeductible?Yes. The following services arecovered before you meet yourdeductible:Preventive Care, PrescriptionDrugs, Primary Care Services,Urgent Care Visits, EmergencyRoom Visits, Speech, Occupationand Physical Therapy Visits,Diagnostic Tests, ImagingServicesThisplan covers some items and services even if you haven't yet met the deductible amount. Butacopayment or coinsurance may apply. For example, this plan covers certain preventive serviceswithout cost-sharing and before you meet your deductible. See a list of covered preventiveservices at https://www.healthcare.gov/coverage/preventive-care-benefits/.Are there otherdeductibles for specificservices?No. You don't have to meetdeductibles for specific services.

Important Questions Answers Why this Matters:2 of 8What is the out-of-pocketlimit for this plan?For in-network:$7,000/individual$14,000/familyFor out-of-network:$17,500/individual$35,000/familyPer Calendar YearTheout-of-pocket limit is the most you could pay in a year for covered services.If you have other family members in thisplan, they have to meet their own out-of-pocket limitsuntil the overall family out-of-pocket limit has been met.What is not included intheout-of-pocket limit?Pre-certification penalties,premiums, balanced-billingcharges, and health care this plandoesn't cover.Even though you pay these expenses, they don't count toward the out-of-pocket limit.Will you pay less if youuse a network provider?Yes. See TrustmarkSB.com or call1-800-522-1246, ext. 26300 for alist ofnetwork providers.This plan uses a provider network. You will pay less if you use a provider in the plan's network.You will pay the most if you use anout-of-network provider, and you might receive a bill from aprovider for the difference between the provider's charge and what your plan pays (balancebilling). Be aware, your network provider might use an out-of-network provider for some services(such as lab work). Check with yourprovider before you get services.Do you need areferral tosee aspecialist?No. You can see the specialist you choose without a referral.All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies.What You Will PayCommon Services You May NeedIn-Network Provider Out-of-Network ProviderLimitations, Exceptions, & Other ImportantMedical Event(You will pay the least) (You will pay the most)InformationPrimary care visit to treatan injury or illness$20copay/office visitand 30%coinsurancefor other outpatientservices.50%coinsuranceYou may have to pay for services that aren'tpreventive. Ask your provider if the services you

Important Questions Answers Why this Matters:2 of 8What is the out-of-pocketlimit for this plan?For in-network:$7,000/individual$14,000/familyFor out-of-network:$17,500/individual$35,000/familyPer Calendar YearTheout-of-pocket limit is the most you could pay in a year for covered services.If you have other family members in thisplan, they have to meet their own out-of-pocket limitsuntil the overall family out-of-pocket limit has been met.What is not included intheout-of-pocket limit?Pre-certification penalties,premiums, balanced-billingcharges, and health care this plandoesn't cover.Even though you pay these expenses, they don't count toward the out-of-pocket limit.Will you pay less if youuse a network provider?Yes. See TrustmarkSB.com or call1-800-522-1246, ext. 26300 for alist ofnetwork providers.This plan uses a provider network. You will pay less if you use a provider in the plan's network.You will pay the most if you use anout-of-network provider, and you might receive a bill from aprovider for the difference between the provider's charge and what your plan pays (balancebilling). Be aware, your network provider might use an out-of-network provider for some services(such as lab work). Check with yourprovider before you get services.Do you need areferral tosee aspecialist?No. You can see the specialist you choose without a referral.All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies.What You Will PayCommon Services You May NeedIn-Network Provider Out-of-Network ProviderLimitations, Exceptions, & Other ImportantMedical Event(You will pay the least) (You will pay the most)InformationPrimary care visit to treatan injury or illness$20copay/office visitand 30%coinsurancefor other outpatientservices.50%coinsuranceYou may have to pay for services that aren'tpreventive. Ask your provider if the services you

What You Will PayCommon Services You May NeedIn-Network Provider Out-of-Network ProviderLimitations, Exceptions, & Other ImportantMedical Event(You will pay the least) (You will pay the most)Information3 of 8If you visit a healthcareprovider’s officeor clinicSpecialist visit$20 copay/office visitand 30%coinsurancefor other outpatientservices.50%coinsuranceneed are preventive. Then check what your plan willpay for.General medical and dermatology telemedicinePreventive care/screening/immunizationNo charge for coveredservices.50%coinsuranceservices via Teladoc® are available for $0 perconsult.If you have a testDiagnostic test (x-ray,blood work)0%coinsurance,deductible does notapply50% coinsurance NoneImaging (CT/PET scans,MRIs)$300copay/procedure 50% coinsurance $300 penalty for failure to precertify.Generic drugs (Tier 1)$20 copay/prescription(retail), $40copay/prescription (mailorder)$20copay/prescription(retail), $40copay/prescription (mailorder)Covers up to a 30-day supply for a retailprescription; up to a 90 day supply for a mail orderprescription.If you need drugs totreat your illness orconditionPreferred brand drugs(Tier 2)$65copay/prescription(retail), $160copay/prescription (mailorder)$65copay/prescription(retail), $160copay/prescription (mailorder)Covers up to a 30-day supply for a retailprescription; up to a 90 day supply for a mail orderprescription.More information aboutprescription drugcoverage is available atNon-preferred brand drugs(Tier 3)$95copay/prescription(retail), $285copay/prescription (mailorder)$95copay/prescription(retail), $285copay/prescription (mailorder)Covers up to a 30-day supply for a retailprescription; up to a 90 day supply for a mail orderprescription.

What You Will PayCommon Services You May NeedIn-Network Provider Out-of-Network ProviderLimitations, Exceptions, & Other ImportantMedical Event(You will pay the least) (You will pay the most)Information3 of 8If you visit a healthcareprovider’s officeor clinicSpecialist visit$20 copay/office visitand 30%coinsurancefor other outpatientservices.50%coinsuranceneed are preventive. Then check what your plan willpay for.General medical and dermatology telemedicinePreventive care/screening/immunizationNo charge for coveredservices.50%coinsuranceservices via Teladoc® are available for $0 perconsult.If you have a testDiagnostic test (x-ray,blood work)0%coinsurance,deductible does notapply50% coinsurance NoneImaging (CT/PET scans,MRIs)$300copay/procedure 50% coinsurance $300 penalty for failure to precertify.Generic drugs (Tier 1)$20 copay/prescription(retail), $40copay/prescription (mailorder)$20copay/prescription(retail), $40copay/prescription (mailorder)Covers up to a 30-day supply for a retailprescription; up to a 90 day supply for a mail orderprescription.If you need drugs totreat your illness orconditionPreferred brand drugs(Tier 2)$65copay/prescription(retail), $160copay/prescription (mailorder)$65copay/prescription(retail), $160copay/prescription (mailorder)Covers up to a 30-day supply for a retailprescription; up to a 90 day supply for a mail orderprescription.More information aboutprescription drugcoverage is available atNon-preferred brand drugs(Tier 3)$95copay/prescription(retail), $285copay/prescription (mailorder)$95copay/prescription(retail), $285copay/prescription (mailorder)Covers up to a 30-day supply for a retailprescription; up to a 90 day supply for a mail orderprescription.

What You Will PayCommon Services You May NeedIn-Network Provider Out-of-Network ProviderLimitations, Exceptions, & Other ImportantMedical Event(You will pay the least) (You will pay the most)Information4 of 8TrustmarkSB.comSpecialty drugs (Tier 4)$0^^PrudentRx eligiblemedicines: 30% afterprescription deductibleis met; $0 if enrolled inPrudentRx.Non-eligible medicines:$200copay/prescription(retail) after prescriptiondeductible is met.Not coveredCovers up to a 30-day supply.For members enrolled in PrudentRx, eligiblespecialty drugs have $0 cost sharing. If you opt outor fail to enroll in PrudentRx, you are responsible forthe 30% coinsurance for PrudentRx eligible drugs.Payments for these medications will not counttoward your deductible or out-of-pocket for non-EHB medications. See plan document for moredetails.If you have outpatientsurgeryFacility fee (e.g.,ambulatory surgery center)$2,000 access fee then30%coinsurance$2,000 access fee then50%coinsuranceNonePhysician/surgeon fees 30%coinsurance 50% coinsuranceEmergency room care $500 copay/visit $500 copay/visitIf you need immediatemedical attentionEmergency medicaltransportation30% coinsurance 30% coinsurance NoneUrgent care $45 copay/visit 50% coinsuranceIf you have a hospitalstayFacility fee (e.g., hospitalroom)$2,000 access fee then30%coinsurance$2,000 access fee then50%coinsurance$300 penalty for failure to precertify.Physician/surgeon fees 30%coinsurance 50% coinsurance $300 penalty for failure to precertify.

What You Will PayCommon Services You May NeedIn-Network Provider Out-of-Network ProviderLimitations, Exceptions, & Other ImportantMedical Event(You will pay the least) (You will pay the most)Information4 of 8TrustmarkSB.comSpecialty drugs (Tier 4)$0^^PrudentRx eligiblemedicines: 30% afterprescription deductibleis met; $0 if enrolled inPrudentRx.Non-eligible medicines:$200copay/prescription(retail) after prescriptiondeductible is met.Not coveredCovers up to a 30-day supply.For members enrolled in PrudentRx, eligiblespecialty drugs have $0 cost sharing. If you opt outor fail to enroll in PrudentRx, you are responsible forthe 30% coinsurance for PrudentRx eligible drugs.Payments for these medications will not counttoward your deductible or out-of-pocket for non-EHB medications. See plan document for moredetails.If you have outpatientsurgeryFacility fee (e.g.,ambulatory surgery center)$2,000 access fee then30%coinsurance$2,000 access fee then50%coinsuranceNonePhysician/surgeon fees 30%coinsurance 50% coinsuranceEmergency room care $500 copay/visit $500 copay/visitIf you need immediatemedical attentionEmergency medicaltransportation30% coinsurance 30% coinsurance NoneUrgent care $45 copay/visit 50% coinsuranceIf you have a hospitalstayFacility fee (e.g., hospitalroom)$2,000 access fee then30%coinsurance$2,000 access fee then50%coinsurance$300 penalty for failure to precertify.Physician/surgeon fees 30%coinsurance 50% coinsurance $300 penalty for failure to precertify.

What You Will PayCommon Services You May NeedIn-Network Provider Out-of-Network ProviderLimitations, Exceptions, & Other ImportantMedical Event(You will pay the least) (You will pay the most)Information5 of 8If you need mentalhealth, behavioralhealth, or substanceabuse servicesOutpatient services$20/visit for primarycare/specialist visit,$45/visit for urgentcare, $500 copay/visitfor emergency roomservices, $2,000Access Fee then 30%coinsurance foroutpatient surgery, or30%coinsurance forother outpatientservices$500copay/visit foremergency roomservices, $2,000 AccessFee then 50%coinsurance for outpatientsurgery, or 50%coinsurance for otheroutpatient servicesMental health telemedicine services viaTeladoc® are available for $0 per consult.Inpatient services$2,000 Access Feethen 30%coinsurancefor inpatienthospitalization, or 30%coinsurance for otherinpatient services$2,000 Access Fee then50%coinsurance forinpatient hospitalization,or 50%coinsurance forother inpatient services$300 penalty for failure to precertify.Office Visits0%coinsurance routineprenatal visits, 30%coinsurance otherservices50%coinsuranceCost sharing does not apply for preventive services.Depending on the type of services,copayment,coinsurance or deductible may apply. Maternitycare may include tests and services describedelsewhere in the SBC (i.e. ultrasound).If you are pregnantChildbirth/deliveryprofessional services30% coinsurance 50% coinsuranceCost sharing does not apply for preventive services.Depending on the type of services,copayment,coinsurance or deductible may apply. Maternitycare may include tests and services describedelsewhere in the SBC (i.e. ultrasound).Childbirth/delivery facilityservices30%coinsurance 50% coinsurance$300 penalty for failure to precertify.Home health care 30% coinsurance 50% coinsurance 100 days/year. $300 penalty for failure to precertify.

What You Will PayCommon Services You May NeedIn-Network Provider Out-of-Network ProviderLimitations, Exceptions, & Other ImportantMedical Event(You will pay the least) (You will pay the most)Information5 of 8If you need mentalhealth, behavioralhealth, or substanceabuse servicesOutpatient services$20/visit for primarycare/specialist visit,$45/visit for urgentcare, $500 copay/visitfor emergency roomservices, $2,000Access Fee then 30%coinsurance foroutpatient surgery, or30%coinsurance forother outpatientservices$500copay/visit foremergency roomservices, $2,000 AccessFee then 50%coinsurance for outpatientsurgery, or 50%coinsurance for otheroutpatient servicesMental health telemedicine services viaTeladoc® are available for $0 per consult.Inpatient services$2,000 Access Feethen 30%coinsurancefor inpatienthospitalization, or 30%coinsurance for otherinpatient services$2,000 Access Fee then50%coinsurance forinpatient hospitalization,or 50%coinsurance forother inpatient services$300 penalty for failure to precertify.Office Visits0%coinsurance routineprenatal visits, 30%coinsurance otherservices50%coinsuranceCost sharing does not apply for preventive services.Depending on the type of services,copayment,coinsurance or deductible may apply. Maternitycare may include tests and services describedelsewhere in the SBC (i.e. ultrasound).If you are pregnantChildbirth/deliveryprofessional services30% coinsurance 50% coinsuranceCost sharing does not apply for preventive services.Depending on the type of services,copayment,coinsurance or deductible may apply. Maternitycare may include tests and services describedelsewhere in the SBC (i.e. ultrasound).Childbirth/delivery facilityservices30%coinsurance 50% coinsurance$300 penalty for failure to precertify.Home health care 30% coinsurance 50% coinsurance 100 days/year. $300 penalty for failure to precertify.

What You Will PayCommon Services You May NeedIn-Network Provider Out-of-Network ProviderLimitations, Exceptions, & Other ImportantMedical Event(You will pay the least) (You will pay the most)Information6 of 8Rehabilitation services$20 copay/visit forSpeech, Occupationaland Physical therapy,30%coinsurance forother services.50%coinsurance60 visits/year. Inpatient rehabilitation: $300 penaltyfor failure to precertify.If you need helprecovering or haveother special healthneedsHabilitation services$20 copay/visit forSpeech, Occupationaland Physical therapy,30%coinsurance forother services.50%coinsurance60 visits/year. Inpatient habilitation: $300 penalty forfailure to precertify.Skilled nursing care 30% coinsurance 50% coinsurance 81 days/year. $300 penalty for failure to precertify.Durable medicalequipment30% coinsurance 50% coinsurance NoneHospice services 30% coinsurance 50% coinsurance6 months while covered under this plan. $300penalty for failure to precertify.If your child needsdental or eye careChildren’s eye examRoutine visionscreening: No charge.Other services,including routine eyeexam: Not covered.Not covered NoneChildren’s glasses Not covered Not coveredChildren’s dental check-up Not covered Not coveredExcluded Services & Other Covered Services:Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.)· Bariatric surgery · Cosmetic surgery · Dental care (Adult)· Hearing aids · Infertility treatment · Long-term care· Non-emergency care when traveling outside theU.S.· Routine eye care (Adult) · Routine foot care· Weight loss programs

What You Will PayCommon Services You May NeedIn-Network Provider Out-of-Network ProviderLimitations, Exceptions, & Other ImportantMedical Event(You will pay the least) (You will pay the most)Information6 of 8Rehabilitation services$20 copay/visit forSpeech, Occupationaland Physical therapy,30%coinsurance forother services.50%coinsurance60 visits/year. Inpatient rehabilitation: $300 penaltyfor failure to precertify.If you need helprecovering or haveother special healthneedsHabilitation services$20 copay/visit forSpeech, Occupationaland Physical therapy,30%coinsurance forother services.50%coinsurance60 visits/year. Inpatient habilitation: $300 penalty forfailure to precertify.Skilled nursing care 30% coinsurance 50% coinsurance 81 days/year. $300 penalty for failure to precertify.Durable medicalequipment30% coinsurance 50% coinsurance NoneHospice services 30% coinsurance 50% coinsurance6 months while covered under this plan. $300penalty for failure to precertify.If your child needsdental or eye careChildren’s eye examRoutine visionscreening: No charge.Other services,including routine eyeexam: Not covered.Not covered NoneChildren’s glasses Not covered Not coveredChildren’s dental check-up Not covered Not coveredExcluded Services & Other Covered Services:Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.)· Bariatric surgery · Cosmetic surgery · Dental care (Adult)· Hearing aids · Infertility treatment · Long-term care· Non-emergency care when traveling outside theU.S.· Routine eye care (Adult) · Routine foot care· Weight loss programs

7 of 8Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see yourplan document.)· Acupuncture (if prescribed for rehabilitationpurposes), 12 visits per plan year· Chiropractic care, 20 visits per plan year · Private-duty nursingYour Rights to Continue Coverage: There are agencies that can help if you want to continue your coverage after it ends. The contact information for thoseagencies is: U.S. Department of Labor, Employee Benefits Security Administration at 1-866-444-EBSA (3272) or www.dol.gov/ebsa/healthreform, or the U.S.Department of Health and Human Services, Center for Consumer Information and Insurance Oversight, at 1-877-267-2323 x61565 or www.cciio.cms.gov. Othercoverage options may be available to you too, including buying individual insurance coverage through theHealth Insurance Marketplace. For more information abouttheMarketplace, visit www.HealthCare.gov or call 1-800-318-2596.Your Grievance and Appeals Rights: There are agencies that can help if you have a complaint against your plan for a denial of a claim. This complaint is called agrievance or appeal. For more information about your rights, look at the explanation of benefits you will receive for that medical claim. Your plan documents alsoprovide complete information to submit aclaim, appeal, or a grievance for any reason to your plan. For more information about your rights, this notice, or assistance,contact: 1-800-522-1246, ext. 26300 or the U.S. Department of Labor’s Employee Benefits Security Administration at 1-866-444-EBSA (3272) orwww.dol.gov/ebsa/healthreform.Does this plan provide Minimum Essential Coverage? YesMinimum Essential Coverage generally includes plans, health insurance available through the Marketplace or other individual market policies, Medicare, Medicaid,CHIP, TRICARE, and certain other coverage. If you are eligible for certain types ofMinimum Essential Coverage, you may not be eligible for the premium tax credit.Does this plan meet the Minimum Value Standards? YesIf yourplan doesn’t meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace.Language Access Services:Spanish (Español): Para obtener asistencia en Español, llame al 1-800-522-1246, ext. 26300Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 1-800-522-1246, ext. 26300Chinese (中文): 如果需要中文的帮助，请拨打这个号码 1-800-522-1246, ext. 26300Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 1-800-522-1246, ext. 26300To see examples of how this plan might cover costs for a sample medical situation, see the next section.

7 of 8Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see yourplan document.)· Acupuncture (if prescribed for rehabilitationpurposes), 12 visits per plan year· Chiropractic care, 20 visits per plan year · Private-duty nursingYour Rights to Continue Coverage: There are agencies that can help if you want to continue your coverage after it ends. The contact information for thoseagencies is: U.S. Department of Labor, Employee Benefits Security Administration at 1-866-444-EBSA (3272) or www.dol.gov/ebsa/healthreform, or the U.S.Department of Health and Human Services, Center for Consumer Information and Insurance Oversight, at 1-877-267-2323 x61565 or www.cciio.cms.gov. Othercoverage options may be available to you too, including buying individual insurance coverage through theHealth Insurance Marketplace. For more information abouttheMarketplace, visit www.HealthCare.gov or call 1-800-318-2596.Your Grievance and Appeals Rights: There are agencies that can help if you have a complaint against your plan for a denial of a claim. This complaint is called agrievance or appeal. For more information about your rights, look at the explanation of benefits you will receive for that medical claim. Your plan documents alsoprovide complete information to submit aclaim, appeal, or a grievance for any reason to your plan. For more information about your rights, this notice, or assistance,contact: 1-800-522-1246, ext. 26300 or the U.S. Department of Labor’s Employee Benefits Security Administration at 1-866-444-EBSA (3272) orwww.dol.gov/ebsa/healthreform.Does this plan provide Minimum Essential Coverage? YesMinimum Essential Coverage generally includes plans, health insurance available through the Marketplace or other individual market policies, Medicare, Medicaid,CHIP, TRICARE, and certain other coverage. If you are eligible for certain types ofMinimum Essential Coverage, you may not be eligible for the premium tax credit.Does this plan meet the Minimum Value Standards? YesIf yourplan doesn’t meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace.Language Access Services:Spanish (Español): Para obtener asistencia en Español, llame al 1-800-522-1246, ext. 26300Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 1-800-522-1246, ext. 26300Chinese (中文): 如果需要中文的帮助，请拨打这个号码 1-800-522-1246, ext. 26300Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 1-800-522-1246, ext. 26300To see examples of how this plan might cover costs for a sample medical situation, see the next section.

The plan would be responsible for the other costs of these EXAMPLE covered services.8 of 8About these Coverage Examples:This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be differentdepending on the actual care you receive, the prices yourproviders charge, and many other factors. Focus on the cost sharing amounts(deductibles, copayments and coinsurance) and excluded services under the plan. Use this information to compare the portion of costs you mightpay under different healthplans. Please note these coverage examples are based on self-only coverage.Peg is Having a Baby(9 months of in-network pre-natalcare and a hospital delivery)Managing Joe’s type 2 Diabetes(a year of routine in-network care of awell-controlled condition)Mia’s Simple Fracture(in-network emergency room visit andfollow up care)n The plan’s overall deductible$4,000n The plan’s overall deductible$4,000n The plan’s overall deductible$4,000n Specialist copay$20n Specialist copay$20n Specialist copay$20n Hospital (facility) coinsurance30%n Hospital (facility) coinsurance30%n Hospital (facility) coinsurance30%n Other coinsurance30%n Other coinsurance30%n Other coinsurance30%This EXAMPLE event includes services like: This EXAMPLE event includes services like: This EXAMPLE event includes services like:Specialist office visits (prenatal care) Primary care physician office visits (including Emergency room care (including medicalChildbirth/Delivery Professional Services disease education) supplies)Childbirth/Delivery Facility ServicesDiagnostic tests (blood work) Diagnostic test (x-ray)Diagnostic tests (ultrasounds and blood work)Prescription drugsDurable medical equipment (crutches)Specialist visit (anesthesia) Durable medical equipment (glucose meter) Rehabilitation services (physical therapy)Total Example Cost $12,700 Total Example Cost $5,600 Total Example Cost $2,800In this example, Peg would pay: In this example, Joe would pay: In this example, Mia would pay:Cost Sharing Cost Sharing Cost SharingDeductibles $6,000 Deductibles $0 Deductibles $1,200Copayments $30 Copayments $1,500 Copayments $600Coinsurance $700 Coinsurance $0 Coinsurance $0What isn’t covered What isn’t covered What isn’t coveredLimits or exclusions $50 Limits or exclusions $500 Limits or exclusions $0The total Peg would pay is $6,780 The total Joe would pay is $2,000 The total Mia would pay is $1,800

The plan would be responsible for the other costs of these EXAMPLE covered services.8 of 8About these Coverage Examples:This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be differentdepending on the actual care you receive, the prices yourproviders charge, and many other factors. Focus on the cost sharing amounts(deductibles, copayments and coinsurance) and excluded services under the plan. Use this information to compare the portion of costs you mightpay under different healthplans. Please note these coverage examples are based on self-only coverage.Peg is Having a Baby(9 months of in-network pre-natalcare and a hospital delivery)Managing Joe’s type 2 Diabetes(a year of routine in-network care of awell-controlled condition)Mia’s Simple Fracture(in-network emergency room visit andfollow up care)n The plan’s overall deductible$4,000n The plan’s overall deductible$4,000n The plan’s overall deductible$4,000n Specialist copay$20n Specialist copay$20n Specialist copay$20n Hospital (facility) coinsurance30%n Hospital (facility) coinsurance30%n Hospital (facility) coinsurance30%n Other coinsurance30%n Other coinsurance30%n Other coinsurance30%This EXAMPLE event includes services like: This EXAMPLE event includes services like: This EXAMPLE event includes services like:Specialist office visits (prenatal care) Primary care physician office visits (including Emergency room care (including medicalChildbirth/Delivery Professional Services disease education) supplies)Childbirth/Delivery Facility ServicesDiagnostic tests (blood work) Diagnostic test (x-ray)Diagnostic tests (ultrasounds and blood work)Prescription drugsDurable medical equipment (crutches)Specialist visit (anesthesia) Durable medical equipment (glucose meter) Rehabilitation services (physical therapy)Total Example Cost $12,700 Total Example Cost $5,600 Total Example Cost $2,800In this example, Peg would pay: In this example, Joe would pay: In this example, Mia would pay:Cost Sharing Cost Sharing Cost SharingDeductibles $6,000 Deductibles $0 Deductibles $1,200Copayments $30 Copayments $1,500 Copayments $600Coinsurance $700 Coinsurance $0 Coinsurance $0What isn’t covered What isn’t covered What isn’t coveredLimits or exclusions $50 Limits or exclusions $500 Limits or exclusions $0The total Peg would pay is $6,780 The total Joe would pay is $2,000 The total Mia would pay is $1,800

1 of 8Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered ServicesCoverage Period: 05/01/2025 - 01/31/2026SM92067S-LIRIANO MOTORS LLC DBA LOST : Health Benefit PlanCoverage for: Family | Plan Type: PPOThe Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan wouldshare the cost for covered health care services. NOTE: Information about the cost of thisplan (called the premium) will be provided separately.This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, visit TrustmarkSB.com or call 1-800-522-1246, ext. 26300. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or otherunderlined terms, see the Glossary. You can view the Glossary at https://www.healthcare.gov/sbc-glossary or call 1-800-522-1246, ext. 26300 to request a copy.Important Questions Answers Why this Matters:What is the overalldeductible?For in-network:$2,000/individual$4,000/familyFor out-of-network:$5,000/individual$10,000/familyPer Calendar YearGenerally, you must pay all of the costs fromproviders up to the deductible amount before thisplan begins to pay.If you have other family members on theplan, each family member must meet their ownindividualdeductible until the total amount of deductible expenses paid by all family membersmeets the overall familydeductible.Are there servicescovered before you meetyourdeductible?Yes. The following services arecovered before you meet yourdeductible:Preventive Care, PrescriptionDrugs, Primary Care Services,Urgent Care Visits, EmergencyRoom Visits, Speech, Occupationand Physical Therapy VisitsThisplan covers some items and services even if you haven't yet met the deductible amount. Butacopayment or coinsurance may apply. For example, this plan covers certain preventive serviceswithout cost-sharing and before you meet your deductible. See a list of covered preventiveservices at https://www.healthcare.gov/coverage/preventive-care-benefits/.Are there otherdeductibles for specificservices?No. You don't have to meetdeductibles for specific services.

1 of 8Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered ServicesCoverage Period: 05/01/2025 - 01/31/2026SM92067S-LIRIANO MOTORS LLC DBA LOST : Health Benefit PlanCoverage for: Family | Plan Type: PPOThe Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan wouldshare the cost for covered health care services. NOTE: Information about the cost of thisplan (called the premium) will be provided separately.This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, visit TrustmarkSB.com or call 1-800-522-1246, ext. 26300. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or otherunderlined terms, see the Glossary. You can view the Glossary at https://www.healthcare.gov/sbc-glossary or call 1-800-522-1246, ext. 26300 to request a copy.Important Questions Answers Why this Matters:What is the overalldeductible?For in-network:$2,000/individual$4,000/familyFor out-of-network:$5,000/individual$10,000/familyPer Calendar YearGenerally, you must pay all of the costs fromproviders up to the deductible amount before thisplan begins to pay.If you have other family members on theplan, each family member must meet their ownindividualdeductible until the total amount of deductible expenses paid by all family membersmeets the overall familydeductible.Are there servicescovered before you meetyourdeductible?Yes. The following services arecovered before you meet yourdeductible:Preventive Care, PrescriptionDrugs, Primary Care Services,Urgent Care Visits, EmergencyRoom Visits, Speech, Occupationand Physical Therapy VisitsThisplan covers some items and services even if you haven't yet met the deductible amount. Butacopayment or coinsurance may apply. For example, this plan covers certain preventive serviceswithout cost-sharing and before you meet your deductible. See a list of covered preventiveservices at https://www.healthcare.gov/coverage/preventive-care-benefits/.Are there otherdeductibles for specificservices?No. You don't have to meetdeductibles for specific services.

Important Questions Answers Why this Matters:2 of 8What is the out-of-pocketlimit for this plan?For in-network:$4,000/individual$8,000/familyFor out-of-network:$15,000/individual$30,000/familyPer Calendar YearTheout-of-pocket limit is the most you could pay in a year for covered services.If you have other family members in thisplan, they have to meet their own out-of-pocket limitsuntil the overall family out-of-pocket limit has been met.What is not included intheout-of-pocket limit?Pre-certification penalties,premiums, balanced-billingcharges, and health care this plandoesn't cover.Even though you pay these expenses, they don't count toward the out-of-pocket limit.Will you pay less if youuse a network provider?Yes. See TrustmarkSB.com or call1-800-522-1246, ext. 26300 for alist ofnetwork providers.This plan uses a provider network. You will pay less if you use a provider in the plan's network.You will pay the most if you use anout-of-network provider, and you might receive a bill from aprovider for the difference between the provider's charge and what your plan pays (balancebilling). Be aware, your network provider might use an out-of-network provider for some services(such as lab work). Check with yourprovider before you get services.Do you need areferral tosee aspecialist?No. You can see the specialist you choose without a referral.All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies.What You Will PayCommon Services You May NeedIn-Network Provider Out-of-Network ProviderLimitations, Exceptions, & Other ImportantMedical Event(You will pay the least) (You will pay the most)InformationPrimary care visit to treatan injury or illness$20copay/office visitand 30%coinsurancefor other outpatientservices.50%coinsuranceYou may have to pay for services that aren'tpreventive. Ask your provider if the services you

Important Questions Answers Why this Matters:2 of 8What is the out-of-pocketlimit for this plan?For in-network:$4,000/individual$8,000/familyFor out-of-network:$15,000/individual$30,000/familyPer Calendar YearTheout-of-pocket limit is the most you could pay in a year for covered services.If you have other family members in thisplan, they have to meet their own out-of-pocket limitsuntil the overall family out-of-pocket limit has been met.What is not included intheout-of-pocket limit?Pre-certification penalties,premiums, balanced-billingcharges, and health care this plandoesn't cover.Even though you pay these expenses, they don't count toward the out-of-pocket limit.Will you pay less if youuse a network provider?Yes. See TrustmarkSB.com or call1-800-522-1246, ext. 26300 for alist ofnetwork providers.This plan uses a provider network. You will pay less if you use a provider in the plan's network.You will pay the most if you use anout-of-network provider, and you might receive a bill from aprovider for the difference between the provider's charge and what your plan pays (balancebilling). Be aware, your network provider might use an out-of-network provider for some services(such as lab work). Check with yourprovider before you get services.Do you need areferral tosee aspecialist?No. You can see the specialist you choose without a referral.All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies.What You Will PayCommon Services You May NeedIn-Network Provider Out-of-Network ProviderLimitations, Exceptions, & Other ImportantMedical Event(You will pay the least) (You will pay the most)InformationPrimary care visit to treatan injury or illness$20copay/office visitand 30%coinsurancefor other outpatientservices.50%coinsuranceYou may have to pay for services that aren'tpreventive. Ask your provider if the services you

What You Will PayCommon Services You May NeedIn-Network Provider Out-of-Network ProviderLimitations, Exceptions, & Other ImportantMedical Event(You will pay the least) (You will pay the most)Information3 of 8If you visit a healthcareprovider’s officeor clinicSpecialist visit$20 copay/office visitand 30%coinsurancefor other outpatientservices.50%coinsuranceneed are preventive. Then check what your plan willpay for.General medical and dermatology telemedicinePreventive care/screening/immunizationNo charge for coveredservices.50%coinsuranceservices via Teladoc® are available for $0 perconsult.If you have a testDiagnostic test (x-ray,blood work)30%coinsurance 50% coinsurance NoneImaging (CT/PET scans,MRIs)30%coinsurance 50% coinsurance $300 penalty for failure to precertify.Generic drugs (Tier 1)$20 copay/prescription(retail), $40copay/prescription (mailorder)$20copay/prescription(retail), $40copay/prescription (mailorder)Covers up to a 30-day supply for a retailprescription; up to a 90 day supply for a mail orderprescription.If you need drugs totreat your illness orconditionPreferred brand drugs(Tier 2)$65copay/prescription(retail), $160copay/prescription (mailorder)$65copay/prescription(retail), $160copay/prescription (mailorder)Covers up to a 30-day supply for a retailprescription; up to a 90 day supply for a mail orderprescription.More information aboutprescription drugcoverage is available atNon-preferred brand drugs(Tier 3)$95copay/prescription(retail), $285copay/prescription (mailorder)$95copay/prescription(retail), $285copay/prescription (mailorder)Covers up to a 30-day supply for a retailprescription; up to a 90 day supply for a mail orderprescription.

What You Will PayCommon Services You May NeedIn-Network Provider Out-of-Network ProviderLimitations, Exceptions, & Other ImportantMedical Event(You will pay the least) (You will pay the most)Information3 of 8If you visit a healthcareprovider’s officeor clinicSpecialist visit$20 copay/office visitand 30%coinsurancefor other outpatientservices.50%coinsuranceneed are preventive. Then check what your plan willpay for.General medical and dermatology telemedicinePreventive care/screening/immunizationNo charge for coveredservices.50%coinsuranceservices via Teladoc® are available for $0 perconsult.If you have a testDiagnostic test (x-ray,blood work)30%coinsurance 50% coinsurance NoneImaging (CT/PET scans,MRIs)30%coinsurance 50% coinsurance $300 penalty for failure to precertify.Generic drugs (Tier 1)$20 copay/prescription(retail), $40copay/prescription (mailorder)$20copay/prescription(retail), $40copay/prescription (mailorder)Covers up to a 30-day supply for a retailprescription; up to a 90 day supply for a mail orderprescription.If you need drugs totreat your illness orconditionPreferred brand drugs(Tier 2)$65copay/prescription(retail), $160copay/prescription (mailorder)$65copay/prescription(retail), $160copay/prescription (mailorder)Covers up to a 30-day supply for a retailprescription; up to a 90 day supply for a mail orderprescription.More information aboutprescription drugcoverage is available atNon-preferred brand drugs(Tier 3)$95copay/prescription(retail), $285copay/prescription (mailorder)$95copay/prescription(retail), $285copay/prescription (mailorder)Covers up to a 30-day supply for a retailprescription; up to a 90 day supply for a mail orderprescription.

What You Will PayCommon Services You May NeedIn-Network Provider Out-of-Network ProviderLimitations, Exceptions, & Other ImportantMedical Event(You will pay the least) (You will pay the most)Information4 of 8TrustmarkSB.comSpecialty drugs (Tier 4)$0^^PrudentRx eligiblemedicines: 30% afterprescription deductibleis met; $0 if enrolled inPrudentRx.Non-eligible medicines:$200copay/prescription(retail) after prescriptiondeductible is met.Not coveredCovers up to a 30-day supply.For members enrolled in PrudentRx, eligiblespecialty drugs have $0 cost sharing. If you opt outor fail to enroll in PrudentRx, you are responsible forthe 30% coinsurance for PrudentRx eligible drugs.Payments for these medications will not counttoward your deductible or out-of-pocket for non-EHB medications. See plan document for moredetails.If you have outpatientsurgeryFacility fee (e.g.,ambulatory surgery center)$1,500 access fee then30%coinsurance$1,500 access fee then50%coinsuranceNonePhysician/surgeon fees 30%coinsurance 50% coinsuranceEmergency room care $500 copay/visit $500 copay/visitIf you need immediatemedical attentionEmergency medicaltransportation30% coinsurance 30% coinsurance NoneUrgent care $40 copay/visit 50% coinsuranceIf you have a hospitalstayFacility fee (e.g., hospitalroom)$1,500 access fee then30%coinsurance$1,500 access fee then50%coinsurance$300 penalty for failure to precertify.Physician/surgeon fees 30%coinsurance 50% coinsurance $300 penalty for failure to precertify.

What You Will PayCommon Services You May NeedIn-Network Provider Out-of-Network ProviderLimitations, Exceptions, & Other ImportantMedical Event(You will pay the least) (You will pay the most)Information4 of 8TrustmarkSB.comSpecialty drugs (Tier 4)$0^^PrudentRx eligiblemedicines: 30% afterprescription deductibleis met; $0 if enrolled inPrudentRx.Non-eligible medicines:$200copay/prescription(retail) after prescriptiondeductible is met.Not coveredCovers up to a 30-day supply.For members enrolled in PrudentRx, eligiblespecialty drugs have $0 cost sharing. If you opt outor fail to enroll in PrudentRx, you are responsible forthe 30% coinsurance for PrudentRx eligible drugs.Payments for these medications will not counttoward your deductible or out-of-pocket for non-EHB medications. See plan document for moredetails.If you have outpatientsurgeryFacility fee (e.g.,ambulatory surgery center)$1,500 access fee then30%coinsurance$1,500 access fee then50%coinsuranceNonePhysician/surgeon fees 30%coinsurance 50% coinsuranceEmergency room care $500 copay/visit $500 copay/visitIf you need immediatemedical attentionEmergency medicaltransportation30% coinsurance 30% coinsurance NoneUrgent care $40 copay/visit 50% coinsuranceIf you have a hospitalstayFacility fee (e.g., hospitalroom)$1,500 access fee then30%coinsurance$1,500 access fee then50%coinsurance$300 penalty for failure to precertify.Physician/surgeon fees 30%coinsurance 50% coinsurance $300 penalty for failure to precertify.

What You Will PayCommon Services You May NeedIn-Network Provider Out-of-Network ProviderLimitations, Exceptions, & Other ImportantMedical Event(You will pay the least) (You will pay the most)Information5 of 8If you need mentalhealth, behavioralhealth, or substanceabuse servicesOutpatient services$20/visit for primarycare/specialist visit,$40/visit for urgentcare, $500 copay/visitfor emergency roomservices, $1,500Access Fee then 30%coinsurance foroutpatient surgery, or30%coinsurance forother outpatientservices$500copay/visit foremergency roomservices, $1,500 AccessFee then 50%coinsurance for outpatientsurgery, or 50%coinsurance for otheroutpatient servicesMental health telemedicine services viaTeladoc® are available for $0 per consult.Inpatient services$1,500 Access Feethen 30%coinsurancefor inpatienthospitalization, or 30%coinsurance for otherinpatient services$1,500 Access Fee then50%coinsurance forinpatient hospitalization,or 50%coinsurance forother inpatient services$300 penalty for failure to precertify.Office Visits0%coinsurance routineprenatal visits, 30%coinsurance otherservices50%coinsuranceCost sharing does not apply for preventive services.Depending on the type of services,copayment,coinsurance or deductible may apply. Maternitycare may include tests and services describedelsewhere in the SBC (i.e. ultrasound).If you are pregnantChildbirth/deliveryprofessional services30% coinsurance 50% coinsuranceCost sharing does not apply for preventive services.Depending on the type of services,copayment,coinsurance or deductible may apply. Maternitycare may include tests and services describedelsewhere in the SBC (i.e. ultrasound).Childbirth/delivery facilityservices30%coinsurance 50% coinsurance$300 penalty for failure to precertify.Home health care 30% coinsurance 50% coinsurance 100 days/year. $300 penalty for failure to precertify.

What You Will PayCommon Services You May NeedIn-Network Provider Out-of-Network ProviderLimitations, Exceptions, & Other ImportantMedical Event(You will pay the least) (You will pay the most)Information5 of 8If you need mentalhealth, behavioralhealth, or substanceabuse servicesOutpatient services$20/visit for primarycare/specialist visit,$40/visit for urgentcare, $500 copay/visitfor emergency roomservices, $1,500Access Fee then 30%coinsurance foroutpatient surgery, or30%coinsurance forother outpatientservices$500copay/visit foremergency roomservices, $1,500 AccessFee then 50%coinsurance for outpatientsurgery, or 50%coinsurance for otheroutpatient servicesMental health telemedicine services viaTeladoc® are available for $0 per consult.Inpatient services$1,500 Access Feethen 30%coinsurancefor inpatienthospitalization, or 30%coinsurance for otherinpatient services$1,500 Access Fee then50%coinsurance forinpatient hospitalization,or 50%coinsurance forother inpatient services$300 penalty for failure to precertify.Office Visits0%coinsurance routineprenatal visits, 30%coinsurance otherservices50%coinsuranceCost sharing does not apply for preventive services.Depending on the type of services,copayment,coinsurance or deductible may apply. Maternitycare may include tests and services describedelsewhere in the SBC (i.e. ultrasound).If you are pregnantChildbirth/deliveryprofessional services30% coinsurance 50% coinsuranceCost sharing does not apply for preventive services.Depending on the type of services,copayment,coinsurance or deductible may apply. Maternitycare may include tests and services describedelsewhere in the SBC (i.e. ultrasound).Childbirth/delivery facilityservices30%coinsurance 50% coinsurance$300 penalty for failure to precertify.Home health care 30% coinsurance 50% coinsurance 100 days/year. $300 penalty for failure to precertify.

What You Will PayCommon Services You May NeedIn-Network Provider Out-of-Network ProviderLimitations, Exceptions, & Other ImportantMedical Event(You will pay the least) (You will pay the most)Information6 of 8Rehabilitation services$20 copay/visit forSpeech, Occupationaland Physical therapy,30%coinsurance forother services.50%coinsurance60 visits/year. Inpatient rehabilitation: $300 penaltyfor failure to precertify.If you need helprecovering or haveother special healthneedsHabilitation services$20 copay/visit forSpeech, Occupationaland Physical therapy,30%coinsurance forother services.50%coinsurance60 visits/year. Inpatient habilitation: $300 penalty forfailure to precertify.Skilled nursing care 30% coinsurance 50% coinsurance 81 days/year. $300 penalty for failure to precertify.Durable medicalequipment30% coinsurance 50% coinsurance NoneHospice services 30% coinsurance 50% coinsurance6 months while covered under this plan. $300penalty for failure to precertify.If your child needsdental or eye careChildren’s eye examRoutine visionscreening: No charge.Other services,including routine eyeexam: Not covered.Not covered NoneChildren’s glasses Not covered Not coveredChildren’s dental check-up Not covered Not coveredExcluded Services & Other Covered Services:Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.)· Bariatric surgery · Cosmetic surgery · Dental care (Adult)· Hearing aids · Infertility treatment · Long-term care· Non-emergency care when traveling outside theU.S.· Routine eye care (Adult) · Routine foot care· Weight loss programs

What You Will PayCommon Services You May NeedIn-Network Provider Out-of-Network ProviderLimitations, Exceptions, & Other ImportantMedical Event(You will pay the least) (You will pay the most)Information6 of 8Rehabilitation services$20 copay/visit forSpeech, Occupationaland Physical therapy,30%coinsurance forother services.50%coinsurance60 visits/year. Inpatient rehabilitation: $300 penaltyfor failure to precertify.If you need helprecovering or haveother special healthneedsHabilitation services$20 copay/visit forSpeech, Occupationaland Physical therapy,30%coinsurance forother services.50%coinsurance60 visits/year. Inpatient habilitation: $300 penalty forfailure to precertify.Skilled nursing care 30% coinsurance 50% coinsurance 81 days/year. $300 penalty for failure to precertify.Durable medicalequipment30% coinsurance 50% coinsurance NoneHospice services 30% coinsurance 50% coinsurance6 months while covered under this plan. $300penalty for failure to precertify.If your child needsdental or eye careChildren’s eye examRoutine visionscreening: No charge.Other services,including routine eyeexam: Not covered.Not covered NoneChildren’s glasses Not covered Not coveredChildren’s dental check-up Not covered Not coveredExcluded Services & Other Covered Services:Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.)· Bariatric surgery · Cosmetic surgery · Dental care (Adult)· Hearing aids · Infertility treatment · Long-term care· Non-emergency care when traveling outside theU.S.· Routine eye care (Adult) · Routine foot care· Weight loss programs

7 of 8Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see yourplan document.)· Acupuncture (if prescribed for rehabilitationpurposes), 12 visits per plan year· Chiropractic care, 20 visits per plan year · Private-duty nursingYour Rights to Continue Coverage: There are agencies that can help if you want to continue your coverage after it ends. The contact information for thoseagencies is: U.S. Department of Labor, Employee Benefits Security Administration at 1-866-444-EBSA (3272) or www.dol.gov/ebsa/healthreform, or the U.S.Department of Health and Human Services, Center for Consumer Information and Insurance Oversight, at 1-877-267-2323 x61565 or www.cciio.cms.gov. Othercoverage options may be available to you too, including buying individual insurance coverage through theHealth Insurance Marketplace. For more information abouttheMarketplace, visit www.HealthCare.gov or call 1-800-318-2596.Your Grievance and Appeals Rights: There are agencies that can help if you have a complaint against your plan for a denial of a claim. This complaint is called agrievance or appeal. For more information about your rights, look at the explanation of benefits you will receive for that medical claim. Your plan documents alsoprovide complete information to submit aclaim, appeal, or a grievance for any reason to your plan. For more information about your rights, this notice, or assistance,contact: 1-800-522-1246, ext. 26300 or the U.S. Department of Labor’s Employee Benefits Security Administration at 1-866-444-EBSA (3272) orwww.dol.gov/ebsa/healthreform.Does this plan provide Minimum Essential Coverage? YesMinimum Essential Coverage generally includes plans, health insurance available through the Marketplace or other individual market policies, Medicare, Medicaid,CHIP, TRICARE, and certain other coverage. If you are eligible for certain types ofMinimum Essential Coverage, you may not be eligible for the premium tax credit.Does this plan meet the Minimum Value Standards? YesIf yourplan doesn’t meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace.Language Access Services:Spanish (Español): Para obtener asistencia en Español, llame al 1-800-522-1246, ext. 26300Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 1-800-522-1246, ext. 26300Chinese (中文): 如果需要中文的帮助，请拨打这个号码 1-800-522-1246, ext. 26300Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 1-800-522-1246, ext. 26300To see examples of how this plan might cover costs for a sample medical situation, see the next section.

7 of 8Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see yourplan document.)· Acupuncture (if prescribed for rehabilitationpurposes), 12 visits per plan year· Chiropractic care, 20 visits per plan year · Private-duty nursingYour Rights to Continue Coverage: There are agencies that can help if you want to continue your coverage after it ends. The contact information for thoseagencies is: U.S. Department of Labor, Employee Benefits Security Administration at 1-866-444-EBSA (3272) or www.dol.gov/ebsa/healthreform, or the U.S.Department of Health and Human Services, Center for Consumer Information and Insurance Oversight, at 1-877-267-2323 x61565 or www.cciio.cms.gov. Othercoverage options may be available to you too, including buying individual insurance coverage through theHealth Insurance Marketplace. For more information abouttheMarketplace, visit www.HealthCare.gov or call 1-800-318-2596.Your Grievance and Appeals Rights: There are agencies that can help if you have a complaint against your plan for a denial of a claim. This complaint is called agrievance or appeal. For more information about your rights, look at the explanation of benefits you will receive for that medical claim. Your plan documents alsoprovide complete information to submit aclaim, appeal, or a grievance for any reason to your plan. For more information about your rights, this notice, or assistance,contact: 1-800-522-1246, ext. 26300 or the U.S. Department of Labor’s Employee Benefits Security Administration at 1-866-444-EBSA (3272) orwww.dol.gov/ebsa/healthreform.Does this plan provide Minimum Essential Coverage? YesMinimum Essential Coverage generally includes plans, health insurance available through the Marketplace or other individual market policies, Medicare, Medicaid,CHIP, TRICARE, and certain other coverage. If you are eligible for certain types ofMinimum Essential Coverage, you may not be eligible for the premium tax credit.Does this plan meet the Minimum Value Standards? YesIf yourplan doesn’t meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace.Language Access Services:Spanish (Español): Para obtener asistencia en Español, llame al 1-800-522-1246, ext. 26300Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 1-800-522-1246, ext. 26300Chinese (中文): 如果需要中文的帮助，请拨打这个号码 1-800-522-1246, ext. 26300Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 1-800-522-1246, ext. 26300To see examples of how this plan might cover costs for a sample medical situation, see the next section.

The plan would be responsible for the other costs of these EXAMPLE covered services.8 of 8About these Coverage Examples:This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be differentdepending on the actual care you receive, the prices yourproviders charge, and many other factors. Focus on the cost sharing amounts(deductibles, copayments and coinsurance) and excluded services under the plan. Use this information to compare the portion of costs you mightpay under different healthplans. Please note these coverage examples are based on self-only coverage.Peg is Having a Baby(9 months of in-network pre-natalcare and a hospital delivery)Managing Joe’s type 2 Diabetes(a year of routine in-network care of awell-controlled condition)Mia’s Simple Fracture(in-network emergency room visit andfollow up care)n The plan’s overall deductible$2,000n The plan’s overall deductible$2,000n The plan’s overall deductible$2,000n Specialist copay$20n Specialist copay$20n Specialist copay$20n Hospital (facility) coinsurance30%n Hospital (facility) coinsurance30%n Hospital (facility) coinsurance30%n Other coinsurance30%n Other coinsurance30%n Other coinsurance30%This EXAMPLE event includes services like: This EXAMPLE event includes services like: This EXAMPLE event includes services like:Specialist office visits (prenatal care) Primary care physician office visits (including Emergency room care (including medicalChildbirth/Delivery Professional Services disease education) supplies)Childbirth/Delivery Facility ServicesDiagnostic tests (blood work) Diagnostic test (x-ray)Diagnostic tests (ultrasounds and blood work)Prescription drugsDurable medical equipment (crutches)Specialist visit (anesthesia) Durable medical equipment (glucose meter) Rehabilitation services (physical therapy)Total Example Cost $12,700 Total Example Cost $5,600 Total Example Cost $2,800In this example, Peg would pay: In this example, Joe would pay: In this example, Mia would pay:Cost Sharing Cost Sharing Cost SharingDeductibles $3,500 Deductibles $100 Deductibles $1,400Copayments $0 Copayments $1,500 Copayments $600Coinsurance $500 Coinsurance $0 Coinsurance $0What isn’t covered What isn’t covered What isn’t coveredLimits or exclusions $50 Limits or exclusions $500 Limits or exclusions $0The total Peg would pay is $4,050 The total Joe would pay is $2,100 The total Mia would pay is $2,000

The plan would be responsible for the other costs of these EXAMPLE covered services.8 of 8About these Coverage Examples:This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be differentdepending on the actual care you receive, the prices yourproviders charge, and many other factors. Focus on the cost sharing amounts(deductibles, copayments and coinsurance) and excluded services under the plan. Use this information to compare the portion of costs you mightpay under different healthplans. Please note these coverage examples are based on self-only coverage.Peg is Having a Baby(9 months of in-network pre-natalcare and a hospital delivery)Managing Joe’s type 2 Diabetes(a year of routine in-network care of awell-controlled condition)Mia’s Simple Fracture(in-network emergency room visit andfollow up care)n The plan’s overall deductible$2,000n The plan’s overall deductible$2,000n The plan’s overall deductible$2,000n Specialist copay$20n Specialist copay$20n Specialist copay$20n Hospital (facility) coinsurance30%n Hospital (facility) coinsurance30%n Hospital (facility) coinsurance30%n Other coinsurance30%n Other coinsurance30%n Other coinsurance30%This EXAMPLE event includes services like: This EXAMPLE event includes services like: This EXAMPLE event includes services like:Specialist office visits (prenatal care) Primary care physician office visits (including Emergency room care (including medicalChildbirth/Delivery Professional Services disease education) supplies)Childbirth/Delivery Facility ServicesDiagnostic tests (blood work) Diagnostic test (x-ray)Diagnostic tests (ultrasounds and blood work)Prescription drugsDurable medical equipment (crutches)Specialist visit (anesthesia) Durable medical equipment (glucose meter) Rehabilitation services (physical therapy)Total Example Cost $12,700 Total Example Cost $5,600 Total Example Cost $2,800In this example, Peg would pay: In this example, Joe would pay: In this example, Mia would pay:Cost Sharing Cost Sharing Cost SharingDeductibles $3,500 Deductibles $100 Deductibles $1,400Copayments $0 Copayments $1,500 Copayments $600Coinsurance $500 Coinsurance $0 Coinsurance $0What isn’t covered What isn’t covered What isn’t coveredLimits or exclusions $50 Limits or exclusions $500 Limits or exclusions $0The total Peg would pay is $4,050 The total Joe would pay is $2,100 The total Mia would pay is $2,000

Liriano Motors LLC dba Lost Pines ToyotaDental and Vision Plan ElectionsEffective 12/01/2024UnitedHealthcare Dental Coverage - 1X750Employee OnlyEmployee / SpouseEmployee / Child(ren)FamilyUnitedHealthcare Vision Coverage - S109VEmployee OnlyEmployee / SpouseEmployee / Child(ren)FamilyEmployee Cost Semi-MonthlyEmployee Cost Semi-Monthly$14.22$28.44$34.79$51.76Employee Cost Bi-Weekly$10.61$7.11$6.75$3.55Employee Cost Bi-Weekly$32.11$47.77$13.12$26.25$3.85$7.70$7.32$11.50

Liriano Motors LLC dba Lost Pines ToyotaDental and Vision Plan ElectionsEffective 12/01/2024UnitedHealthcare Dental Coverage - 1X750Employee OnlyEmployee / SpouseEmployee / Child(ren)FamilyUnitedHealthcare Vision Coverage - S109VEmployee OnlyEmployee / SpouseEmployee / Child(ren)FamilyEmployee Cost Semi-MonthlyEmployee Cost Semi-Monthly$14.22$28.44$34.79$51.76Employee Cost Bi-Weekly$10.61$7.11$6.75$3.55Employee Cost Bi-Weekly$32.11$47.77$13.12$26.25$3.85$7.70$7.32$11.50

UnitedHealthcare® FlexAppeal Enhanced dental plan1X750 /MACVoluntary National Options PPO 20 Network/covered dental servicesNETWORKNON-NETWORKIndividual Annual Deductible$50$50Family Annual Deductible$150 $150Annual Maximum Benefit (The total benefit payable by the plan will not exceed the highest listed maximum amount for either Network or Non-Network services.)$5000 per person per Calendar Year$5000 per person per Calendar YearNoAnnual Deductible Applies to Preventive and Diagnostic ServicesWaiting PeriodNo waiting periodCOVERED SERVICES*NETWORK PLAN PAYS**BENEFIT GUIDELINESNON-NETWORKPLAN PAYS***PREVENTIVE & DIAGNOSTIC SERVICES 100% 100%Periodic Oral Evaluation Limited to 2 times per consecutive 12 months. 100% 100%Radiographs - Bitewing Bitewing: Limited to 1 series of films per calendar year. Complete/Panorex: Limited to 1 time per consecutive 36 months. Dental Prophylaxis (Cleanings) 100% 100%Benefit is not to exceed in combination with periodontal maintenance 4 per consecutive 12 months.Fluoride TreatmentsLimited to covered persons under the age of 16 years and limited to 2 times per consecutive 12 months. 100% 100%Sealants 100% 100%Limited to covered persons under the age of 16 years and once per first or second permanent molar every consecutive 36 months.BASIC DENTAL SERVICESRadiographs - Intraoral/Extraoral 80% 80%Limited to 2 films per calendar year.Lab and Other Diagnostic Tests 80% 80%Space Maintainers 80% 80%For covered persons under the age of 16 years, limit 1 per consecutive 60 months. 80% 80%Multiple restorations on one surface will be treated as a single filling.Restorations; Amalgam or Composite (Anterior & Posterior) 80% 80%General Services - Emergency TreatmentCovered as a separate benefit only if no other service was done during the visit other than X-rays.Simple ExtractionsLimited to 1 time per tooth per lifetime. 80% 80%Oral Surgery - Brush Biopsy 80% 80%Endodontics - Pulpotomy 80% 80%Root Canal Therapy: Limited to 1 time per tooth per lifetime.Periodontal Maintenance 80% 80%Benefit is not to exceed in combination with dental prophylaxis 4 per consecutive 12 months.MAJOR DENTAL SERVICESGeneral Services - Occlusal Guards 50% 50%Limited to 1 guard every consecutive 36 months.General Services - Anesthesia 50% 50%When clinically necessary.Oral Surgery - Surgical Extractions 50% 50%Oral Surgery - Partial/Bony 50% 50%Oral Surgery - Other 50% 50%Endodontics - Other 50% 50%Periodontics - Non Surgical 50% 50%Scaling and Root Planing: Limited to 1 time per quadrant per consecutive 24 months.Periodontics - Surgical 50% 50%Limited to 1 quadrant or site per consecutive 36 months per surgical area.Periodontics - Osseous Surgery 50% 50%Limited to 1 quadrant or site per consecutive 36 months per surgical area. 50% 50%Inlays/Onlays/Crowns*Limited to 1 time per tooth per consecutive 60 months.Dentures and other Removable Prosthetics 50% 50%Full Denture/Partial Denture: Limited to 1 per consecutive 60 months. No additionalallowances for precision or semi-precision attachments.Fixed Partial Dentures (Bridges)* 50% 50%Limited to 1 time per tooth per consecutive 60 months.Implant Services 50% 50%Limited to 1 time per tooth per consecutive 60 months.* Your dental plan provides that where two or more professionally acceptable dental treatments for a dental condition exist, your plan bases reimbursement on the least costly treatment alternative. If you and your dentist have agreed on a treatment which is more costly than the treatment on which the plan benefit is based, you will be responsible for the difference between the fee for service rendered and the fee covered by the plan. In addition, a pre-treatment estimate is recommended for any service estimated to cost over $500; please consult your dentist.** The network percentage of benefits is based on the discounted fee negotiated with the provider.*** The non-network percentage of benefits is based on the allowable amount applicable for the same service that would have been rendered by a network provider.In accordance with the Illinois state requirement, a partner in a Civil Union is included in the definition of Dependent. For a complete description of Dependent Coverage, please refer to your Certificate of Coverage.The Prenatal Dental Care (not available in WA) and Oral Cancer Screening programs are covered under this plan. The material contained in the above table is for informational purposes only and is not an offer of coverage. Please note that the above provides only a brief, general description of coverage and does not constitute a contract. For a complete listing of your coverage, including exclusions and limitations relating to your coverage, please refer to your Certificate of Coverage or contact your benefits administrator. If differences exist between this Summary Benefits and your Certificate of Coverage/benefits administrator, the Certificate/benefits administrator will govern. All terms and conditions of coverage are subject to applicable state and federal laws. State mandates regarding benefit levels and age limitations may supersede plan design features.UnitedHealthcare Dental® Voluntary Options PPO Plan is either underwritten or provided by: UnitedHealthcare Insurance Company, Hartford, Connecticut; UnitedHealthcare Insurance Company of New York, Hauppage, New York; Unimerica Insurance Company, Milwaukee, Wisconsin; Unimerica Life Insurance Company of New York, New York, New York; or United Healthcare Services, Inc.100-17648 10/16©2016-2017 United HealthCare Services, Inc. NCA-01A (v1.2)

UnitedHealthcare® FlexAppeal Enhanced dental plan1X750 /MACVoluntary National Options PPO 20 Network/covered dental servicesNETWORKNON-NETWORKIndividual Annual Deductible$50$50Family Annual Deductible$150 $150Annual Maximum Benefit (The total benefit payable by the plan will not exceed the highest listed maximum amount for either Network or Non-Network services.)$5000 per person per Calendar Year$5000 per person per Calendar YearNoAnnual Deductible Applies to Preventive and Diagnostic ServicesWaiting PeriodNo waiting periodCOVERED SERVICES*NETWORK PLAN PAYS**BENEFIT GUIDELINESNON-NETWORKPLAN PAYS***PREVENTIVE & DIAGNOSTIC SERVICES 100% 100%Periodic Oral Evaluation Limited to 2 times per consecutive 12 months. 100% 100%Radiographs - Bitewing Bitewing: Limited to 1 series of films per calendar year. Complete/Panorex: Limited to 1 time per consecutive 36 months. Dental Prophylaxis (Cleanings) 100% 100%Benefit is not to exceed in combination with periodontal maintenance 4 per consecutive 12 months.Fluoride TreatmentsLimited to covered persons under the age of 16 years and limited to 2 times per consecutive 12 months. 100% 100%Sealants 100% 100%Limited to covered persons under the age of 16 years and once per first or second permanent molar every consecutive 36 months.BASIC DENTAL SERVICESRadiographs - Intraoral/Extraoral 80% 80%Limited to 2 films per calendar year.Lab and Other Diagnostic Tests 80% 80%Space Maintainers 80% 80%For covered persons under the age of 16 years, limit 1 per consecutive 60 months. 80% 80%Multiple restorations on one surface will be treated as a single filling.Restorations; Amalgam or Composite (Anterior & Posterior) 80% 80%General Services - Emergency TreatmentCovered as a separate benefit only if no other service was done during the visit other than X-rays.Simple ExtractionsLimited to 1 time per tooth per lifetime. 80% 80%Oral Surgery - Brush Biopsy 80% 80%Endodontics - Pulpotomy 80% 80%Root Canal Therapy: Limited to 1 time per tooth per lifetime.Periodontal Maintenance 80% 80%Benefit is not to exceed in combination with dental prophylaxis 4 per consecutive 12 months.MAJOR DENTAL SERVICESGeneral Services - Occlusal Guards 50% 50%Limited to 1 guard every consecutive 36 months.General Services - Anesthesia 50% 50%When clinically necessary.Oral Surgery - Surgical Extractions 50% 50%Oral Surgery - Partial/Bony 50% 50%Oral Surgery - Other 50% 50%Endodontics - Other 50% 50%Periodontics - Non Surgical 50% 50%Scaling and Root Planing: Limited to 1 time per quadrant per consecutive 24 months.Periodontics - Surgical 50% 50%Limited to 1 quadrant or site per consecutive 36 months per surgical area.Periodontics - Osseous Surgery 50% 50%Limited to 1 quadrant or site per consecutive 36 months per surgical area. 50% 50%Inlays/Onlays/Crowns*Limited to 1 time per tooth per consecutive 60 months.Dentures and other Removable Prosthetics 50% 50%Full Denture/Partial Denture: Limited to 1 per consecutive 60 months. No additionalallowances for precision or semi-precision attachments.Fixed Partial Dentures (Bridges)* 50% 50%Limited to 1 time per tooth per consecutive 60 months.Implant Services 50% 50%Limited to 1 time per tooth per consecutive 60 months.* Your dental plan provides that where two or more professionally acceptable dental treatments for a dental condition exist, your plan bases reimbursement on the least costly treatment alternative. If you and your dentist have agreed on a treatment which is more costly than the treatment on which the plan benefit is based, you will be responsible for the difference between the fee for service rendered and the fee covered by the plan. In addition, a pre-treatment estimate is recommended for any service estimated to cost over $500; please consult your dentist.** The network percentage of benefits is based on the discounted fee negotiated with the provider.*** The non-network percentage of benefits is based on the allowable amount applicable for the same service that would have been rendered by a network provider.In accordance with the Illinois state requirement, a partner in a Civil Union is included in the definition of Dependent. For a complete description of Dependent Coverage, please refer to your Certificate of Coverage.The Prenatal Dental Care (not available in WA) and Oral Cancer Screening programs are covered under this plan. The material contained in the above table is for informational purposes only and is not an offer of coverage. Please note that the above provides only a brief, general description of coverage and does not constitute a contract. For a complete listing of your coverage, including exclusions and limitations relating to your coverage, please refer to your Certificate of Coverage or contact your benefits administrator. If differences exist between this Summary Benefits and your Certificate of Coverage/benefits administrator, the Certificate/benefits administrator will govern. All terms and conditions of coverage are subject to applicable state and federal laws. State mandates regarding benefit levels and age limitations may supersede plan design features.UnitedHealthcare Dental® Voluntary Options PPO Plan is either underwritten or provided by: UnitedHealthcare Insurance Company, Hartford, Connecticut; UnitedHealthcare Insurance Company of New York, Hauppage, New York; Unimerica Insurance Company, Milwaukee, Wisconsin; Unimerica Life Insurance Company of New York, New York, New York; or United Healthcare Services, Inc.100-17648 10/16©2016-2017 United HealthCare Services, Inc. NCA-01A (v1.2)

UnitedHealthcare/dental exclusions and limitationsDental Services described in this section are covered when such services are:A. Necessary;B. Provided by or under the direction of a Dentist or other appropriate provider as specifically described;C. The least costly, clinically accepted treatment; andD. Not excluded as described in the Section entitled, General Exclusions.GENERAL LIMITATIONS1. PERIODIC ORAL EVALUATION Limited to 2 times per consecutive 12 months.2. COMPLETE SERIES OR PANOREX RADIOGRAPHS Limited to 1 time per consecutive 36 months.3. BITEWING RADIOGRAPHS Limited to 1 series of films per calendar year.4. EXTRAORAL RADIOGRAPHS Limited to 2 films per calendar year.5. DENTAL PROPHYLAXIS Is Covered in combination with periodontal maintenance but not on the same date of service, benefit is not to exceed in combination with periodontal maintenance 4 per consecutive 12 months.6. FLUORIDE TREATMENTS Limited to covered persons under the age of 16 years, and limited to 2 times per consecutive 12 months.7. SPACE MAINTAINERS Limited to covered persons under the age of 16 years, limited to 1 per consecutive 60 months. Benefit includes all adjustments within 6 months of installation.8. SEALANTS Limited to covered persons under the age of 16 years, and once per first or second permanent molar every consecutive 36 months.9. RESTORATIONS (Amalgam or Composite) Multiple restorations on one surface will be treated as a single filling.10. PIN RETENTION Limited to 2 pins per tooth; not covered in addition to cast restoration.11. INLAYS AND ONLAYS Limited to 1 time per tooth per consecutive 60 months. Covered only when a filling cannot restore the tooth.12. CROWNS Limited to 1 time per tooth per consecutive 60 months. Covered only when a filling cannot restore the tooth.13. POST AND CORES Covered only for teeth that have had root canal therapy.14. SEDATIVE FILLINGS Covered as a separate benefit only if no other service, other than x-rays and exam, were performed on the same tooth during the visit.15. SCALING AND ROOT PLANING Limited to 1 time per quadrant per consecutive 24 months.16. ROOT CANAL THERAPY Limited to 1 time per tooth per lifetime.17. PERIODONTAL MAINTENANCE Is covered in combination with dental prophylaxis but not on the same date of service, benefit is not to exceed in combination with dental prophylaxis 4 per consecutive 12 months.18. FULL DENTURES Limited to 1 time every consecutive 60 months. No additional allowances for precision or semi-precision attachments.19. PARTIAL DENTURES Limited to 1 time every consecutive 60 months. No additional allowances for precision or semi-precision attachments.20. RELINING AND REBASING DENTURES Limited to relining/rebasing performed more than 6 months after the initial insertion. Limited to 1 time per consecutive 12 months.21. REPAIRS TO FULL DENTURES, PARTIAL DENTURES, BRIDGES Limited to repairs or adjustments performed more than 12 months after the initial insertion. Limited to 1 per consecutive 6 months.22. PALLIATIVE TREATMENT Covered as a separate benefit only if no other service, other than the exam and radiographs, were performed on the same tooth during the visit.23. OCCLUSAL GUARDS Limited to 1 guard every consecutive 36 months and only covered if prescribed to control habitual grinding.24. FULL MOUTH DEBRIDEMENT Limited to 1 time every consecutive 36 months.25. GENERAL ANESTHESIA Covered only when clinically necessary.26. OSSEOUS GRAFTS Limited to 1 per quadrant or site per consecutive 36 months.27. PERIODONTAL SURGERY Hard tissue and soft tissue periodontal surgery are limited to 1 quadrant or site per consecutive 36 months per surgical area.28. REPLACEMENT OF COMPLETE DENTURES, FIXED OR REMOVABLE PARTIAL DENTURES, CROWNS, INLAYS OR ONLAYS AND IMPLANTS, IMPLANT CROWNS, IMPLANT PROTHESIS Replacement of complete dentures, fixed or removable partial dentures, crowns, inlays or onlays previously submitted for payment under the plan is limited to 1 time per consecutive 60 months from initial or supplemental placement. This includes retainers, habit appliances, and any fixed or removable interceptive orthodontic appliances. GENERAL EXCLUSIONS1. Dental Services that are not Necessary.2. Hospitalization or other facility charges.3. Any Dental Procedure performed solely for cosmetic/aesthetic reasons. (Cosmetic procedures are those procedures that improve physical appearance.)4.Reconstructive surgery, regardless of whether or not the surgery is incidental to a dental disease, injury, or Congenital Anomaly, when the primary purpose is to improve physiological functioning of the involved part of the body.5. Any Dental Procedure not directly associated with dental disease.6. Any Dental Procedure not performed in a dental setting.7.Procedures that are considered to be Experimental, Investigational or Unproven. This includes pharmacological regimens not accepted by the American Dental Association (ADA) Council on Dental Therapeutics. The fact that an Experimental, Investigational or Unproven Service, treatment, device or pharmacological regimen is the only available treatment for a particular condition will not result in Coverage if the procedure is considered to be Experimental, Investigational or Unproven in the treatment of that particular condition.8. Any implant procedures performed which are not listed as Covered implant procedures in the Schedule of Covered Dental Services.9. Drugs/medications, obtainable with or without a prescription, unless they are dispensed and utilized in the dental office during the patient visit.10.Services for injuries or conditions covered by Worker's Compensation or employer liability laws, and services that are provided without cost to the Covered Person by any municipality, county, or other political subdivision. This exclusion does not apply to any services covered by Medicaid or Medicare.11. Setting of facial bony fractures and any treatment associated with the dislocation of facial skeletal hard tissue.12. Treatment of benign neoplasms, cysts, or other pathology involving benign lesions, except excisional removal. Treatment of malignant neoplasms or Congenital Anomalies of hard or soft tissue, including excision.13. Replacement of complete dentures, fixed and removable partial dentures or crowns if damage or breakage was directly related to provider error. This type of replacement is the responsibility of the Dentist. If replacement is Necessary because of patient non-compliance, the patient is liable for the cost of replacement.14. Services related to the temporomandibular joint (TMJ), either bilateral or unilateral. Upper and lower jaw bone surgery (including that related to the temporomandibular joint). No Coverage is provided for orthognathic surgery, jaw alignment, or treatment for the temporomandibular joint.15. Charges for failure to keep a scheduled appointment without giving the dental office 24 hours notice.16. Expenses for Dental Procedures begun prior to the Covered Person becoming enrolled under the Policy.17. Fixed or removable prosthodontic restoration procedures for complete oral rehabilitation or reconstruction.18.Attachments to conventional removable prostheses or fixed bridgework. This includes semi-precision or precision attachments associated with partial dentures, crown or bridge abutments, full or partial overdentures, any internal attachment associated with an implant prosthesis, and any elective endodontic procedure related to a tooth or root involved in the construction of a prosthesis of this nature.19. Procedures related to the reconstruction of a patient's correct vertical dimension of occlusion (VDO).100-17648 10/16©2016-2017 United HealthCare Services, Inc. NCA-01A (v1.2)

UnitedHealthcare/dental exclusions and limitationsDental Services described in this section are covered when such services are:A. Necessary;B. Provided by or under the direction of a Dentist or other appropriate provider as specifically described;C. The least costly, clinically accepted treatment; andD. Not excluded as described in the Section entitled, General Exclusions.GENERAL LIMITATIONS1. PERIODIC ORAL EVALUATION Limited to 2 times per consecutive 12 months.2. COMPLETE SERIES OR PANOREX RADIOGRAPHS Limited to 1 time per consecutive 36 months.3. BITEWING RADIOGRAPHS Limited to 1 series of films per calendar year.4. EXTRAORAL RADIOGRAPHS Limited to 2 films per calendar year.5. DENTAL PROPHYLAXIS Is Covered in combination with periodontal maintenance but not on the same date of service, benefit is not to exceed in combination with periodontal maintenance 4 per consecutive 12 months.6. FLUORIDE TREATMENTS Limited to covered persons under the age of 16 years, and limited to 2 times per consecutive 12 months.7. SPACE MAINTAINERS Limited to covered persons under the age of 16 years, limited to 1 per consecutive 60 months. Benefit includes all adjustments within 6 months of installation.8. SEALANTS Limited to covered persons under the age of 16 years, and once per first or second permanent molar every consecutive 36 months.9. RESTORATIONS (Amalgam or Composite) Multiple restorations on one surface will be treated as a single filling.10. PIN RETENTION Limited to 2 pins per tooth; not covered in addition to cast restoration.11. INLAYS AND ONLAYS Limited to 1 time per tooth per consecutive 60 months. Covered only when a filling cannot restore the tooth.12. CROWNS Limited to 1 time per tooth per consecutive 60 months. Covered only when a filling cannot restore the tooth.13. POST AND CORES Covered only for teeth that have had root canal therapy.14. SEDATIVE FILLINGS Covered as a separate benefit only if no other service, other than x-rays and exam, were performed on the same tooth during the visit.15. SCALING AND ROOT PLANING Limited to 1 time per quadrant per consecutive 24 months.16. ROOT CANAL THERAPY Limited to 1 time per tooth per lifetime.17. PERIODONTAL MAINTENANCE Is covered in combination with dental prophylaxis but not on the same date of service, benefit is not to exceed in combination with dental prophylaxis 4 per consecutive 12 months.18. FULL DENTURES Limited to 1 time every consecutive 60 months. No additional allowances for precision or semi-precision attachments.19. PARTIAL DENTURES Limited to 1 time every consecutive 60 months. No additional allowances for precision or semi-precision attachments.20. RELINING AND REBASING DENTURES Limited to relining/rebasing performed more than 6 months after the initial insertion. Limited to 1 time per consecutive 12 months.21. REPAIRS TO FULL DENTURES, PARTIAL DENTURES, BRIDGES Limited to repairs or adjustments performed more than 12 months after the initial insertion. Limited to 1 per consecutive 6 months.22. PALLIATIVE TREATMENT Covered as a separate benefit only if no other service, other than the exam and radiographs, were performed on the same tooth during the visit.23. OCCLUSAL GUARDS Limited to 1 guard every consecutive 36 months and only covered if prescribed to control habitual grinding.24. FULL MOUTH DEBRIDEMENT Limited to 1 time every consecutive 36 months.25. GENERAL ANESTHESIA Covered only when clinically necessary.26. OSSEOUS GRAFTS Limited to 1 per quadrant or site per consecutive 36 months.27. PERIODONTAL SURGERY Hard tissue and soft tissue periodontal surgery are limited to 1 quadrant or site per consecutive 36 months per surgical area.28. REPLACEMENT OF COMPLETE DENTURES, FIXED OR REMOVABLE PARTIAL DENTURES, CROWNS, INLAYS OR ONLAYS AND IMPLANTS, IMPLANT CROWNS, IMPLANT PROTHESIS Replacement of complete dentures, fixed or removable partial dentures, crowns, inlays or onlays previously submitted for payment under the plan is limited to 1 time per consecutive 60 months from initial or supplemental placement. This includes retainers, habit appliances, and any fixed or removable interceptive orthodontic appliances. GENERAL EXCLUSIONS1. Dental Services that are not Necessary.2. Hospitalization or other facility charges.3. Any Dental Procedure performed solely for cosmetic/aesthetic reasons. (Cosmetic procedures are those procedures that improve physical appearance.)4.Reconstructive surgery, regardless of whether or not the surgery is incidental to a dental disease, injury, or Congenital Anomaly, when the primary purpose is to improve physiological functioning of the involved part of the body.5. Any Dental Procedure not directly associated with dental disease.6. Any Dental Procedure not performed in a dental setting.7.Procedures that are considered to be Experimental, Investigational or Unproven. This includes pharmacological regimens not accepted by the American Dental Association (ADA) Council on Dental Therapeutics. The fact that an Experimental, Investigational or Unproven Service, treatment, device or pharmacological regimen is the only available treatment for a particular condition will not result in Coverage if the procedure is considered to be Experimental, Investigational or Unproven in the treatment of that particular condition.8. Any implant procedures performed which are not listed as Covered implant procedures in the Schedule of Covered Dental Services.9. Drugs/medications, obtainable with or without a prescription, unless they are dispensed and utilized in the dental office during the patient visit.10.Services for injuries or conditions covered by Worker's Compensation or employer liability laws, and services that are provided without cost to the Covered Person by any municipality, county, or other political subdivision. This exclusion does not apply to any services covered by Medicaid or Medicare.11. Setting of facial bony fractures and any treatment associated with the dislocation of facial skeletal hard tissue.12. Treatment of benign neoplasms, cysts, or other pathology involving benign lesions, except excisional removal. Treatment of malignant neoplasms or Congenital Anomalies of hard or soft tissue, including excision.13. Replacement of complete dentures, fixed and removable partial dentures or crowns if damage or breakage was directly related to provider error. This type of replacement is the responsibility of the Dentist. If replacement is Necessary because of patient non-compliance, the patient is liable for the cost of replacement.14. Services related to the temporomandibular joint (TMJ), either bilateral or unilateral. Upper and lower jaw bone surgery (including that related to the temporomandibular joint). No Coverage is provided for orthognathic surgery, jaw alignment, or treatment for the temporomandibular joint.15. Charges for failure to keep a scheduled appointment without giving the dental office 24 hours notice.16. Expenses for Dental Procedures begun prior to the Covered Person becoming enrolled under the Policy.17. Fixed or removable prosthodontic restoration procedures for complete oral rehabilitation or reconstruction.18.Attachments to conventional removable prostheses or fixed bridgework. This includes semi-precision or precision attachments associated with partial dentures, crown or bridge abutments, full or partial overdentures, any internal attachment associated with an implant prosthesis, and any elective endodontic procedure related to a tooth or root involved in the construction of a prosthesis of this nature.19. Procedures related to the reconstruction of a patient's correct vertical dimension of occlusion (VDO).100-17648 10/16©2016-2017 United HealthCare Services, Inc. NCA-01A (v1.2)

GENERAL EXCLUSIONS20.Replacement of crowns, bridges, and fixed or removable prosthetic appliances inserted prior to plan Coverage unless the patient has been Covered under the Policy for 12 continuous months. If loss of a tooth requires the addition of a clasp, pontic, and/or abutment(s) within this 12 period, the plan is responsible only for the procedures associated with the addition.21. Replacement of missing natural teeth lost prior to the onset of plan Coverage until the patient has been Covered under the Policy for 12 continuous months.22. Occlusal guards used as safety items or to affect performance primarily in sports-related activities.23. Placement of fixed partial dentures solely for the purpose of achieving periodontal stability.24. Services rendered by a provider with the same legal residence as a Covered Person or who is a member of a Covered Person's family, including spouse, brother, sister, parent or child.25. Dental Services otherwise Covered under the Policy, but rendered after the date individual Coverage under the Policy terminates, including Dental Services for dental conditions arising prior to the date individual Coverage under the Policy terminates.26. Acupuncture; acupressure and other forms of alternative treatment, whether or not used as anesthesia.27. Orthodontic Services.28. Foreign Services are not Covered unless required as an Emergency.29. Dental Services received as a result of war or any act of war, whether declared or undeclared or caused during service in the armed forces of any country.30. Any Dental Services or Procedures not listed in the Schedule of Covered Dental Services.100-17648 10/16©2016-2017 United HealthCare Services, Inc. NCA-01A (v1.2)

GENERAL EXCLUSIONS20.Replacement of crowns, bridges, and fixed or removable prosthetic appliances inserted prior to plan Coverage unless the patient has been Covered under the Policy for 12 continuous months. If loss of a tooth requires the addition of a clasp, pontic, and/or abutment(s) within this 12 period, the plan is responsible only for the procedures associated with the addition.21. Replacement of missing natural teeth lost prior to the onset of plan Coverage until the patient has been Covered under the Policy for 12 continuous months.22. Occlusal guards used as safety items or to affect performance primarily in sports-related activities.23. Placement of fixed partial dentures solely for the purpose of achieving periodontal stability.24. Services rendered by a provider with the same legal residence as a Covered Person or who is a member of a Covered Person's family, including spouse, brother, sister, parent or child.25. Dental Services otherwise Covered under the Policy, but rendered after the date individual Coverage under the Policy terminates, including Dental Services for dental conditions arising prior to the date individual Coverage under the Policy terminates.26. Acupuncture; acupressure and other forms of alternative treatment, whether or not used as anesthesia.27. Orthodontic Services.28. Foreign Services are not Covered unless required as an Emergency.29. Dental Services received as a result of war or any act of war, whether declared or undeclared or caused during service in the armed forces of any country.30. Any Dental Services or Procedures not listed in the Schedule of Covered Dental Services.100-17648 10/16©2016-2017 United HealthCare Services, Inc. NCA-01A (v1.2)

Vision Benefit SummaryCustomer Service and Provider Locator: (800) 638-3120myuhcvision.comUnitedHealthcare 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.Plan S109VPowered by Spectera Eyecare NetworksExam with MaterialsBenefit FrequencyComprehensive Exam(s)Once every 12 monthsComprehensive Exam(s) for diabetics onlyTwice every 12 monthsEyeglass Lenses Once every 12 monthsFramesOnce every 24 monthsContact Lenses instead of Eyeglasses Once every 12 monthsIn-Network ServicesCopaysExam(s)$ 10.00Eyeglasses (lenses and frame) $ 25.00Contact lenses instead of Eyeglasses$ 25.00Retinal Screening for Diabetics $ 0.00Frame Benefit (for frames that exceed the allowance, an additional 30% discount may be applied to the overage)¹Private Practice Provider$130.00 retail frame allowanceRetail Chain Provider$130.00 retail frame allowanceLens OptionsStandard Scratch-resistant Coating,Polycarbonate Lenses for Dependent Children (up to age 19) - covered in full.Contact Lens Benefit²Elective contact lensesAllowance is applied toward the purchase of contact lenses. Contact lens copay is waived. $125.00Elective contact lens fitting and evaluationAllowance is applied toward the contact lens fitting/evaluation fees.$30.00 {@Bullet} Necessary contact lens 3Necessary contact lenses Covered in full after copay (if applicable).Children's and Maternity Eye Care BenefitMembers 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 $40.00FramesUp to $45.00Single Vision LensesUp to $40.00Lined Bifocal and Progressive LensesUp to $60.00Lined Trifocal LensesUp to $80.00Lenticular LensesUp to $80.00Elective Contacts instead of Eyeglasses²Up to $100.00Contact Lens Fitting and EvaluationUp to $0.00{@Bullet} Necessary conta 3Necessary Contacts instead of EyeglassesUp to $210.00

Vision Benefit SummaryCustomer Service and Provider Locator: (800) 638-3120myuhcvision.comUnitedHealthcare 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.Plan S109VPowered by Spectera Eyecare NetworksExam with MaterialsBenefit FrequencyComprehensive Exam(s)Once every 12 monthsComprehensive Exam(s) for diabetics onlyTwice every 12 monthsEyeglass Lenses Once every 12 monthsFramesOnce every 24 monthsContact Lenses instead of Eyeglasses Once every 12 monthsIn-Network ServicesCopaysExam(s)$ 10.00Eyeglasses (lenses and frame) $ 25.00Contact lenses instead of Eyeglasses$ 25.00Retinal Screening for Diabetics $ 0.00Frame Benefit (for frames that exceed the allowance, an additional 30% discount may be applied to the overage)¹Private Practice Provider$130.00 retail frame allowanceRetail Chain Provider$130.00 retail frame allowanceLens OptionsStandard Scratch-resistant Coating,Polycarbonate Lenses for Dependent Children (up to age 19) - covered in full.Contact Lens Benefit²Elective contact lensesAllowance is applied toward the purchase of contact lenses. Contact lens copay is waived. $125.00Elective contact lens fitting and evaluationAllowance is applied toward the contact lens fitting/evaluation fees.$30.00 {@Bullet} Necessary contact lens 3Necessary contact lenses Covered in full after copay (if applicable).Children's and Maternity Eye Care BenefitMembers 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 $40.00FramesUp to $45.00Single Vision LensesUp to $40.00Lined Bifocal and Progressive LensesUp to $60.00Lined Trifocal LensesUp to $80.00Lenticular LensesUp to $80.00Elective Contacts instead of Eyeglasses²Up to $100.00Contact Lens Fitting and EvaluationUp to $0.00{@Bullet} Necessary conta 3Necessary Contacts instead of EyeglassesUp to $210.00

DiscountsLaser visionUnitedHealthcare 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 MaterialAt 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 AidsAs 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 ProvidersUnitedHealthcare 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.03/20 © 2020 United HealthCare Services, Inc. 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.NCA-03C (v4.0)S109V

DiscountsLaser visionUnitedHealthcare 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 MaterialAt 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 AidsAs 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 ProvidersUnitedHealthcare 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.03/20 © 2020 United HealthCare Services, Inc. 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.NCA-03C (v4.0)S109V

Get in on UHC RewardsGood news — your health plan comes with a new way to earn up to $1,000. UnitedHealthcare Rewards is included in your health plan at no additional cost.There’s so much good to getWith UHC Rewards, a variety of actions — including many things you may already be doing — lead to rewards. The activities you go for are up to you — same goes for ways to spend your earnings. Here are some ways you can earn: Reach daily goals • Track 5,000 steps or 15 active minutes each day, or double it for an even bigger reward• Track 14 nights of sleepComplete one-time reward activities• Go paperless• Get a biometric screening • Take a health survey• Connect a tracker Personalize your experience by selecting activities that are right for you — and look for new ways of earning rewards to be added throughout the year. Earn up to $1,000continued

Get in on UHC RewardsGood news — your health plan comes with a new way to earn up to $1,000. UnitedHealthcare Rewards is included in your health plan at no additional cost.There’s so much good to getWith UHC Rewards, a variety of actions — including many things you may already be doing — lead to rewards. The activities you go for are up to you — same goes for ways to spend your earnings. Here are some ways you can earn: Reach daily goals • Track 5,000 steps or 15 active minutes each day, or double it for an even bigger reward• Track 14 nights of sleepComplete one-time reward activities• Go paperless• Get a biometric screening • Take a health survey• Connect a tracker Personalize your experience by selecting activities that are right for you — and look for new ways of earning rewards to be added throughout the year. Earn up to $1,000continued

There are 2 ways to get startedOn the UnitedHealthcare® app• Scan this code to download the app • Sign in or register• Select the Menu tab and choose UHC Rewards• Activate UHC Rewards and start earning• Though not required, connect a tracker and get access to even more reward activities On myuhc.com®• Sign in or register• Select UHC Rewards• Activate UHC Rewards• Choose reward activities that inspire you — and start earningYour healthGet in on an experience that’s designed to help inspire healthier habitsYour goalsPersonalize how you earn by choosing the activities that are right for youYour rewardsEarn up to $1,000 and use it however you wantQuestions?Call customer service at 1-866-230-2505UnitedHealthcare Rewards is a voluntary program. The information provided under this program is for general informational purposes only and is not intended to be nor should be construed as medical advice. You should consult an appropriate health care professional before beginning any exercise program and/or to determine what may be right for you. Receiving an activity tracker, certain credits and/or rewards and/or purchasing an activity tracker with earnings may have tax implications. You should consult with an appropriate tax professional to determine if you have any tax obligations under this program, as applicable. If any fraudulent activity is detected (e.g., misrepresented physical activity), you may be suspended and/or terminated from the program. If you are unable to meet a standard related to health factor to receive a reward under this program, you might qualify for an opportunity to receive the reward by different means. You may call us toll-free at 1-866-230-2505 or at the number on your health plan ID card, and we will work with you (and, if necessary, your doctor) to find another way for you to earn the same reward. Rewards may be limited due to incentive limits under applicable law. Subject to HSA eligibility, as applicable. This program is not available in Hawaii, Kansas, Vermont and Puerto Rico. Components subject to change.The UnitedHealthcare® app is available for download for iPhone® or Android®. iPhone is a registered trademark of Apple, Inc. Android is a registered trademark of Google LLC.Insurance coverage provided by or through UnitedHealthcare Insurance Company or its affiliates.B2C EI221796992.2 1/23 © 2023 United HealthCare Services, Inc. All Rights Reserved. 23-2037105-C

There are 2 ways to get startedOn the UnitedHealthcare® app• Scan this code to download the app • Sign in or register• Select the Menu tab and choose UHC Rewards• Activate UHC Rewards and start earning• Though not required, connect a tracker and get access to even more reward activities On myuhc.com®• Sign in or register• Select UHC Rewards• Activate UHC Rewards• Choose reward activities that inspire you — and start earningYour healthGet in on an experience that’s designed to help inspire healthier habitsYour goalsPersonalize how you earn by choosing the activities that are right for youYour rewardsEarn up to $1,000 and use it however you wantQuestions?Call customer service at 1-866-230-2505UnitedHealthcare Rewards is a voluntary program. The information provided under this program is for general informational purposes only and is not intended to be nor should be construed as medical advice. You should consult an appropriate health care professional before beginning any exercise program and/or to determine what may be right for you. Receiving an activity tracker, certain credits and/or rewards and/or purchasing an activity tracker with earnings may have tax implications. You should consult with an appropriate tax professional to determine if you have any tax obligations under this program, as applicable. If any fraudulent activity is detected (e.g., misrepresented physical activity), you may be suspended and/or terminated from the program. If you are unable to meet a standard related to health factor to receive a reward under this program, you might qualify for an opportunity to receive the reward by different means. You may call us toll-free at 1-866-230-2505 or at the number on your health plan ID card, and we will work with you (and, if necessary, your doctor) to find another way for you to earn the same reward. Rewards may be limited due to incentive limits under applicable law. Subject to HSA eligibility, as applicable. This program is not available in Hawaii, Kansas, Vermont and Puerto Rico. Components subject to change.The UnitedHealthcare® app is available for download for iPhone® or Android®. iPhone is a registered trademark of Apple, Inc. Android is a registered trademark of Google LLC.Insurance coverage provided by or through UnitedHealthcare Insurance Company or its affiliates.B2C EI221796992.2 1/23 © 2023 United HealthCare Services, Inc. All Rights Reserved. 23-2037105-C

Deductions per year: 24Group Accident (GAC4100) for TXApplicable to policy forms GAC4100-P,GAC4100-ClAdditional Benefits:Accident Hospital Benefits Preferred, Recovery Plus Package, Active Lifestyles, WellbeingAssistance Max - $100, Building BenefitOn/Off-Job Accident CoverageBENEFIT LEVEL AD&D BENEFIT LEVEL ISSUE AGE EMPLOYEE EMPLOYEE ANDSPOUSEEMPLOYEE ANDDEPENDENTCHILD(REN)EMPLOYEE, SPOUSEAND DEPENDENTCHILD(REN)Preferred Preferred 17-99 $9.52 $15.69 $19.11 $25.38Group Medical Bridge (GMB7000) for TXCompositeApplicable to Policy Forms GMB7000–P & GMB7000-ClWellbeing Assistance: Standard - $100, Outpatient Surgical Procedure: Option 2 - ($750 / $1500 / $2500), Daily HospitalConfinementHOSPITAL CONFINEMENT LEVEL ISSUE AGE NAMED INSURED EMPLOYEE & SPOUSE ONE PARENT FAMILY TWO PARENT FAMILYLevel 4: $200017-99 $22.17 $47.13 $30.80 $55.77HOSPITAL CONFINEMENT LEVEL ISSUE AGE NAMED INSURED EMPLOYEE & SPOUSE ONE PARENT FAMILY TWO PARENT FAMILYLevel 6: $300017-99 $30.92 $65.88 $42.75 $77.72Group Critical Illness (GCI6000) for TXApplicable to policy forms GCI6000-P, GCI6000-C,R-GCI6000-CB, R-GCI6000-BB, R-GCI6000-HB,R-GCI6000-INF, R-GCI6000-PDlPlan 2 - Critical Illness & Cancer, Wellbeing Assistance Benefit - $100 BenefitUni-Tobacco RatesISSUE AGE NAMED INSURED NAMED INSURED ANDSPOUSENAMED INSURED ANDDEPENDENT CHILD(REN)NAMED INSURED, SPOUSEAND DEPENDENT CHILD(REN)$10,000 17-24 $5.48 $8.28 $5.48 $8.2825-29 $6.43 $9.68 $6.43 $9.6830-34 $7.38 $11.13 $7.38 $11.1335-39 $9.58 $14.38 $9.58 $14.3840-44 $11.78 $17.68 $11.78 $17.6845-49 $15.28 $23.23 $15.28 $23.2350-54 $18.83 $28.73 $18.83 $28.7355-59 $23.73 $36.18 $23.73 $36.1860-64 $31.18 $47.48 $31.18 $47.4865-69 $37.48 $57.13 $37.48 $57.1370-74 $37.48 $57.13 $37.48 $57.13Lost Pines Toyota Smarter Benefit SolutionsPage 1 of 4Underwritten by Colonial Life & Accident Insurance CompanySee page 4 for Important Notice

Deductions per year: 24Group Accident (GAC4100) for TXApplicable to policy forms GAC4100-P,GAC4100-ClAdditional Benefits:Accident Hospital Benefits Preferred, Recovery Plus Package, Active Lifestyles, WellbeingAssistance Max - $100, Building BenefitOn/Off-Job Accident CoverageBENEFIT LEVEL AD&D BENEFIT LEVEL ISSUE AGE EMPLOYEE EMPLOYEE ANDSPOUSEEMPLOYEE ANDDEPENDENTCHILD(REN)EMPLOYEE, SPOUSEAND DEPENDENTCHILD(REN)Preferred Preferred 17-99 $9.52 $15.69 $19.11 $25.38Group Medical Bridge (GMB7000) for TXCompositeApplicable to Policy Forms GMB7000–P & GMB7000-ClWellbeing Assistance: Standard - $100, Outpatient Surgical Procedure: Option 2 - ($750 / $1500 / $2500), Daily HospitalConfinementHOSPITAL CONFINEMENT LEVEL ISSUE AGE NAMED INSURED EMPLOYEE & SPOUSE ONE PARENT FAMILY TWO PARENT FAMILYLevel 4: $200017-99 $22.17 $47.13 $30.80 $55.77HOSPITAL CONFINEMENT LEVEL ISSUE AGE NAMED INSURED EMPLOYEE & SPOUSE ONE PARENT FAMILY TWO PARENT FAMILYLevel 6: $300017-99 $30.92 $65.88 $42.75 $77.72Group Critical Illness (GCI6000) for TXApplicable to policy forms GCI6000-P, GCI6000-C,R-GCI6000-CB, R-GCI6000-BB, R-GCI6000-HB,R-GCI6000-INF, R-GCI6000-PDlPlan 2 - Critical Illness & Cancer, Wellbeing Assistance Benefit - $100 BenefitUni-Tobacco RatesISSUE AGE NAMED INSURED NAMED INSURED ANDSPOUSENAMED INSURED ANDDEPENDENT CHILD(REN)NAMED INSURED, SPOUSEAND DEPENDENT CHILD(REN)$10,000 17-24 $5.48 $8.28 $5.48 $8.2825-29 $6.43 $9.68 $6.43 $9.6830-34 $7.38 $11.13 $7.38 $11.1335-39 $9.58 $14.38 $9.58 $14.3840-44 $11.78 $17.68 $11.78 $17.6845-49 $15.28 $23.23 $15.28 $23.2350-54 $18.83 $28.73 $18.83 $28.7355-59 $23.73 $36.18 $23.73 $36.1860-64 $31.18 $47.48 $31.18 $47.4865-69 $37.48 $57.13 $37.48 $57.1370-74 $37.48 $57.13 $37.48 $57.13Lost Pines Toyota Smarter Benefit SolutionsPage 1 of 4Underwritten by Colonial Life & Accident Insurance CompanySee page 4 for Important Notice

Group Critical Illness (GCI6000) for TXApplicable to policy forms GCI6000-P, GCI6000-C,R-GCI6000-CB, R-GCI6000-BB, R-GCI6000-HB,R-GCI6000-INF, R-GCI6000-PDlPlan 2 - Critical Illness & Cancer, Wellbeing Assistance Benefit - $100 BenefitUni-Tobacco RatesISSUE AGE NAMED INSURED NAMED INSURED ANDSPOUSENAMED INSURED ANDDEPENDENT CHILD(REN)NAMED INSURED, SPOUSEAND DEPENDENT CHILD(REN)$20,000 17-24 $7.63 $11.38 $7.63 $11.3825-29 $9.53 $14.18 $9.53 $14.1830-34 $11.43 $17.08 $11.43 $17.0835-39 $15.83 $23.58 $15.83 $23.5840-44 $20.23 $30.18 $20.23 $30.1845-49 $27.23 $41.28 $27.23 $41.2850-54 $34.33 $52.28 $34.33 $52.2855-59 $44.13 $67.18 $44.13 $67.1860-64 $59.03 $89.78 $59.03 $89.7865-69 $71.63 $109.08 $71.63 $109.0870-74 $71.63 $109.08 $71.63 $109.08$30,000 17-24 $9.78 $14.48 $9.78 $14.4825-29 $12.63 $18.68 $12.63 $18.6830-34 $15.48 $23.03 $15.48 $23.0335-39 $22.08 $32.78 $22.08 $32.7840-44 $28.68 $42.68 $28.68 $42.6845-49 $39.18 $59.33 $39.18 $59.3350-54 $49.83 $75.83 $49.83 $75.8355-59 $64.53 $98.18 $64.53 $98.1860-64 $86.88 $132.08 $86.88 $132.0865-69 $105.78 $161.03 $105.78 $161.0370-74 $105.78 $161.03 $105.78 $161.03Individual Disability - ISTD3000 for TX AAA Risk ClassApplicable to policy form Individual DisabilitylOn/Off Job Accident and On/Off Job Sickness3 Month Benefit PeriodELIMINATION PERIOD ISSUE AGE $1,000* $2,000* $2,500* $3,000* $4,000**monthly benefit amount7 days Accident/7 days Sickness 17-49 $14.00 $28.00 $35.00 $42.00 $56.0050-64 $16.50 $33.00 $41.25 $49.50 $66.0065-74 $19.55 $39.10 $48.88 $58.65 $78.206 Month Benefit PeriodELIMINATION PERIOD ISSUE AGE $1,000* $2,000* $2,500* $3,000* $4,000**monthly benefit amount7 days Accident/7 days Sickness 17-49 $17.75 $35.50 $44.38 $53.25 $71.0050-64 $23.50 $47.00 $58.75 $70.50 $94.0065-74 $32.05 $64.10 $80.13 $96.15 $128.20Lost Pines Toyota Smarter Benefit Solutions(Continued...)Page 2 of 4Underwritten by Colonial Life & Accident Insurance CompanySee page 4 for Important Notice

Group Critical Illness (GCI6000) for TXApplicable to policy forms GCI6000-P, GCI6000-C,R-GCI6000-CB, R-GCI6000-BB, R-GCI6000-HB,R-GCI6000-INF, R-GCI6000-PDlPlan 2 - Critical Illness & Cancer, Wellbeing Assistance Benefit - $100 BenefitUni-Tobacco RatesISSUE AGE NAMED INSURED NAMED INSURED ANDSPOUSENAMED INSURED ANDDEPENDENT CHILD(REN)NAMED INSURED, SPOUSEAND DEPENDENT CHILD(REN)$20,000 17-24 $7.63 $11.38 $7.63 $11.3825-29 $9.53 $14.18 $9.53 $14.1830-34 $11.43 $17.08 $11.43 $17.0835-39 $15.83 $23.58 $15.83 $23.5840-44 $20.23 $30.18 $20.23 $30.1845-49 $27.23 $41.28 $27.23 $41.2850-54 $34.33 $52.28 $34.33 $52.2855-59 $44.13 $67.18 $44.13 $67.1860-64 $59.03 $89.78 $59.03 $89.7865-69 $71.63 $109.08 $71.63 $109.0870-74 $71.63 $109.08 $71.63 $109.08$30,000 17-24 $9.78 $14.48 $9.78 $14.4825-29 $12.63 $18.68 $12.63 $18.6830-34 $15.48 $23.03 $15.48 $23.0335-39 $22.08 $32.78 $22.08 $32.7840-44 $28.68 $42.68 $28.68 $42.6845-49 $39.18 $59.33 $39.18 $59.3350-54 $49.83 $75.83 $49.83 $75.8355-59 $64.53 $98.18 $64.53 $98.1860-64 $86.88 $132.08 $86.88 $132.0865-69 $105.78 $161.03 $105.78 $161.0370-74 $105.78 $161.03 $105.78 $161.03Individual Disability - ISTD3000 for TX AAA Risk ClassApplicable to policy form Individual DisabilitylOn/Off Job Accident and On/Off Job Sickness3 Month Benefit PeriodELIMINATION PERIOD ISSUE AGE $1,000* $2,000* $2,500* $3,000* $4,000**monthly benefit amount7 days Accident/7 days Sickness 17-49 $14.00 $28.00 $35.00 $42.00 $56.0050-64 $16.50 $33.00 $41.25 $49.50 $66.0065-74 $19.55 $39.10 $48.88 $58.65 $78.206 Month Benefit PeriodELIMINATION PERIOD ISSUE AGE $1,000* $2,000* $2,500* $3,000* $4,000**monthly benefit amount7 days Accident/7 days Sickness 17-49 $17.75 $35.50 $44.38 $53.25 $71.0050-64 $23.50 $47.00 $58.75 $70.50 $94.0065-74 $32.05 $64.10 $80.13 $96.15 $128.20Lost Pines Toyota Smarter Benefit Solutions(Continued...)Page 2 of 4Underwritten by Colonial Life & Accident Insurance CompanySee page 4 for Important Notice

12 Month Benefit PeriodELIMINATION PERIOD ISSUE AGE $1,000* $2,000* $2,500* $3,000* $4,000**monthly benefit amount7 days Accident/7 days Sickness 17-49 $25.25 $50.50 $63.13 $75.75 $101.0050-64 $32.05 $64.10 $80.13 $96.15 $128.2065-74 $51.25 $102.50 $128.13 $153.75 $205.00Term Life (ITL5000) for TXApplicable to policy form ITL5000l10-Year Term Base PlanNon-Tobacco RatesISSUE AGE $10,000 $20,000 $50,00025 $3.32 $4.64 $5.1135 $3.79 $5.58 $5.6345 $4.59 $7.17 $9.3155 $8.09 $14.18 $18.1965 $17.44 $18.54 $43.3375 $45.70 $54.55 $133.37Tobacco RatesISSUE AGE $10,000 $20,000 $50,00025 $5.20 $8.40 $8.8835 $5.76 $9.53 $9.8645 $7.49 $12.98 $20.4655 $16.11 $30.21 $49.0465 $32.83 $37.87 $91.6775 $68.65 $81.28 $200.20Whole Life Plus (IWL5000) for TXApplicable to policy forms ICC19-IWL5000-70/IWL5000-70,ICC19-IWL5000-100/IWL5000-100,ICC19-IWL5000J/IWL5000J and rider formsICC19-R-IWL5000-STR/R-IWL5000-STR,ICC19-R-IWL5000-CTR/R-IWL5000-CTR,ICC19-R-IWL5000-WP/R-IWL5000-WP,ICC19-R-IWL5000-ACCD/R-IWL5000-ACCD,ICC19-R-IWL5000-CI/R-IWL5000-CI,ICC19-R-IWL5000-CC/R-IWL5000-CC,ICC19-R-IWL5000-GPO/R-IWL5000-GPO,ICC23-IWL5000-LTC/IWL5000-LTClAdult Base Plan Paid-Up at Age 100Non-Tobacco RatesISSUE AGE $10,000 $15,000 $20,000 $25,00025 $4.60 $6.90 $9.20 $11.5035 $6.26 $9.39 $12.52 $15.6545 $9.94 $14.91 $19.89 $24.8655 $16.23 $24.34 $32.45 $40.5665 $28.88 $43.31 $57.75 $72.19Lost Pines Toyota Smarter Benefit Solutions(Continued...)Page 3 of 4Underwritten by Colonial Life & Accident Insurance CompanySee page 4 for Important Notice

12 Month Benefit PeriodELIMINATION PERIOD ISSUE AGE $1,000* $2,000* $2,500* $3,000* $4,000**monthly benefit amount7 days Accident/7 days Sickness 17-49 $25.25 $50.50 $63.13 $75.75 $101.0050-64 $32.05 $64.10 $80.13 $96.15 $128.2065-74 $51.25 $102.50 $128.13 $153.75 $205.00Term Life (ITL5000) for TXApplicable to policy form ITL5000l10-Year Term Base PlanNon-Tobacco RatesISSUE AGE $10,000 $20,000 $50,00025 $3.32 $4.64 $5.1135 $3.79 $5.58 $5.6345 $4.59 $7.17 $9.3155 $8.09 $14.18 $18.1965 $17.44 $18.54 $43.3375 $45.70 $54.55 $133.37Tobacco RatesISSUE AGE $10,000 $20,000 $50,00025 $5.20 $8.40 $8.8835 $5.76 $9.53 $9.8645 $7.49 $12.98 $20.4655 $16.11 $30.21 $49.0465 $32.83 $37.87 $91.6775 $68.65 $81.28 $200.20Whole Life Plus (IWL5000) for TXApplicable to policy forms ICC19-IWL5000-70/IWL5000-70,ICC19-IWL5000-100/IWL5000-100,ICC19-IWL5000J/IWL5000J and rider formsICC19-R-IWL5000-STR/R-IWL5000-STR,ICC19-R-IWL5000-CTR/R-IWL5000-CTR,ICC19-R-IWL5000-WP/R-IWL5000-WP,ICC19-R-IWL5000-ACCD/R-IWL5000-ACCD,ICC19-R-IWL5000-CI/R-IWL5000-CI,ICC19-R-IWL5000-CC/R-IWL5000-CC,ICC19-R-IWL5000-GPO/R-IWL5000-GPO,ICC23-IWL5000-LTC/IWL5000-LTClAdult Base Plan Paid-Up at Age 100Non-Tobacco RatesISSUE AGE $10,000 $15,000 $20,000 $25,00025 $4.60 $6.90 $9.20 $11.5035 $6.26 $9.39 $12.52 $15.6545 $9.94 $14.91 $19.89 $24.8655 $16.23 $24.34 $32.45 $40.5665 $28.88 $43.31 $57.75 $72.19Lost Pines Toyota Smarter Benefit Solutions(Continued...)Page 3 of 4Underwritten by Colonial Life & Accident Insurance CompanySee page 4 for Important Notice

Whole Life Plus (IWL5000) for TXApplicable to policy forms ICC19-IWL5000-70/IWL5000-70,ICC19-IWL5000-100/IWL5000-100,ICC19-IWL5000J/IWL5000J and rider formsICC19-R-IWL5000-STR/R-IWL5000-STR,ICC19-R-IWL5000-CTR/R-IWL5000-CTR,ICC19-R-IWL5000-WP/R-IWL5000-WP,ICC19-R-IWL5000-ACCD/R-IWL5000-ACCD,ICC19-R-IWL5000-CI/R-IWL5000-CI,ICC19-R-IWL5000-CC/R-IWL5000-CC,ICC19-R-IWL5000-GPO/R-IWL5000-GPO,ICC23-IWL5000-LTC/IWL5000-LTClAdult Base Plan Paid-Up at Age 100Tobacco RatesISSUE AGE $10,000 $15,000 $20,000 $25,00025 $8.04 $12.05 $16.07 $20.0935 $9.78 $14.66 $19.55 $24.4445 $14.56 $21.83 $29.11 $36.3955 $24.53 $36.80 $49.07 $61.3365 $41.96 $62.94 $83.92 $104.89Important NoticeInsurance coverage has exclusions and limitations that may affect benefits payable. For a complete description of benefits, limitations and exclusions, please refer to anoutline of coverage, sample policy/certificate, proposal description or see your Colonial Life benefits counselor. Coverage type, benefits and rates vary by state. Coverage maynot be available in all states. Rates provided are illustrative and your actual premium may be different depending on your particular situation and plan choices.Colonial Life products are underwritten by Colonial Life & Accident Insurance Company, for which Colonial Life is the marketing brand.© 2024 Colonial Life & Accident Insurance Company"Colonial Life," and the Colonial Life logo, separately and in combination, are service marks of Colonial Life & Accident Insurance Company. All rights reserved.Houston Hamilton |Lost Pines Toyota Smarter Benefit Solutions(Continued...)Page 4 of 4Underwritten by Colonial Life & Accident Insurance CompanySee page 4 for Important Notice

Whole Life Plus (IWL5000) for TXApplicable to policy forms ICC19-IWL5000-70/IWL5000-70,ICC19-IWL5000-100/IWL5000-100,ICC19-IWL5000J/IWL5000J and rider formsICC19-R-IWL5000-STR/R-IWL5000-STR,ICC19-R-IWL5000-CTR/R-IWL5000-CTR,ICC19-R-IWL5000-WP/R-IWL5000-WP,ICC19-R-IWL5000-ACCD/R-IWL5000-ACCD,ICC19-R-IWL5000-CI/R-IWL5000-CI,ICC19-R-IWL5000-CC/R-IWL5000-CC,ICC19-R-IWL5000-GPO/R-IWL5000-GPO,ICC23-IWL5000-LTC/IWL5000-LTClAdult Base Plan Paid-Up at Age 100Tobacco RatesISSUE AGE $10,000 $15,000 $20,000 $25,00025 $8.04 $12.05 $16.07 $20.0935 $9.78 $14.66 $19.55 $24.4445 $14.56 $21.83 $29.11 $36.3955 $24.53 $36.80 $49.07 $61.3365 $41.96 $62.94 $83.92 $104.89Important NoticeInsurance coverage has exclusions and limitations that may affect benefits payable. For a complete description of benefits, limitations and exclusions, please refer to anoutline of coverage, sample policy/certificate, proposal description or see your Colonial Life benefits counselor. Coverage type, benefits and rates vary by state. Coverage maynot be available in all states. Rates provided are illustrative and your actual premium may be different depending on your particular situation and plan choices.Colonial Life products are underwritten by Colonial Life & Accident Insurance Company, for which Colonial Life is the marketing brand.© 2024 Colonial Life & Accident Insurance Company"Colonial Life," and the Colonial Life logo, separately and in combination, are service marks of Colonial Life & Accident Insurance Company. All rights reserved.Houston Hamilton |Lost Pines Toyota Smarter Benefit Solutions(Continued...)Page 4 of 4Underwritten by Colonial Life & Accident Insurance CompanySee page 4 for Important Notice

Group Accident InsurancePreferred PlanIf you are in an accident, your focus should be on recovery, not how you’re going to pay your bills. Colonial Life accident insurance can pay benets directly to you to use however you like — from medical costs to everyday expenses. Whether you’ve had a fall or a car accident, these benets can offer nancial support when you need it.Our coverage includes:• Benets payable directly to you• No medical questions to qualify for coverage• Coverage for simple and complex injuries• Benets payable regardless of other insurance• Worldwide coverage• Works alongside your Health Savings Account (HSA)BENEFITS STORY Milo was working in his yard when he tripped and injured his hand.With Colonial Life accident benets, Milo was able to pay the annual deductible and co-payments for his health insurance plan without using his savings or taking on debt.MILO’S ACCIDENT BENEFITSMilo went to an urgent care facility and received immediate care.Treatment in a physician’s office or urgent care facility$100The doctor ordered an X-ray and discovered Milo had fractured his hand.• X-ray• Fracture (hand)$60$1,200The doctor also found that Milo had a cut on his hand but did not require stitches. Laceration (no repair) $50Milo was discharged with a splint. Durable medical equipment $50Over the next several weeks, Milo had two follow-up appointments with his doctor. Physician follow-up visits (2 visits)$50 x 2 = $100Total $1,560For illustrative purposes only. Benet amounts may vary and may not cover all expenses. GROUP ACCIDENT (GAC4100) — PREFERRED PLAN

Group Accident InsurancePreferred PlanIf you are in an accident, your focus should be on recovery, not how you’re going to pay your bills. Colonial Life accident insurance can pay benets directly to you to use however you like — from medical costs to everyday expenses. Whether you’ve had a fall or a car accident, these benets can offer nancial support when you need it.Our coverage includes:• Benets payable directly to you• No medical questions to qualify for coverage• Coverage for simple and complex injuries• Benets payable regardless of other insurance• Worldwide coverage• Works alongside your Health Savings Account (HSA)BENEFITS STORY Milo was working in his yard when he tripped and injured his hand.With Colonial Life accident benets, Milo was able to pay the annual deductible and co-payments for his health insurance plan without using his savings or taking on debt.MILO’S ACCIDENT BENEFITSMilo went to an urgent care facility and received immediate care.Treatment in a physician’s office or urgent care facility$100The doctor ordered an X-ray and discovered Milo had fractured his hand.• X-ray• Fracture (hand)$60$1,200The doctor also found that Milo had a cut on his hand but did not require stitches. Laceration (no repair) $50Milo was discharged with a splint. Durable medical equipment $50Over the next several weeks, Milo had two follow-up appointments with his doctor. Physician follow-up visits (2 visits)$50 x 2 = $100Total $1,560For illustrative purposes only. Benet amounts may vary and may not cover all expenses. GROUP ACCIDENT (GAC4100) — PREFERRED PLAN

Give your benets a boostWe know that more complicated or severe accidents result in more expensive medical bills and more disruption in your life. Group Accident includes a Benet Booster* to provide additional nancial support for serious accidents. If you have more than $5,000 in payable benets for a covered accident, we will give you a $500 boost to your benets to help you with whatever expenses you have. *Payable once per Insured per covered accidentBENEFITS STORY Olivia was driving to the store when she got into a car accident.Olivia’s benets helped her cover her medical expenses when she was injured in a car accident, helping her to focus on her recovery.OLIVIA’S ACCIDENT BENEFITSOlivia arrived by ambulance at the nearest emergency room and received immediate care.• Ambulance• Emergency department visit• Injury due to auto accident$300$200 $250The doctor ordered an X-ray and discovered Olivia had fractured her thigh (femur). He also ordered a CT scan of her head to check for brain injury.• X-ray• Medical imaging• Fracture (thigh)$60$200 $3,150Olivia required surgery for her leg.• Surgical repair (thigh fracture)• General anesthesia$3,150$250Olivia boarded her pet for two nights after her surgery. Pet boarding (2 days) $20 x 2 = $40Olivia had eight sessions of physical therapy to help regain the strength in her leg and two follow-up appointments with her doctor.• Therapy services (8 sessions)• Physician follow-up visits (2 visits)$45 x 8 = $360$50 x 2 = $100Olivia’s benefits for this accident totaled more than $5,000.Benefit Booster $500Total $8,560For illustrative purposes only. Benet amounts may vary and may not cover all expenses. Benets are per covered person per covered accident unless stated otherwiseInjury benets • Burns (based on size and degree) ............. $500–$15,000• Concussion .........................................$375• Connective tissue damage ......................$100–$200• Eye injury .......................................... $300 • Hearing loss injuries ..................................$120(Maximum once per lifetime per ear per insured)• Injury due to auto accident ........................... $250 • Internal injuries ..................................... $200 • Knee cartilage (meniscus) injury .......................$150 • Lacerations ....................................$50–$600• Loss of a digit — partial .........................$300–$600• Loss of a digit ...............................$750–$2,000• Ruptured or herniated disc ......................$150–$300

Give your benets a boostWe know that more complicated or severe accidents result in more expensive medical bills and more disruption in your life. Group Accident includes a Benet Booster* to provide additional nancial support for serious accidents. If you have more than $5,000 in payable benets for a covered accident, we will give you a $500 boost to your benets to help you with whatever expenses you have. *Payable once per Insured per covered accidentBENEFITS STORY Olivia was driving to the store when she got into a car accident.Olivia’s benets helped her cover her medical expenses when she was injured in a car accident, helping her to focus on her recovery.OLIVIA’S ACCIDENT BENEFITSOlivia arrived by ambulance at the nearest emergency room and received immediate care.• Ambulance• Emergency department visit• Injury due to auto accident$300$200 $250The doctor ordered an X-ray and discovered Olivia had fractured her thigh (femur). He also ordered a CT scan of her head to check for brain injury.• X-ray• Medical imaging• Fracture (thigh)$60$200 $3,150Olivia required surgery for her leg.• Surgical repair (thigh fracture)• General anesthesia$3,150$250Olivia boarded her pet for two nights after her surgery. Pet boarding (2 days) $20 x 2 = $40Olivia had eight sessions of physical therapy to help regain the strength in her leg and two follow-up appointments with her doctor.• Therapy services (8 sessions)• Physician follow-up visits (2 visits)$45 x 8 = $360$50 x 2 = $100Olivia’s benefits for this accident totaled more than $5,000.Benefit Booster $500Total $8,560For illustrative purposes only. Benet amounts may vary and may not cover all expenses. Benets are per covered person per covered accident unless stated otherwiseInjury benets • Burns (based on size and degree) ............. $500–$15,000• Concussion .........................................$375• Connective tissue damage ......................$100–$200• Eye injury .......................................... $300 • Hearing loss injuries ..................................$120(Maximum once per lifetime per ear per insured)• Injury due to auto accident ........................... $250 • Internal injuries ..................................... $200 • Knee cartilage (meniscus) injury .......................$150 • Lacerations ....................................$50–$600• Loss of a digit — partial .........................$300–$600• Loss of a digit ...............................$750–$2,000• Ruptured or herniated disc ......................$150–$300

Fracture benets• Injury .......................................$200–$3,750 Examples: nger: $200 | wrist: $1,200 | hip: $3,150• Surgical repair of fracture ............................100%(Payable as an additional % of the applicable fractures benet)• Chip fracture ........................................25%(Payable as a % of the applicable fractures benet)Dislocation benets• Injury .......................................$200–$3,000 Examples: elbow: $450 | ankle: $1,200 | hip: $3,000• Surgical repair of dislocation ..........................100%(Payable as an additional % of the applicable dislocations benet)• Incomplete dislocation ................................25%(Payable as a % of the applicable dislocations benet)Treatment benets• Air ambulance .....................................$1,500 • Ambulance (ground or water) ......................... $300 • Durable medical equipment ......................$50–$200• Emergency dental repair ........................$100–$300• Emergency department .............................. $200(Maximum 4 per year) • Family care ................................... $50 per day(Maximum of one benet per day for all Insureds combined, up to a maximum of three days per covered accident, regardless of the number of children)• Injections to prevent or limit infection ...................$50 • Lodging .....................................$200 per day(Maximum 30 days)• Medical imaging ..................................... $200 • Pain management injections ..........................$100 • Pet boarding .................................. $20 per day (Maximum of one benet per day for all insureds combined, up to a maximum of three days per covered accident, regardless of the number of pets that are boarded)• Prosthetic device or articial limb ............$1,250–$2,500• Skin grafts (due to burns) .............................50%(Payable as a % of the applicable burn benet)• Skin grafts (not due to burns) ....................$250–$500• Transfusions ........................................ $400 • Transportation ................................$150 per trip (Maximum 6 one-way trips)• Treatment in a physician’s oce or urgent care facility ...$100(Maximum 4 per year) • X-ray or ultrasound ....................................$60Surgery benets• Anesthesia ....................................$150–$250• Connective tissue surgery ......................$125–$1,600• Eye surgery ......................................... $300• General surgery –Abdominal, thoracic, or cranial ....................$1,500 –Exploratory surgery ...............................$225 • Hernia surgery ......................................$300 • Knee cartilage (meniscus) surgery ...............$100–$600• Outpatient surgical facility ............................$300 • Ruptured or herniated disc surgery .............$125–$1,500Recovery care benets• At-home care ................................ $100 per day(Maximum 5 days) • Benet Booster .....................................$500• Physician follow-up visits ............................. $50 (Maximum 4 days per covered accident and 16 days per calendar year)• Rehabilitation or sub-acute rehabilitation unit connement ............................. $150 per day (Maximum 15 days per covered accident and 30 days per calendar year)• Therapy services (speech, physical therapy, occupational therapy) ..........................$45 per day(Maximum 15 days)Recovery Plus package• Behavioral health therapy .................. $45 per day (Maximum 15 days)• Post-traumatic stress disorder (PTSD) ............ $200 • Prescription drug .................................$25 • Additional therapy services (chiropractic, acupuncture, alternative therapy) ......$45 (Existing therapy services benet maximum applies to additional therapy services, maximum 15 days)• Injury due to felonious act of violence or sexual assault ................................ $250(Maximum once per insured per calendar year, with an accompanying police report)

Fracture benets• Injury .......................................$200–$3,750 Examples: nger: $200 | wrist: $1,200 | hip: $3,150• Surgical repair of fracture ............................100%(Payable as an additional % of the applicable fractures benet)• Chip fracture ........................................25%(Payable as a % of the applicable fractures benet)Dislocation benets• Injury .......................................$200–$3,000 Examples: elbow: $450 | ankle: $1,200 | hip: $3,000• Surgical repair of dislocation ..........................100%(Payable as an additional % of the applicable dislocations benet)• Incomplete dislocation ................................25%(Payable as a % of the applicable dislocations benet)Treatment benets• Air ambulance .....................................$1,500 • Ambulance (ground or water) ......................... $300 • Durable medical equipment ......................$50–$200• Emergency dental repair ........................$100–$300• Emergency department .............................. $200(Maximum 4 per year) • Family care ................................... $50 per day(Maximum of one benet per day for all Insureds combined, up to a maximum of three days per covered accident, regardless of the number of children)• Injections to prevent or limit infection ...................$50 • Lodging .....................................$200 per day(Maximum 30 days)• Medical imaging ..................................... $200 • Pain management injections ..........................$100 • Pet boarding .................................. $20 per day (Maximum of one benet per day for all insureds combined, up to a maximum of three days per covered accident, regardless of the number of pets that are boarded)• Prosthetic device or articial limb ............$1,250–$2,500• Skin grafts (due to burns) .............................50%(Payable as a % of the applicable burn benet)• Skin grafts (not due to burns) ....................$250–$500• Transfusions ........................................ $400 • Transportation ................................$150 per trip (Maximum 6 one-way trips)• Treatment in a physician’s oce or urgent care facility ...$100(Maximum 4 per year) • X-ray or ultrasound ....................................$60Surgery benets• Anesthesia ....................................$150–$250• Connective tissue surgery ......................$125–$1,600• Eye surgery ......................................... $300• General surgery –Abdominal, thoracic, or cranial ....................$1,500 –Exploratory surgery ...............................$225 • Hernia surgery ......................................$300 • Knee cartilage (meniscus) surgery ...............$100–$600• Outpatient surgical facility ............................$300 • Ruptured or herniated disc surgery .............$125–$1,500Recovery care benets• At-home care ................................ $100 per day(Maximum 5 days) • Benet Booster .....................................$500• Physician follow-up visits ............................. $50 (Maximum 4 days per covered accident and 16 days per calendar year)• Rehabilitation or sub-acute rehabilitation unit connement ............................. $150 per day (Maximum 15 days per covered accident and 30 days per calendar year)• Therapy services (speech, physical therapy, occupational therapy) ..........................$45 per day(Maximum 15 days)Recovery Plus package• Behavioral health therapy .................. $45 per day (Maximum 15 days)• Post-traumatic stress disorder (PTSD) ............ $200 • Prescription drug .................................$25 • Additional therapy services (chiropractic, acupuncture, alternative therapy) ......$45 (Existing therapy services benet maximum applies to additional therapy services, maximum 15 days)• Injury due to felonious act of violence or sexual assault ................................ $250(Maximum once per insured per calendar year, with an accompanying police report)

Contact your Colonial Life benets counselor to learn more.CT: We will pay the air ambulance or ambulance benets directly to the licensed professional ambulance company. CT includes a benet for “outpatient emergency medical care for accidental ingestion of a controlled substance.” The at-home care benet maximum is 80 days. KS: Chiropractic therapy is not available. NH: NH includes a burn benet for 2nd degree burns under 5% of skin surface. The minimum benet for the loss or partial loss of a digit is $1,000.MD: The prescription drug benet is not available.PA: The pet boarding benet is not available. TN: The therapy services benet includes chiropractic. TX: The concussion benet is replaced by the “concussion and acquired brain injuries” benet. The therapy services benet includes the following services: cognitive communication therapy; cognitive rehabilitation therapy; community reintegration services; neurobehavioral; neurocognitive therapy and rehabilitation; neurofeedback therapy; neurophysiological; neuropsychological; post-acute transition services; psychophysiological testing or treatment; and remediation.HEALTH SAVINGS ACCOUNT (HSA) COMPATIBLEThis plan is compatible with HSA guidelines and any other HSA plan in which a covered family member may participate.It may also be offered to employees who do not have HSAs.THIS INSURANCE PROVIDES LIMITED BENEFITS.This coverage is a supplement to health insurance. It is not a substitute for essential health benets or minimum essential coverage as dened in federal law. Insureds in some states must be covered by comprehensive health insurance before applying for this insurance. EXCLUSIONSWe will not pay benets for claims that are caused by, contributed to by, or resulting from elective procedures, felonies or illegal occupations, hazardous avocations, impaired driving, incarceration, racing, semi-professional or professional sports, sickness, suicide or self-inicted injuries, war, or armed conict. ID: ”Semi-professional sports or professional sports” exclusion is replaced by “professional sports” exclusion. IL: We will not pay benets for claims that are caused by or resulting from Exclusions.MD: Includes an exclusion for “Prohibited referrals.” The “felonies or illegal occupations” and “impaired driving” exclusions apply only to Accidental Death and Dismemberment benets.MI: “Impaired driving” and “suicide or self-inicted injuries” exclusions do not apply. MN: “Suicide or self-inicted injuries” exclusion does not apply.NH: “Incarceration” and “racing” exclusions do not apply.UT: We will not pay benets for claims that are caused by or resulting from Exclusions.VT: “Impaired driving” exclusion does not apply. This information is not intended to be a complete description of the insurance coverage available. The insurance or its provisions may vary or be unavailable in some states. The insurance has exclusions and limitations which may affect any benets payable. Applicable to policy form GAC4100-P and certicate form GAC4100-C (including state abbreviations where used, for example: GAC4100-P-TX and GAC4100-C-TX). For cost and complete details of coverage, call or write your Colonial Life benets counselor or the company.Underwritten by Colonial Life & Accident Insurance Company, Columbia, SC.© 2023 Colonial Life & Accident Insurance Company. All rights reserved. Colonial Life is a registered trademark and marketing brand of Colonial Life & Accident Insurance Company. FOR EMPLOYEES 3-23 | 1212757ColonialLife.com

Contact your Colonial Life benets counselor to learn more.CT: We will pay the air ambulance or ambulance benets directly to the licensed professional ambulance company. CT includes a benet for “outpatient emergency medical care for accidental ingestion of a controlled substance.” The at-home care benet maximum is 80 days. KS: Chiropractic therapy is not available. NH: NH includes a burn benet for 2nd degree burns under 5% of skin surface. The minimum benet for the loss or partial loss of a digit is $1,000.MD: The prescription drug benet is not available.PA: The pet boarding benet is not available. TN: The therapy services benet includes chiropractic. TX: The concussion benet is replaced by the “concussion and acquired brain injuries” benet. The therapy services benet includes the following services: cognitive communication therapy; cognitive rehabilitation therapy; community reintegration services; neurobehavioral; neurocognitive therapy and rehabilitation; neurofeedback therapy; neurophysiological; neuropsychological; post-acute transition services; psychophysiological testing or treatment; and remediation.HEALTH SAVINGS ACCOUNT (HSA) COMPATIBLEThis plan is compatible with HSA guidelines and any other HSA plan in which a covered family member may participate.It may also be offered to employees who do not have HSAs.THIS INSURANCE PROVIDES LIMITED BENEFITS.This coverage is a supplement to health insurance. It is not a substitute for essential health benets or minimum essential coverage as dened in federal law. Insureds in some states must be covered by comprehensive health insurance before applying for this insurance. EXCLUSIONSWe will not pay benets for claims that are caused by, contributed to by, or resulting from elective procedures, felonies or illegal occupations, hazardous avocations, impaired driving, incarceration, racing, semi-professional or professional sports, sickness, suicide or self-inicted injuries, war, or armed conict. ID: ”Semi-professional sports or professional sports” exclusion is replaced by “professional sports” exclusion. IL: We will not pay benets for claims that are caused by or resulting from Exclusions.MD: Includes an exclusion for “Prohibited referrals.” The “felonies or illegal occupations” and “impaired driving” exclusions apply only to Accidental Death and Dismemberment benets.MI: “Impaired driving” and “suicide or self-inicted injuries” exclusions do not apply. MN: “Suicide or self-inicted injuries” exclusion does not apply.NH: “Incarceration” and “racing” exclusions do not apply.UT: We will not pay benets for claims that are caused by or resulting from Exclusions.VT: “Impaired driving” exclusion does not apply. This information is not intended to be a complete description of the insurance coverage available. The insurance or its provisions may vary or be unavailable in some states. The insurance has exclusions and limitations which may affect any benets payable. Applicable to policy form GAC4100-P and certicate form GAC4100-C (including state abbreviations where used, for example: GAC4100-P-TX and GAC4100-C-TX). For cost and complete details of coverage, call or write your Colonial Life benets counselor or the company.Underwritten by Colonial Life & Accident Insurance Company, Columbia, SC.© 2023 Colonial Life & Accident Insurance Company. All rights reserved. Colonial Life is a registered trademark and marketing brand of Colonial Life & Accident Insurance Company. FOR EMPLOYEES 3-23 | 1212757ColonialLife.com

Group Accident InsuranceAccident Hospital BenetsThese benets can help with medical costs related to a hospital stay for a covered accident, including costs that your health insurance may not cover, like co-pays and deductibles. Accident hospital benets are available to you with group accident coverage, as well as all your covered family members Talk with your benets counselor about the level of accident hospital benets available to you.Benets are per covered person per covered accident unless stated otherwise.Economy Basic Preferred Premier Hospital Admission $500 $750 $1,000 $1,500Hospital Admission – ICU $1,250 $1,500 $1,750 $2,500Hospital Confinement – Daily Stay Max. of 365 days per insured per covered accident$100 $200 $250 $350Hospital ICU Confinement – Daily Stay Max. of 15 days per insured per covered accident$150 $250 $350 $500Hospital Sub-Acute ICU Confinement – Daily Stay Max. of 30 days per insured per covered accident$200 $300 $400 $600Short Stay Min. of 8 hours up to 20 hours$200 $200 $200 $200To learn more, talk with your Colonial Life benets counselor.GROUP ACCIDENT (GAC4100) – ACCIDENT HOSPITAL BENEFITS

Group Accident InsuranceAccident Hospital BenetsThese benets can help with medical costs related to a hospital stay for a covered accident, including costs that your health insurance may not cover, like co-pays and deductibles. Accident hospital benets are available to you with group accident coverage, as well as all your covered family members Talk with your benets counselor about the level of accident hospital benets available to you.Benets are per covered person per covered accident unless stated otherwise.Economy Basic Preferred Premier Hospital Admission $500 $750 $1,000 $1,500Hospital Admission – ICU $1,250 $1,500 $1,750 $2,500Hospital Confinement – Daily Stay Max. of 365 days per insured per covered accident$100 $200 $250 $350Hospital ICU Confinement – Daily Stay Max. of 15 days per insured per covered accident$150 $250 $350 $500Hospital Sub-Acute ICU Confinement – Daily Stay Max. of 30 days per insured per covered accident$200 $300 $400 $600Short Stay Min. of 8 hours up to 20 hours$200 $200 $200 $200To learn more, talk with your Colonial Life benets counselor.GROUP ACCIDENT (GAC4100) – ACCIDENT HOSPITAL BENEFITS

STATE VARIATIONS FOR BENEFITSMD includes a second opinion benet. HEALTH SAVINGS ACCOUNT (HSA) COMPATIBLEThis plan is compatible with HSA guidelines and any other HSA plan in which a covered family member may participate. It may also be offered to employees who do not have HSAs.THIS INSURANCE PROVIDES LIMITED BENEFITS.This coverage is a supplement to health insurance. It is not a substitute for essential health benets or minimum essential coverage as dened in federal law. Insureds in some states must be covered by comprehensive health insurance before applying for this insurance.EXCLUSIONS AND LIMITATIONSWe will not pay benets for claims that are caused by, contributed to by, or resulting from elective procedures, felonies or illegal occupations, hazardous avocations, impaired driving, incarceration, racing, semi-professional or professional sports, sickness, suicide or self-inicted injuries, war, or armed conict.STATE VARIATIONS FOR EXCLUSIONS AND LIMITATIONSID: “Semi-professional sports or professional sports” exclusion is replaced by “professional sports” exclusion.IL: We will not pay benets for claims that are caused by or resulting from Exclusions.MD: Includes an exclusion for “Prohibited referrals.” The “felonies or illegal occupations” and “impaired driving” exclusions apply only to Accidental Death and Dismemberment benets.MI: “Impaired driving” and “suicide or self-inicted injuries” exclusions do not apply.MN: “Suicide or self-inicted injuries” exclusion does not apply.NH: “Incarceration” and “racing” exclusions do not apply.UT: We will not pay benets for claims that are caused by or resulting from Exclusions.VT: “Impaired driving” exclusion does not apply.This information is not intended to be a complete description of the insurance coverage available. The insurance or its provisions may vary or be unavailable in some states. The insurance has exclusions and limitations which may affect any benets payable. Applicable to policy form GAC4100-P and certicate form GAC4100-C (including state abbreviations where used, for example, GAC4100-P-TX). For cost and complete details of coverage, call or write your Colonial Life benets counselor or the company.Underwritten by Colonial Life & Accident Insurance Company, Columbia, SC. © 2023 Colonial Life & Accident Insurance Company. All rights reserved. Colonial Life is a registered trademark and marketing brand of Colonial Life & Accident Insurance Company. FOR EMPLOYEES 2-23 | 1284160ColonialLife.com

STATE VARIATIONS FOR BENEFITSMD includes a second opinion benet. HEALTH SAVINGS ACCOUNT (HSA) COMPATIBLEThis plan is compatible with HSA guidelines and any other HSA plan in which a covered family member may participate. It may also be offered to employees who do not have HSAs.THIS INSURANCE PROVIDES LIMITED BENEFITS.This coverage is a supplement to health insurance. It is not a substitute for essential health benets or minimum essential coverage as dened in federal law. Insureds in some states must be covered by comprehensive health insurance before applying for this insurance.EXCLUSIONS AND LIMITATIONSWe will not pay benets for claims that are caused by, contributed to by, or resulting from elective procedures, felonies or illegal occupations, hazardous avocations, impaired driving, incarceration, racing, semi-professional or professional sports, sickness, suicide or self-inicted injuries, war, or armed conict.STATE VARIATIONS FOR EXCLUSIONS AND LIMITATIONSID: “Semi-professional sports or professional sports” exclusion is replaced by “professional sports” exclusion.IL: We will not pay benets for claims that are caused by or resulting from Exclusions.MD: Includes an exclusion for “Prohibited referrals.” The “felonies or illegal occupations” and “impaired driving” exclusions apply only to Accidental Death and Dismemberment benets.MI: “Impaired driving” and “suicide or self-inicted injuries” exclusions do not apply.MN: “Suicide or self-inicted injuries” exclusion does not apply.NH: “Incarceration” and “racing” exclusions do not apply.UT: We will not pay benets for claims that are caused by or resulting from Exclusions.VT: “Impaired driving” exclusion does not apply.This information is not intended to be a complete description of the insurance coverage available. The insurance or its provisions may vary or be unavailable in some states. The insurance has exclusions and limitations which may affect any benets payable. Applicable to policy form GAC4100-P and certicate form GAC4100-C (including state abbreviations where used, for example, GAC4100-P-TX). For cost and complete details of coverage, call or write your Colonial Life benets counselor or the company.Underwritten by Colonial Life & Accident Insurance Company, Columbia, SC. © 2023 Colonial Life & Accident Insurance Company. All rights reserved. Colonial Life is a registered trademark and marketing brand of Colonial Life & Accident Insurance Company. FOR EMPLOYEES 2-23 | 1284160ColonialLife.com

Group Accident InsuranceAccidental Death & Dismemberment BenetsThese benets can help pay for expenses related to an accidental death. They can also help pay costs related to recovery and rehabilitation from an accidental dismemberment, including costs that your medical plan doesn’t cover, like co-pays and deductibles.Accidental death & dismemberment (AD&D) benets Accidental death and dismemberment benets are available to you with group accident coverage, as well as all your covered family members. Talk with your benets counselor about the level of AD&D benets available to you.Benets are per covered person per covered accident unless stated otherwise.Economy Basic Preferred Premier Accidental death• Named insured $25,000 $25,000 $50,000 $50,000• Spouse1$25,000 $25,000 $50,000 $50,000• Children $5,000 $5,000 $10,000 $10,000Accidental death – Common carrier• Named insured $100,000 $100,000 $200,000 $200,000• Spouse1$100,000 $100,000 $200,000 $200,000• Children $20,000 $20,000 $40,000 $40,000Accidental dismemberment• Both feet $25,000 $50,000 $75,000 $100,000 • Both hands $25,000 $50,000 $75,000 $100,000 • One foot $6,000 $7,500 $9,000 $15,000• One hand $6,000 $7,500 $9,000 $15,000• Thumb and index nger of the same hand $3,000 $3,750 $4,500 $7,500Coma (7 or more consecutive days) $5,000 $7,500 $10,000 $20,000Home alterations and automobile modifications $500 $1,000 $1,500 $2,000 GROUP ACCIDENT (GAC4100) – AD&D BENEFITS

Group Accident InsuranceAccidental Death & Dismemberment BenetsThese benets can help pay for expenses related to an accidental death. They can also help pay costs related to recovery and rehabilitation from an accidental dismemberment, including costs that your medical plan doesn’t cover, like co-pays and deductibles.Accidental death & dismemberment (AD&D) benets Accidental death and dismemberment benets are available to you with group accident coverage, as well as all your covered family members. Talk with your benets counselor about the level of AD&D benets available to you.Benets are per covered person per covered accident unless stated otherwise.Economy Basic Preferred Premier Accidental death• Named insured $25,000 $25,000 $50,000 $50,000• Spouse1$25,000 $25,000 $50,000 $50,000• Children $5,000 $5,000 $10,000 $10,000Accidental death – Common carrier• Named insured $100,000 $100,000 $200,000 $200,000• Spouse1$100,000 $100,000 $200,000 $200,000• Children $20,000 $20,000 $40,000 $40,000Accidental dismemberment• Both feet $25,000 $50,000 $75,000 $100,000 • Both hands $25,000 $50,000 $75,000 $100,000 • One foot $6,000 $7,500 $9,000 $15,000• One hand $6,000 $7,500 $9,000 $15,000• Thumb and index nger of the same hand $3,000 $3,750 $4,500 $7,500Coma (7 or more consecutive days) $5,000 $7,500 $10,000 $20,000Home alterations and automobile modifications $500 $1,000 $1,500 $2,000 GROUP ACCIDENT (GAC4100) – AD&D BENEFITS

Accidental death & dismemberment benets (continued)Economy Basic Preferred Premier Loss of use• Hearing (one ear) $6,000 $7,500 $9,000 $15,000• Hearing (both ears) $25,000 $50,000 $75,000 $100,000 • Sight of one eye $6,000 $7,500 $9,000 $15,000• Sight of both eyes $25,000 $50,000 $75,000 $100,000 • Speech $25,000 $50,000 $75,000 $100,000Paralysis• Uniplegia $6,000 $7,500 $9,000 $15,000• Hemiplegia $25,000 $50,000 $75,000 $100,000 • Paraplegia $25,000 $50,000 $75,000 $100,000 • Triplegia $25,000 $50,000 $75,000 $100,000 • Quadriplegia $25,000 $50,000 $75,000 $100,000To learn more, talk with your Colonial Life benets counselor.1. Or domestic partner where permitted by law.HEALTH SAVINGS ACCOUNT (HSA) COMPATIBLEThis plan is compatible with HSA guidelines and any other HSA plan in which a covered family member may participate. It may also be offered to employees who do not have HSAs.THIS INSURANCE PROVIDES LIMITED BENEFITS.This coverage is a supplement to health insurance. It is not a substitute for essential health benets or minimum essential coverage as dened in federal law. Insureds in some states must be covered by comprehensive health insurance before applying for this insurance.EXCLUSIONS AND LIMITATIONSWe will not pay benets for claims that are caused by, contributed to by, or resulting from elective procedures, felonies or illegal occupations, hazardous avocations, impaired driving, incarceration, racing, semi-professional or professional sports, sickness, suicide or self-inicted injuries, war, or armed conict.STATE VARIATIONS FOR EXCLUSIONS AND LIMITATIONSID: “Semi-professional sports or professional sports” exclusion is replaced by “professional sports” exclusion.IL: We will not pay benets for claims that are caused by or resulting from Exclusions.MD: Includes an exclusion for “Prohibited referrals.” The “felonies or illegal occupations” and “impaired driving” exclusions apply only to Accidental Death and Dismemberment benets.MI: “Impaired driving” and “suicide or self-inicted injuries” exclusions do not apply.MN: “Suicide or self-inicted injuries” exclusion does not apply.NH: “Incarceration” and “racing” exclusions do not apply.UT: We will not pay benets for claims that are caused by or resulting from Exclusions.VT: “Impaired driving” exclusion does not apply.This information is not intended to be a complete description of the insurance coverage available. The insurance or its provisions may vary or be unavailable in some states. The insurance has exclusions and limitations which may affect any benets payable. Applicable to policy form GAC4100-P and certicate form GAC4100-C (including state abbreviations where used, for example, GAC4100-P-TX). For cost and complete details of coverage, call or write your Colonial Life benets counselor or the company.Underwritten by Colonial Life & Accident Insurance Company, Columbia, SC. © 2023 Colonial Life & Accident Insurance Company. All rights reserved. Colonial Life is a registered trademark and marketing brand of Colonial Life & Accident Insurance Company.FOR EMPLOYEES 2-23 | 1284100ColonialLife.com

Accidental death & dismemberment benets (continued)Economy Basic Preferred Premier Loss of use• Hearing (one ear) $6,000 $7,500 $9,000 $15,000• Hearing (both ears) $25,000 $50,000 $75,000 $100,000 • Sight of one eye $6,000 $7,500 $9,000 $15,000• Sight of both eyes $25,000 $50,000 $75,000 $100,000 • Speech $25,000 $50,000 $75,000 $100,000Paralysis• Uniplegia $6,000 $7,500 $9,000 $15,000• Hemiplegia $25,000 $50,000 $75,000 $100,000 • Paraplegia $25,000 $50,000 $75,000 $100,000 • Triplegia $25,000 $50,000 $75,000 $100,000 • Quadriplegia $25,000 $50,000 $75,000 $100,000To learn more, talk with your Colonial Life benets counselor.1. Or domestic partner where permitted by law.HEALTH SAVINGS ACCOUNT (HSA) COMPATIBLEThis plan is compatible with HSA guidelines and any other HSA plan in which a covered family member may participate. It may also be offered to employees who do not have HSAs.THIS INSURANCE PROVIDES LIMITED BENEFITS.This coverage is a supplement to health insurance. It is not a substitute for essential health benets or minimum essential coverage as dened in federal law. Insureds in some states must be covered by comprehensive health insurance before applying for this insurance.EXCLUSIONS AND LIMITATIONSWe will not pay benets for claims that are caused by, contributed to by, or resulting from elective procedures, felonies or illegal occupations, hazardous avocations, impaired driving, incarceration, racing, semi-professional or professional sports, sickness, suicide or self-inicted injuries, war, or armed conict.STATE VARIATIONS FOR EXCLUSIONS AND LIMITATIONSID: “Semi-professional sports or professional sports” exclusion is replaced by “professional sports” exclusion.IL: We will not pay benets for claims that are caused by or resulting from Exclusions.MD: Includes an exclusion for “Prohibited referrals.” The “felonies or illegal occupations” and “impaired driving” exclusions apply only to Accidental Death and Dismemberment benets.MI: “Impaired driving” and “suicide or self-inicted injuries” exclusions do not apply.MN: “Suicide or self-inicted injuries” exclusion does not apply.NH: “Incarceration” and “racing” exclusions do not apply.UT: We will not pay benets for claims that are caused by or resulting from Exclusions.VT: “Impaired driving” exclusion does not apply.This information is not intended to be a complete description of the insurance coverage available. The insurance or its provisions may vary or be unavailable in some states. The insurance has exclusions and limitations which may affect any benets payable. Applicable to policy form GAC4100-P and certicate form GAC4100-C (including state abbreviations where used, for example, GAC4100-P-TX). For cost and complete details of coverage, call or write your Colonial Life benets counselor or the company.Underwritten by Colonial Life & Accident Insurance Company, Columbia, SC. © 2023 Colonial Life & Accident Insurance Company. All rights reserved. Colonial Life is a registered trademark and marketing brand of Colonial Life & Accident Insurance Company.FOR EMPLOYEES 2-23 | 1284100ColonialLife.com

Group Accident InsuranceActive Lifestyles BenetThis benet increases the amount you receive by 20% for your covered eligible benets, giving you more nancial protection for the unexpected. The active lifestyles benet is available to you with group accident coverage, as well as all your covered family members.Eligible benets1• Concussion • Connective tissue damage • Dislocations • Emergency dental repair • Eye injury • Fractures • Knee cartilage (meniscus) injury • Lacerations • Medical imaging • Ruptured or herniated disc • Surgery ‐ Connective tissue surgery ‐ Dislocations — surgical repair ‐ Eye surgery ‐ Fractures — surgical repair ‐ General surgery — abdominal, thoracic, cranial, exploratory ‐ Knee cartilage (meniscus) surgery ‐ Ruptured or herniated disc surgery• X-ray or ultrasoundTo learn more, talk with your Colonial Life benets counselor.BENEFITS STORYOlivia slipped off the stair climber at the gym …And hit her head on the oor. She had a concussion and fractured her ankle. Olivia’s payable claim added up to $2,500 in accident benets. Her claim included benets that were eligible for a 20% active lifestyles benet. $2,500Eligible benets$2,500x 20%$500Eligible benet amountActive lifestyles benetActive lifestyles benet calculation $2,500 + $500$3,000Eligible benet amountActive lifestyles benetTotalFor illustrative purposes only.GROUP ACCIDENT (GAC4100) - ACTIVE LIFESTYLES BENEFIT

Group Accident InsuranceActive Lifestyles BenetThis benet increases the amount you receive by 20% for your covered eligible benets, giving you more nancial protection for the unexpected. The active lifestyles benet is available to you with group accident coverage, as well as all your covered family members.Eligible benets1• Concussion • Connective tissue damage • Dislocations • Emergency dental repair • Eye injury • Fractures • Knee cartilage (meniscus) injury • Lacerations • Medical imaging • Ruptured or herniated disc • Surgery ‐ Connective tissue surgery ‐ Dislocations — surgical repair ‐ Eye surgery ‐ Fractures — surgical repair ‐ General surgery — abdominal, thoracic, cranial, exploratory ‐ Knee cartilage (meniscus) surgery ‐ Ruptured or herniated disc surgery• X-ray or ultrasoundTo learn more, talk with your Colonial Life benets counselor.BENEFITS STORYOlivia slipped off the stair climber at the gym …And hit her head on the oor. She had a concussion and fractured her ankle. Olivia’s payable claim added up to $2,500 in accident benets. Her claim included benets that were eligible for a 20% active lifestyles benet. $2,500Eligible benets$2,500x 20%$500Eligible benet amountActive lifestyles benetActive lifestyles benet calculation $2,500 + $500$3,000Eligible benet amountActive lifestyles benetTotalFor illustrative purposes only.GROUP ACCIDENT (GAC4100) - ACTIVE LIFESTYLES BENEFIT

1. Active lifestyles benet applies to any combination of these injuries or services due to a covered accident.HEALTH SAVINGS ACCOUNT (HSA) COMPATIBLEThis plan is compatible with HSA guidelines and any other HSA plan in which a covered family member may participate. It may also be offered to employees who do not have HSAs.THIS INSURANCE PROVIDES LIMITED BENEFITS.This coverage is a supplement to health insurance. It is not a substitute for essential health benets or minimum essential coverage as dened in federal law. Insureds in some states must be covered by comprehensive health insurance before applying for this insurance.EXCLUSIONS AND LIMITATIONSWe will not pay benets for claims that are caused by, contributed to by, or resulting from elective procedures, felonies or illegal occupations, hazardous avocations, impaired driving, incarceration, racing, semi-professional or professional sports, sickness, suicide or self-inicted injuries, war, or armed conict.STATE VARIATIONS FOR EXCLUSIONS AND LIMITATIONSID: “Semi-professional sports or professional sports” exclusion is replaced by “professional sports” exclusion.IL: We will not pay benets for claims that are caused by or resulting from Exclusions.MD: Includes an exclusion for “Prohibited referrals.” The “felonies or illegal occupations” and “impaired driving” exclusions apply only to Accidental Death and Dismemberment benets.MI: “Impaired driving” and “suicide or self-inicted injuries” exclusions do not apply.MN: “Suicide or self-inicted injuries” exclusion does not apply.NH: “Incarceration” and “racing” exclusions do not apply.UT: We will not pay benets for claims that are caused by or resulting from Exclusions.VT: “Impaired driving” exclusion does not apply.This information is not intended to be a complete description of the insurance coverage available. The insurance or its provisions may vary or be unavailable in some states. The insurance has exclusions and limitations which may affect any benets payable. Applicable to policy form GAC4100-P and certicate form GAC4100-C (including state abbreviations where used, for example, GAC4100-P-TX). For cost and complete details of coverage, call or write your Colonial Life benets counselor or the company.Underwritten by Colonial Life & Accident Insurance Company, Columbia, SC. © 2023 Colonial Life & Accident Insurance Company. All rights reserved. Colonial Life is a registered trademark and marketing brand of Colonial Life & Accident Insurance Company.FOR EMPLOYEES 3-23 | 1335475ColonialLife.com

1. Active lifestyles benet applies to any combination of these injuries or services due to a covered accident.HEALTH SAVINGS ACCOUNT (HSA) COMPATIBLEThis plan is compatible with HSA guidelines and any other HSA plan in which a covered family member may participate. It may also be offered to employees who do not have HSAs.THIS INSURANCE PROVIDES LIMITED BENEFITS.This coverage is a supplement to health insurance. It is not a substitute for essential health benets or minimum essential coverage as dened in federal law. Insureds in some states must be covered by comprehensive health insurance before applying for this insurance.EXCLUSIONS AND LIMITATIONSWe will not pay benets for claims that are caused by, contributed to by, or resulting from elective procedures, felonies or illegal occupations, hazardous avocations, impaired driving, incarceration, racing, semi-professional or professional sports, sickness, suicide or self-inicted injuries, war, or armed conict.STATE VARIATIONS FOR EXCLUSIONS AND LIMITATIONSID: “Semi-professional sports or professional sports” exclusion is replaced by “professional sports” exclusion.IL: We will not pay benets for claims that are caused by or resulting from Exclusions.MD: Includes an exclusion for “Prohibited referrals.” The “felonies or illegal occupations” and “impaired driving” exclusions apply only to Accidental Death and Dismemberment benets.MI: “Impaired driving” and “suicide or self-inicted injuries” exclusions do not apply.MN: “Suicide or self-inicted injuries” exclusion does not apply.NH: “Incarceration” and “racing” exclusions do not apply.UT: We will not pay benets for claims that are caused by or resulting from Exclusions.VT: “Impaired driving” exclusion does not apply.This information is not intended to be a complete description of the insurance coverage available. The insurance or its provisions may vary or be unavailable in some states. The insurance has exclusions and limitations which may affect any benets payable. Applicable to policy form GAC4100-P and certicate form GAC4100-C (including state abbreviations where used, for example, GAC4100-P-TX). For cost and complete details of coverage, call or write your Colonial Life benets counselor or the company.Underwritten by Colonial Life & Accident Insurance Company, Columbia, SC. © 2023 Colonial Life & Accident Insurance Company. All rights reserved. Colonial Life is a registered trademark and marketing brand of Colonial Life & Accident Insurance Company.FOR EMPLOYEES 3-23 | 1335475ColonialLife.com

Group Accident InsuranceBuilding BenetThis benet can increase the value of your accident coverage the longer you keep it by increasing the amount you receive for covered eligible benets, giving you more nancial protection for the unexpected. The building benet is available to you with group accident coverage, as well as all your covered family members.The building benet applies to benets for injury, fractures and dislocations, treatment, surgery, and recovery care due to a covered accident, as described in the certicate of coverage. Additional benets may be eligible for the building benet to apply. Refer to the certicate of coverage for a complete list of covered benets.1How your benets may increase in value Continuous coverage Percentage increase13 to 36 months 5%37 to 60 months 10%61+ months 15%To learn more, talk with your Colonial Life benets counselor.BENEFITS STORYNoah had a bicycle accident and fractured his wrist and forearm. His payable claim added up to $2,500 in eligible accident benets. Noah had been continuously covered under his accident coverage for 14 months. He was eligible for a 5% building benet.$2,500 Eligible benetsCoverage time: 14 months5% Building benet$2,500x 5%$125Eligible benet amountBuilding benetBuilding benet calculation $2,500 + $125$2,625Eligible benet amountBuilding benetTotalFor illustrative purposes only.GROUP ACCIDENT (GAC4100) - BUILDING BENEFIT

Group Accident InsuranceBuilding BenetThis benet can increase the value of your accident coverage the longer you keep it by increasing the amount you receive for covered eligible benets, giving you more nancial protection for the unexpected. The building benet is available to you with group accident coverage, as well as all your covered family members.The building benet applies to benets for injury, fractures and dislocations, treatment, surgery, and recovery care due to a covered accident, as described in the certicate of coverage. Additional benets may be eligible for the building benet to apply. Refer to the certicate of coverage for a complete list of covered benets.1How your benets may increase in value Continuous coverage Percentage increase13 to 36 months 5%37 to 60 months 10%61+ months 15%To learn more, talk with your Colonial Life benets counselor.BENEFITS STORYNoah had a bicycle accident and fractured his wrist and forearm. His payable claim added up to $2,500 in eligible accident benets. Noah had been continuously covered under his accident coverage for 14 months. He was eligible for a 5% building benet.$2,500 Eligible benetsCoverage time: 14 months5% Building benet$2,500x 5%$125Eligible benet amountBuilding benetBuilding benet calculation $2,500 + $125$2,625Eligible benet amountBuilding benetTotalFor illustrative purposes only.GROUP ACCIDENT (GAC4100) - BUILDING BENEFIT

1. Building benet applies to any combination of these injuries or services due to a covered accident. This benet is payable once per insured per covered accident.HEALTH SAVINGS ACCOUNT (HSA) COMPATIBLEThis plan is compatible with HSA guidelines and any other HSA plan in which a covered family member may participate. It may also be offered to employees who do not have HSAs.THIS INSURANCE PROVIDES LIMITED BENEFITS.This coverage is a supplement to health insurance. It is not a substitute for essential health benets or minimum essential coverage as dened in federal law. Insureds in some states must be covered by comprehensive health insurance before applying for this insurance.EXCLUSIONS AND LIMITATIONSWe will not pay benets for claims that are caused by, contributed to by, or resulting from elective procedures, felonies or illegal occupations, hazardous avocations, impaired driving, incarceration, racing, semi-professional or professional sports, sickness, suicide or self-inicted injuries, war, or armed conict.STATE VARIATIONS FOR EXCLUSIONS AND LIMITATIONSID: “Semi-professional sports or professional sports” exclusion is replaced by “professional sports” exclusion.IL: We will not pay benets for claims that are caused by or resulting from Exclusions.MD: Includes an exclusion for “Prohibited referrals.” The “felonies or illegal occupations” and “impaired driving” exclusions apply only to Accidental Death and Dismemberment benets.MI: “Impaired driving” and “suicide or self-inicted injuries” exclusions do not apply.MN: “Suicide or self-inicted injuries” exclusion does not apply.NH: “Incarceration” and “racing” exclusions do not apply.UT: We will not pay benets for claims that are caused by or resulting from Exclusions.VT: “Impaired driving” exclusion does not apply.This information is not intended to be a complete description of the insurance coverage available. The insurance or its provisions may vary or be unavailable in some states. The insurance has exclusions and limitations which may affect any benets payable. Applicable to policy form GAC4100-P and certicate form GAC4100-C (including state abbreviations where used, for example, GAC4100-P-TX). For cost and complete details of coverage, call or write your Colonial Life benets counselor or the company.Underwritten by Colonial Life & Accident Insurance Company, Columbia, SC. © 2023 Colonial Life & Accident Insurance Company. All rights reserved. Colonial Life is a registered trademark and marketing brand of Colonial Life & Accident Insurance Company.FOR EMPLOYEES 3-23 | 1285095ColonialLife.com

1. Building benet applies to any combination of these injuries or services due to a covered accident. This benet is payable once per insured per covered accident.HEALTH SAVINGS ACCOUNT (HSA) COMPATIBLEThis plan is compatible with HSA guidelines and any other HSA plan in which a covered family member may participate. It may also be offered to employees who do not have HSAs.THIS INSURANCE PROVIDES LIMITED BENEFITS.This coverage is a supplement to health insurance. It is not a substitute for essential health benets or minimum essential coverage as dened in federal law. Insureds in some states must be covered by comprehensive health insurance before applying for this insurance.EXCLUSIONS AND LIMITATIONSWe will not pay benets for claims that are caused by, contributed to by, or resulting from elective procedures, felonies or illegal occupations, hazardous avocations, impaired driving, incarceration, racing, semi-professional or professional sports, sickness, suicide or self-inicted injuries, war, or armed conict.STATE VARIATIONS FOR EXCLUSIONS AND LIMITATIONSID: “Semi-professional sports or professional sports” exclusion is replaced by “professional sports” exclusion.IL: We will not pay benets for claims that are caused by or resulting from Exclusions.MD: Includes an exclusion for “Prohibited referrals.” The “felonies or illegal occupations” and “impaired driving” exclusions apply only to Accidental Death and Dismemberment benets.MI: “Impaired driving” and “suicide or self-inicted injuries” exclusions do not apply.MN: “Suicide or self-inicted injuries” exclusion does not apply.NH: “Incarceration” and “racing” exclusions do not apply.UT: We will not pay benets for claims that are caused by or resulting from Exclusions.VT: “Impaired driving” exclusion does not apply.This information is not intended to be a complete description of the insurance coverage available. The insurance or its provisions may vary or be unavailable in some states. The insurance has exclusions and limitations which may affect any benets payable. Applicable to policy form GAC4100-P and certicate form GAC4100-C (including state abbreviations where used, for example, GAC4100-P-TX). For cost and complete details of coverage, call or write your Colonial Life benets counselor or the company.Underwritten by Colonial Life & Accident Insurance Company, Columbia, SC. © 2023 Colonial Life & Accident Insurance Company. All rights reserved. Colonial Life is a registered trademark and marketing brand of Colonial Life & Accident Insurance Company.FOR EMPLOYEES 3-23 | 1285095ColonialLife.com

Group Accident InsuranceWellbeing Assistance Benet – MaxThis benet can help reduce the risk of serious illness through early detection of disease or other risk factors, giving you more protection from the unexpected.The wellbeing assistance benet is available to you with group accident coverage, as well as all your covered family members.Wellbeing assistance bene it ....................$ 100.00Payable once per covered person per calendar year; subject to a 30-day waiting period.• Annual physical, including annual exams, sports physicals and well child visits • Blood test for triglycerides • Bone marrow testing• BRCA1 or BRCA2 testing• Breast ultrasound• CA 15-3 (blood test for breast cancer) • CA 125 (blood test for ovarian cancer) • Carotid Doppler• CEA (blood test for colon cancer)• Chest X-ray • Colonoscopy• Echocardiogram (ECHO) • Electrocardiogram (EKG, ECG) • Fasting blood glucose test • Flexible sigmoidoscopy • Hemoccult stool analysis• Immunizations • Mammography • Pap smear • Physical • PSA (blood test for prostate cancer)• Serum cholesterol test for HDL andLDL levels• Serum protein electrophoresis (blood test for myeloma)• Skin cancer biopsy • Stress test on a bicycle or treadmill • Thermography • ThinPrep pap test • Virtual colonoscopyTo learn more, talk with your Colonial Life benets counselor.GROUP ACCIDENT (GAC4100) – WELLBEING ASSISTANCE BENEFIT - MAX

Group Accident InsuranceWellbeing Assistance Benet – MaxThis benet can help reduce the risk of serious illness through early detection of disease or other risk factors, giving you more protection from the unexpected.The wellbeing assistance benet is available to you with group accident coverage, as well as all your covered family members.Wellbeing assistance bene it ....................$ 100.00Payable once per covered person per calendar year; subject to a 30-day waiting period.• Annual physical, including annual exams, sports physicals and well child visits • Blood test for triglycerides • Bone marrow testing• BRCA1 or BRCA2 testing• Breast ultrasound• CA 15-3 (blood test for breast cancer) • CA 125 (blood test for ovarian cancer) • Carotid Doppler• CEA (blood test for colon cancer)• Chest X-ray • Colonoscopy• Echocardiogram (ECHO) • Electrocardiogram (EKG, ECG) • Fasting blood glucose test • Flexible sigmoidoscopy • Hemoccult stool analysis• Immunizations • Mammography • Pap smear • Physical • PSA (blood test for prostate cancer)• Serum cholesterol test for HDL andLDL levels• Serum protein electrophoresis (blood test for myeloma)• Skin cancer biopsy • Stress test on a bicycle or treadmill • Thermography • ThinPrep pap test • Virtual colonoscopyTo learn more, talk with your Colonial Life benets counselor.GROUP ACCIDENT (GAC4100) – WELLBEING ASSISTANCE BENEFIT - MAX

STATE VARIATIONS FOR BENEFITS MD: Waiting period does not apply WV: Includes human papillomavirus screening test HEALTH SAVINGS ACCOUNT (HSA) COMPATIBLE This plan is compatible with HSA guidelines and any other HSA plan in which a covered family member may participate. It may also be offered to employees who do not have HSAs. THIS INSURANCE PROVIDES LIMITED BENEFITS. This coverage is a supplement to health insurance. It is not a substitute for essential health benets or minimum essential coverage as dened in federal law. Insureds in some states must be covered by comprehensive health insurance before applying for this insurance. EXCLUSIONS AND LIMITATIONS We will not pay benets for claims that are caused by, contributed to by, or resulting from elective procedures, felonies or illegal occupations, hazardous avocations, impaired driving, incarceration, racing, semi-professional or professional sports, sickness, suicide or self-inicted injuries, war, or armed conict. STATE VARIATIONS FOR EXCLUSIONS AND LIMITATIONS IL: We will not pay benets for claims that are caused by or resulting from Exclusions. MD: Includes an exclusion for “Prohibited referrals.” The “felonies or illegal occupations” and “impaired driving” exclusions apply only to Accidental Death and Dismemberment benets. MN: “Suicide or self-inicted injuries” exclusion does not apply. UT: We will not pay benets for claims that are caused by or resulting from Exclusions. VT: “Impaired driving” exclusion does not apply. This information is not intended to be a complete description of the insurance coverage available. The insurance or its provisions may vary or be unavailable in some states. The insurance has exclusions and limitations which may affect any benets payable. Applicable to policy form GAC4100-P and certicate form GAC4100-C (including state abbreviations where used, for example, GAC4100-P-TX). For cost and complete details of coverage, call or write your Colonial Life benets counselor or the company. Underwritten by Colonial Life & Accident Insurance Company, Columbia, SC. © 2023 Colonial Life & Accident Insurance Company. All rights reserved. Colonial Life is a registered trademark and marketing brand of Colonial Life & Accident Insurance Company. FOR EMPLOYEES 2-23 | 1345452ColonialLife.com

STATE VARIATIONS FOR BENEFITS MD: Waiting period does not apply WV: Includes human papillomavirus screening test HEALTH SAVINGS ACCOUNT (HSA) COMPATIBLE This plan is compatible with HSA guidelines and any other HSA plan in which a covered family member may participate. It may also be offered to employees who do not have HSAs. THIS INSURANCE PROVIDES LIMITED BENEFITS. This coverage is a supplement to health insurance. It is not a substitute for essential health benets or minimum essential coverage as dened in federal law. Insureds in some states must be covered by comprehensive health insurance before applying for this insurance. EXCLUSIONS AND LIMITATIONS We will not pay benets for claims that are caused by, contributed to by, or resulting from elective procedures, felonies or illegal occupations, hazardous avocations, impaired driving, incarceration, racing, semi-professional or professional sports, sickness, suicide or self-inicted injuries, war, or armed conict. STATE VARIATIONS FOR EXCLUSIONS AND LIMITATIONS IL: We will not pay benets for claims that are caused by or resulting from Exclusions. MD: Includes an exclusion for “Prohibited referrals.” The “felonies or illegal occupations” and “impaired driving” exclusions apply only to Accidental Death and Dismemberment benets. MN: “Suicide or self-inicted injuries” exclusion does not apply. UT: We will not pay benets for claims that are caused by or resulting from Exclusions. VT: “Impaired driving” exclusion does not apply. This information is not intended to be a complete description of the insurance coverage available. The insurance or its provisions may vary or be unavailable in some states. The insurance has exclusions and limitations which may affect any benets payable. Applicable to policy form GAC4100-P and certicate form GAC4100-C (including state abbreviations where used, for example, GAC4100-P-TX). For cost and complete details of coverage, call or write your Colonial Life benets counselor or the company. Underwritten by Colonial Life & Accident Insurance Company, Columbia, SC. © 2023 Colonial Life & Accident Insurance Company. All rights reserved. Colonial Life is a registered trademark and marketing brand of Colonial Life & Accident Insurance Company. FOR EMPLOYEES 2-23 | 1345452ColonialLife.com

For more information, talk with your benefits counselor.Group Hospital Indemnity InsurancePlan 2ColonialLife.comGroup Medical BridgeTM insurance can help with medical costs associated with a hospital stay that your health insurance may not cover. These benefits are available for you, your spouse and eligible dependent children.Hospital confinement ............................................................... $ _______________ per dayMaximum of one day per covered person per calendar yearWaiver of premiumAvailable aer 30 continuous days of a covered confinement of the named insuredDaily hospital confinement ................................................................... $100 per dayMaximum of 365 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. Outpatient surgical procedure¾ Tier 1 .................................................................................... $750.00 per day¾ Tier 2 .................................................................................... $1,500.00 per dayMaximum of $2,500.00 per covered person per calendar year for Tier 1 and 2 combined Maximum of one day per outpatient surgical procedureGMB7000 – PLAN 2

For more information, talk with your benefits counselor.Group Hospital Indemnity InsurancePlan 2ColonialLife.comGroup Medical BridgeTM insurance can help with medical costs associated with a hospital stay that your health insurance may not cover. These benefits are available for you, your spouse and eligible dependent children.Hospital confinement ............................................................... $ _______________ per dayMaximum of one day per covered person per calendar yearWaiver of premiumAvailable aer 30 continuous days of a covered confinement of the named insuredDaily hospital confinement ................................................................... $100 per dayMaximum of 365 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. Outpatient surgical procedure¾ Tier 1 .................................................................................... $750.00 per day¾ Tier 2 .................................................................................... $1,500.00 per dayMaximum of $2,500.00 per covered person per calendar year for Tier 1 and 2 combined Maximum of one day per outpatient surgical procedureGMB7000 – PLAN 2

ColonialLife.com11-21 | 101918-2THIS INSURANCE PROVIDES LIMITED BENEFITS.EXCLUSIONSWe will not pay any benefits for injuries received in accidents or for sicknesses which are caused by, contributed to by or occur as a result of the following exclusions and limitations. (a) alcoholism or drug addiction; (b) dental procedures; (c) elective procedures and cosmetic surgery; (d) felonies or illegal occupations; (e) mental or nervous disorders; (f) pregnancy of a dependent child; (g) suicide or injuries which any covered person intentionally does to himself or herself; (h) war or armed forces service. We will not pay benefits for hospital confinement (i) due to giving birth within the first nine months aer the eective date of the policy or (j) for a newborn who is neither injured nor sick.(k) The policy may have additional exclusions and limitations which may aect any benefits payable.PRE-EXISTING CONDITION LIMITATIONS(l) We will not pay benefits for loss during the first 12 months aer the certificate eective date due to a pre-existing condition. (m) A pre-existing condition is a sickness or physical condition, whether diagnosed or not, for which a covered person was treated, had medical testing, received medical advice or had taken medication within the 12 months before the certificate eective date. (n) This limitation applies to the following benefits, if applicable: Hospital Confinement, Daily Hospital Confinement, Inpatient Mental and Nervous, Rehabilitation Unit Confinement, Specified Critical Illness, Diagnostic Procedure, and Outpatient Surgical Procedure.This information is not intended to be a complete description of the insurance coverage available. The insurance or its provisions may vary or be unavailable in some states. The insurance has exclusions and limitations which may aect any benefits payable. Applicable to policy form GMB7000-P and certificate form GMB7000-C (including state abbreviations where used, for example: GMB7000-C-TX). For cost and complete details of coverage, call or write your Colonial Life benefits counselor or the company.  Breast– Breast reconstruction– Breast reduction  Cardiac– Angioplasty– Cardiac catheterization  Digestive– Exploratory laparoscopy– Laparoscopic appendectomy– Laparoscopic cholecystectomy  Ear, nose, throat, mouth– Ethmoidectomy– Mastoidectomy– Septoplasty– Stapedectomy– TympanoplastyTier 2 outpatient surgical procedures Eye– Cataract surgery– Corneal surgery (penetrating keratoplasty)– Glaucoma surgery (trabeculectomy)– Vitrectomy  Gynecological– Hysterectomy– Myomectomy  Musculoskeletal system– Arthroscopic knee surgery with meniscectomy (knee cartilage repair)– Arthroscopic shoulder surgery– Clavicle resection– Dislocations (open reduction with internal fixation)– Fracture (open reduction with internal fixation)– Removal or implantation of cartilage– Tendon/ligament repairThe procedures listed below are only a sampling of the procedures that may be covered if the outpatient surgical procedure benefit is selected. Procedures must be performed by a doctor in a hospital or ambulatory surgical center. For complete details and definitions, refer to your certificate.Tier 1 outpatient surgical procedures Breast– Axillary node dissection– Breast capsulotomy– Lumpectomy  Cardiac– Pacemaker insertion  Digestive– Colonoscopy* – Fistulotomy– Hemorrhoidectomy– Lysis of adhesions  Ear, nose, throat, mouth– Adenoidectomy– Removal of oral lesions– Myringotomy– Tonsillectomy– Tracheostomy– Tympanotomy  Gynecological– Dilation and curettage (D&C)– Endometrial ablation– Lysis of adhesions  Liver– Paracentesis  Musculoskeletal system– Carpal/cubital repair or release– Foot surgery (bunionectomy, exostectomy, arthroplasty, hammertoe repair)– Removal of orthopedic hardware– Removal of tendon lesion  Skin– Laparoscopic hernia repair– Skin graingKS: "Surgical Procedure" benefit replaces "Outpatient Surgical Procedure." Diagnostic Procedures must be performed in a hospital or an ambulatory surgical center.PA: "Hospital Confinement Admission" benefit replaces the "Hospital Confinement" benefit* Colonoscopy must result in polyp removal or be recommended by a physician for the purposes of treating or diagnosing a sickness.If a covered family member has a qualified high deductible health plan (HDHP) and actively contributes to a health savings account (HSA), their HSA can be disqualified with this coverage.  Thyroid– Excision of a mass  Urologic– LithotripsyUnderwritten by Colonial Life & Accident Insurance Company, Columbia, SC©2021 Colonial Life & Accident Insurance Company. All rights reserved. Colonial Life is a registered trademark and marketing brand of Colonial Life & Accident Insurance Company.

ColonialLife.com11-21 | 101918-2THIS INSURANCE PROVIDES LIMITED BENEFITS.EXCLUSIONSWe will not pay any benefits for injuries received in accidents or for sicknesses which are caused by, contributed to by or occur as a result of the following exclusions and limitations. (a) alcoholism or drug addiction; (b) dental procedures; (c) elective procedures and cosmetic surgery; (d) felonies or illegal occupations; (e) mental or nervous disorders; (f) pregnancy of a dependent child; (g) suicide or injuries which any covered person intentionally does to himself or herself; (h) war or armed forces service. We will not pay benefits for hospital confinement (i) due to giving birth within the first nine months aer the eective date of the policy or (j) for a newborn who is neither injured nor sick.(k) The policy may have additional exclusions and limitations which may aect any benefits payable.PRE-EXISTING CONDITION LIMITATIONS(l) We will not pay benefits for loss during the first 12 months aer the certificate eective date due to a pre-existing condition. (m) A pre-existing condition is a sickness or physical condition, whether diagnosed or not, for which a covered person was treated, had medical testing, received medical advice or had taken medication within the 12 months before the certificate eective date. (n) This limitation applies to the following benefits, if applicable: Hospital Confinement, Daily Hospital Confinement, Inpatient Mental and Nervous, Rehabilitation Unit Confinement, Specified Critical Illness, Diagnostic Procedure, and Outpatient Surgical Procedure.This information is not intended to be a complete description of the insurance coverage available. The insurance or its provisions may vary or be unavailable in some states. The insurance has exclusions and limitations which may aect any benefits payable. Applicable to policy form GMB7000-P and certificate form GMB7000-C (including state abbreviations where used, for example: GMB7000-C-TX). For cost and complete details of coverage, call or write your Colonial Life benefits counselor or the company.  Breast– Breast reconstruction– Breast reduction  Cardiac– Angioplasty– Cardiac catheterization  Digestive– Exploratory laparoscopy– Laparoscopic appendectomy– Laparoscopic cholecystectomy  Ear, nose, throat, mouth– Ethmoidectomy– Mastoidectomy– Septoplasty– Stapedectomy– TympanoplastyTier 2 outpatient surgical procedures Eye– Cataract surgery– Corneal surgery (penetrating keratoplasty)– Glaucoma surgery (trabeculectomy)– Vitrectomy  Gynecological– Hysterectomy– Myomectomy  Musculoskeletal system– Arthroscopic knee surgery with meniscectomy (knee cartilage repair)– Arthroscopic shoulder surgery– Clavicle resection– Dislocations (open reduction with internal fixation)– Fracture (open reduction with internal fixation)– Removal or implantation of cartilage– Tendon/ligament repairThe procedures listed below are only a sampling of the procedures that may be covered if the outpatient surgical procedure benefit is selected. Procedures must be performed by a doctor in a hospital or ambulatory surgical center. For complete details and definitions, refer to your certificate.Tier 1 outpatient surgical procedures Breast– Axillary node dissection– Breast capsulotomy– Lumpectomy  Cardiac– Pacemaker insertion  Digestive– Colonoscopy* – Fistulotomy– Hemorrhoidectomy– Lysis of adhesions  Ear, nose, throat, mouth– Adenoidectomy– Removal of oral lesions– Myringotomy– Tonsillectomy– Tracheostomy– Tympanotomy  Gynecological– Dilation and curettage (D&C)– Endometrial ablation– Lysis of adhesions  Liver– Paracentesis  Musculoskeletal system– Carpal/cubital repair or release– Foot surgery (bunionectomy, exostectomy, arthroplasty, hammertoe repair)– Removal of orthopedic hardware– Removal of tendon lesion  Skin– Laparoscopic hernia repair– Skin graingKS: "Surgical Procedure" benefit replaces "Outpatient Surgical Procedure." Diagnostic Procedures must be performed in a hospital or an ambulatory surgical center.PA: "Hospital Confinement Admission" benefit replaces the "Hospital Confinement" benefit* Colonoscopy must result in polyp removal or be recommended by a physician for the purposes of treating or diagnosing a sickness.If a covered family member has a qualified high deductible health plan (HDHP) and actively contributes to a health savings account (HSA), their HSA can be disqualified with this coverage.  Thyroid– Excision of a mass  Urologic– LithotripsyUnderwritten by Colonial Life & Accident Insurance Company, Columbia, SC©2021 Colonial Life & Accident Insurance Company. All rights reserved. Colonial Life is a registered trademark and marketing brand of Colonial Life & Accident Insurance Company.

For more information, talk with your benefits counselor.Group Hospital Confinement Indemnity InsuranceHealth Screening BenefitFor cost and complete details, see your Colonial Life benefits counselor. Applicable to policy form GMB1.0-P-R and certificate form GMB1.0-C-R. 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.GROUP MEDICAL BRIDGE HEALTH SCREENING BENEFIT | 5-18 | 100029-4ColonialLife.comHealth screening benefit ............................................................................ $100 per dayMaximum of one day per covered person per calendar year  Blood test for triglycerides  Bone marrow testing  Breast ultrasound  CA 15-3 (blood test for breast cancer)  CA 125 (blood test for ovarian cancer)  Carotid Doppler  CEA (blood test for colon cancer)  Chest X-ray  Colonoscopy  Echocardiogram (ECHO)  Electrocardiogram (EKG, ECG)  Fasting blood glucose test  Flexible sigmoidoscopy  Hemoccult stool analysis  Mammography  Pap smear  PSA (blood test for prostate cancer)  Serum cholesterol test for HDLand LDL levels  Serum protein electrophoresis(blood test for myeloma)  Skin cancer biopsy  Stress test on a bicycleor treadmill  Thermography  ThinPrep pap test  Virtual colonoscopyGroup Medical BridgeSM insurance’s health screening benefit can help pay for health and wellness tests you have each year.Underwritten by Colonial Life & Accident Insurance Company, Columbia, SC ©2018 Colonial Life & Accident Insurance Company. All rights reserved. Colonial Life is a registered trademark and marketing brand of Colonial Life & Accident Insurance Company.

For more information, talk with your benefits counselor.Group Hospital Confinement Indemnity InsuranceHealth Screening BenefitFor cost and complete details, see your Colonial Life benefits counselor. Applicable to policy form GMB1.0-P-R and certificate form GMB1.0-C-R. 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.GROUP MEDICAL BRIDGE HEALTH SCREENING BENEFIT | 5-18 | 100029-4ColonialLife.comHealth screening benefit ............................................................................ $100 per dayMaximum of one day per covered person per calendar year  Blood test for triglycerides  Bone marrow testing  Breast ultrasound  CA 15-3 (blood test for breast cancer)  CA 125 (blood test for ovarian cancer)  Carotid Doppler  CEA (blood test for colon cancer)  Chest X-ray  Colonoscopy  Echocardiogram (ECHO)  Electrocardiogram (EKG, ECG)  Fasting blood glucose test  Flexible sigmoidoscopy  Hemoccult stool analysis  Mammography  Pap smear  PSA (blood test for prostate cancer)  Serum cholesterol test for HDLand LDL levels  Serum protein electrophoresis(blood test for myeloma)  Skin cancer biopsy  Stress test on a bicycleor treadmill  Thermography  ThinPrep pap test  Virtual colonoscopyGroup Medical BridgeSM insurance’s health screening benefit can help pay for health and wellness tests you have each year.Underwritten by Colonial Life & Accident Insurance Company, Columbia, SC ©2018 Colonial Life & Accident Insurance Company. All rights reserved. Colonial Life is a registered trademark and marketing brand of Colonial Life & Accident Insurance Company.

Group Critical Illness InsurancePlan 2GCI6000 – PLAN 2 – CRITICAL ILLNESS AND CANCERWhen life takes an unexpected turn, your focus should be on recovery — not finances. Colonial Life’s group critical illness insurance helps relieve financial worries by providing a lump-sum benefit payable directly to you to use as needed.Coverage amount: ____________________________COVERED CRITICAL ILLNESS CONDITIONPERCENTAGE OF APPLICABLE COVERAGE AMOUNTBenign brain tumor100%Coma100%End stage renal (kidney) failure100%Heart attack (myocardial infarction)100%Loss of hearing100%Loss of sight100%Loss of speech100%Major organ failure requiring transplant100%Occupational infectious HIV or occupational infectious hepatitis B, C or D100%Stroke100%Sudden cardiac arrest 100%Coronary artery disease25%COVERED CANCER CONDITIONPERCENTAGE OF APPLICABLE COVERAGE AMOUNTInvasive cancer (including all breast cancer)100%Non-invasive cancer25%Skin cancer initial diagnosis ............................................................ $400 per lifetimeCritical illness and cancer benefitsSpecial needs daycareA hospital stay and treatment for corrective heart surgeryPhysical therapy to build muscle strengthFor illustrative purposes only.Preparing for a lifelong journeyRebecca was born with Down syndrome. Her parents’ critical illness coverage provided a benefit that can help cover expenses related to Rebecca’s care and her changing needs. HOW THEIR COVERAGE HELPEDThe lump-sum amount from the family coverage benefit helped pay for:

Group Critical Illness InsurancePlan 2GCI6000 – PLAN 2 – CRITICAL ILLNESS AND CANCERWhen life takes an unexpected turn, your focus should be on recovery — not finances. Colonial Life’s group critical illness insurance helps relieve financial worries by providing a lump-sum benefit payable directly to you to use as needed.Coverage amount: ____________________________COVERED CRITICAL ILLNESS CONDITIONPERCENTAGE OF APPLICABLE COVERAGE AMOUNTBenign brain tumor100%Coma100%End stage renal (kidney) failure100%Heart attack (myocardial infarction)100%Loss of hearing100%Loss of sight100%Loss of speech100%Major organ failure requiring transplant100%Occupational infectious HIV or occupational infectious hepatitis B, C or D100%Stroke100%Sudden cardiac arrest 100%Coronary artery disease25%COVERED CANCER CONDITIONPERCENTAGE OF APPLICABLE COVERAGE AMOUNTInvasive cancer (including all breast cancer)100%Non-invasive cancer25%Skin cancer initial diagnosis ............................................................ $400 per lifetimeCritical illness and cancer benefitsSpecial needs daycareA hospital stay and treatment for corrective heart surgeryPhysical therapy to build muscle strengthFor illustrative purposes only.Preparing for a lifelong journeyRebecca was born with Down syndrome. Her parents’ critical illness coverage provided a benefit that can help cover expenses related to Rebecca’s care and her changing needs. HOW THEIR COVERAGE HELPEDThe lump-sum amount from the family coverage benefit helped pay for:

ColonialLife.com6-20 | 387100-TX1. Refer to the certificate for complete definitions of covered conditions. 2. Dates of diagnoses of a covered critical illness must be separated by more than 180 days. 3. Critical illnesses that do not qualify include: coronary artery disease, loss of hearing, loss of sight, loss of speech, and occupational infectious HIV or occupational infectious hepatitis B, C or D.THIS INSURANCE PROVIDES LIMITED BENEFITS.EXCLUSIONS AND LIMITATIONS FOR CRITICAL ILLNESS We will not pay the Critical Illness Benefit, Benefits Payable Upon Subsequent Diagnosis of a Critical Illness or Additional Critical Illness Benefit for Dependent Children that occurs as a result of a covered person’s: doctor or physician relationship; felonies or illegal occupations; intoxicants and narcotics; suicide or injuring oneself intentionally, whether sane or not; war or armed conflict; or pre-existing condition, unless the covered person has satisfied the pre-existing condition limitation period shown on the Certificate Schedule on the date the covered person is diagnosed with a critical illness.EXCLUSIONS AND LIMITATIONS FOR CANCER We will not pay the Invasive Cancer (including all Breast Cancer) Benefit, Non-Invasive Cancer Benefit, Benefit Payable Upon Reoccurrence of Invasive Cancer (including all Breast Cancer) or Skin Cancer Initial Diagnosis Benefit for a covered person’s invasive cancer or non-invasive cancer that: is diagnosed or treated outside the territorial limits of the United States, its possessions, or the countries of Canada and Mexico; is a pre-existing condition, unless the covered person has satisfied the pre-existing condition limitation period shown on the Certificate Schedule on the date the covered person is initially diagnosed as having invasive or non-invasive cancer. No pre-existing condition limitation will be applied for dependent children who are born or adopted while the named insured is covered under the certificate, and who are continuously covered from the date of birth or adoption.PRE-EXISTING CONDITION LIMITATION We will not pay a benefit for a pre-existing condition that occurs during the 12-month period aer the coverage eective date. Pre-existing condition means a sickness or physical condition for which a covered person received medical advice or treatment within 12 months before the coverage eective date.This information is not intended to be a complete description of the insurance coverage available. The insurance has exclusions and limitations which may aect any benefits payable. Applicable to policy forms GCI6000-P-EE-TX and GCI6000-P-AU-TX and certificate forms GCI6000-C-EE-TX and GCI6000-C-AU-TX. For cost and complete details of coverage, call or write your Colonial Life benefits counselor or the company.Underwritten by Colonial Life & Accident Insurance Company, Columbia, SC.©2020 Colonial Life & Accident Insurance Company. All rights reserved. Colonial Life is a registered trademark and marketing brand of Colonial Life & Accident Insurance Company.COVERED CONDITIONPERCENTAGE OF APPLICABLE COVERAGE AMOUNTCerebral palsy 100%Cle lip or palate 100%Cystic fibrosis 100%Down syndrome 100%Spina bifida 100%KEY BENEFITSAdditional covered conditions for dependent childrenSubsequent diagnosis of a dierent critical illnessIf you receive a benefit for a critical illness and are later diagnosed with a dierent critical illness, 100% of the coverage amount may be payable for that particular critical illness.Subsequent diagnosis of the same critical illnessIf you receive a benefit for a critical illness and are later diagnosed with the same critical illness,3 25% of the coverage amount is payable for that critical illness.Reoccurrence of invasive cancer (including all breast cancer)If you receive a benefit for invasive cancer and are later diagnosed with a reoccurrence of invasive cancer, 25% of the coverage amount is payable if treatment-free for at least 12 months and in complete remission prior to the date of reoccurrence; excludes non-invasive or skin cancer.For more information, talk with your benefits counselor.Preparing for the unexpected is simpler than you think. With Colonial Life, youʼll have the support you need to face lifeʼs toughest challenges.  Available coverage for spouse and eligible dependent children at 50% of your coverage amount  Cover your eligible dependent children at no additional cost  Receive coverage regardless of medical history, within specified limits  Works alongside your health savings account (HSA)  Benefits payable regardless of other insurance

ColonialLife.com6-20 | 387100-TX1. Refer to the certificate for complete definitions of covered conditions. 2. Dates of diagnoses of a covered critical illness must be separated by more than 180 days. 3. Critical illnesses that do not qualify include: coronary artery disease, loss of hearing, loss of sight, loss of speech, and occupational infectious HIV or occupational infectious hepatitis B, C or D.THIS INSURANCE PROVIDES LIMITED BENEFITS.EXCLUSIONS AND LIMITATIONS FOR CRITICAL ILLNESS We will not pay the Critical Illness Benefit, Benefits Payable Upon Subsequent Diagnosis of a Critical Illness or Additional Critical Illness Benefit for Dependent Children that occurs as a result of a covered person’s: doctor or physician relationship; felonies or illegal occupations; intoxicants and narcotics; suicide or injuring oneself intentionally, whether sane or not; war or armed conflict; or pre-existing condition, unless the covered person has satisfied the pre-existing condition limitation period shown on the Certificate Schedule on the date the covered person is diagnosed with a critical illness.EXCLUSIONS AND LIMITATIONS FOR CANCER We will not pay the Invasive Cancer (including all Breast Cancer) Benefit, Non-Invasive Cancer Benefit, Benefit Payable Upon Reoccurrence of Invasive Cancer (including all Breast Cancer) or Skin Cancer Initial Diagnosis Benefit for a covered person’s invasive cancer or non-invasive cancer that: is diagnosed or treated outside the territorial limits of the United States, its possessions, or the countries of Canada and Mexico; is a pre-existing condition, unless the covered person has satisfied the pre-existing condition limitation period shown on the Certificate Schedule on the date the covered person is initially diagnosed as having invasive or non-invasive cancer. No pre-existing condition limitation will be applied for dependent children who are born or adopted while the named insured is covered under the certificate, and who are continuously covered from the date of birth or adoption.PRE-EXISTING CONDITION LIMITATION We will not pay a benefit for a pre-existing condition that occurs during the 12-month period aer the coverage eective date. Pre-existing condition means a sickness or physical condition for which a covered person received medical advice or treatment within 12 months before the coverage eective date.This information is not intended to be a complete description of the insurance coverage available. The insurance has exclusions and limitations which may aect any benefits payable. Applicable to policy forms GCI6000-P-EE-TX and GCI6000-P-AU-TX and certificate forms GCI6000-C-EE-TX and GCI6000-C-AU-TX. For cost and complete details of coverage, call or write your Colonial Life benefits counselor or the company.Underwritten by Colonial Life & Accident Insurance Company, Columbia, SC.©2020 Colonial Life & Accident Insurance Company. All rights reserved. Colonial Life is a registered trademark and marketing brand of Colonial Life & Accident Insurance Company.COVERED CONDITIONPERCENTAGE OF APPLICABLE COVERAGE AMOUNTCerebral palsy 100%Cle lip or palate 100%Cystic fibrosis 100%Down syndrome 100%Spina bifida 100%KEY BENEFITSAdditional covered conditions for dependent childrenSubsequent diagnosis of a dierent critical illnessIf you receive a benefit for a critical illness and are later diagnosed with a dierent critical illness, 100% of the coverage amount may be payable for that particular critical illness.Subsequent diagnosis of the same critical illnessIf you receive a benefit for a critical illness and are later diagnosed with the same critical illness,3 25% of the coverage amount is payable for that critical illness.Reoccurrence of invasive cancer (including all breast cancer)If you receive a benefit for invasive cancer and are later diagnosed with a reoccurrence of invasive cancer, 25% of the coverage amount is payable if treatment-free for at least 12 months and in complete remission prior to the date of reoccurrence; excludes non-invasive or skin cancer.For more information, talk with your benefits counselor.Preparing for the unexpected is simpler than you think. With Colonial Life, youʼll have the support you need to face lifeʼs toughest challenges.  Available coverage for spouse and eligible dependent children at 50% of your coverage amount  Cover your eligible dependent children at no additional cost  Receive coverage regardless of medical history, within specified limits  Works alongside your health savings account (HSA)  Benefits payable regardless of other insurance

Group Critical Illness InsuranceWellbeing Assistance BenefitThe wellbeing assistance benefit can help reduce the risk of serious illness through early detection of disease or risk factors.Wellbeing assistance benefit ............................................................. $100.00Maximum of one test per covered person per calendar year; subject to a 30-day waiting period before the benefit is payable. The test must be performed aer the waiting period. Blood test for triglycerides Bone marrow testing BRCA1 or BRCA2 testing (genetic test for breast cancer) Breast ultrasound CA 15-3 (blood test for ovarian cancer) CA 125 (blood test for breast cancer) Carotid Doppler CEA (blood test for colon cancer) Chest x-ray Colonoscopy Echocardiogram (ECHO) Electrocardiogram (EKG, ECG) Fasting blood glucose test Flexible sigmoidoscopy Hemoccult stool analysis Mammography Pap smear PSA (blood test for prostate cancer) Serum cholesterol test for HDL and LDL levels Serum protein electrophoresis (blood test for myeloma) Skin cancer biopsy Stress test on a bicycle or treadmill Thermography ThinPrep pap test Virtual colonoscopyFor more information, talk with your benefits counselor.ColonialLife.comGCI6000 – WELLBEING ASSISTANCE BENEFIT | 5-20 | 387307Underwritten by Colonial Life & Accident Insurance Company, Columbia, SC.©2020 Colonial Life & Accident Insurance Company. All rights reserved. Colonial Life is a registered trademark and marketing brand of Colonial Life & Accident Insurance Company.THIS INSURANCE PROVIDES LIMITED BENEFITS.This information is not intended to be a complete description of the insurance coverage available. The insurance or its provisions may vary or be unavailable in some states. The insurance has exclusions and limitations which may aect any benefits payable. Applicable to policy form GCI6000-P and certificate form GCI6000-C (including state abbreviations where used, for example: GCI6000-C-TX). For cost and complete details of coverage, call or write your Colonial Life benefits counselor or the company.

Group Critical Illness InsuranceWellbeing Assistance BenefitThe wellbeing assistance benefit can help reduce the risk of serious illness through early detection of disease or risk factors.Wellbeing assistance benefit ............................................................. $100.00Maximum of one test per covered person per calendar year; subject to a 30-day waiting period before the benefit is payable. The test must be performed aer the waiting period. Blood test for triglycerides Bone marrow testing BRCA1 or BRCA2 testing (genetic test for breast cancer) Breast ultrasound CA 15-3 (blood test for ovarian cancer) CA 125 (blood test for breast cancer) Carotid Doppler CEA (blood test for colon cancer) Chest x-ray Colonoscopy Echocardiogram (ECHO) Electrocardiogram (EKG, ECG) Fasting blood glucose test Flexible sigmoidoscopy Hemoccult stool analysis Mammography Pap smear PSA (blood test for prostate cancer) Serum cholesterol test for HDL and LDL levels Serum protein electrophoresis (blood test for myeloma) Skin cancer biopsy Stress test on a bicycle or treadmill Thermography ThinPrep pap test Virtual colonoscopyFor more information, talk with your benefits counselor.ColonialLife.comGCI6000 – WELLBEING ASSISTANCE BENEFIT | 5-20 | 387307Underwritten by Colonial Life & Accident Insurance Company, Columbia, SC.©2020 Colonial Life & Accident Insurance Company. All rights reserved. Colonial Life is a registered trademark and marketing brand of Colonial Life & Accident Insurance Company.THIS INSURANCE PROVIDES LIMITED BENEFITS.This information is not intended to be a complete description of the insurance coverage available. The insurance or its provisions may vary or be unavailable in some states. The insurance has exclusions and limitations which may aect any benefits payable. Applicable to policy form GCI6000-P and certificate form GCI6000-C (including state abbreviations where used, for example: GCI6000-C-TX). For cost and complete details of coverage, call or write your Colonial Life benefits counselor or the company.

Individual Short-Term Disability Insurance ISTD3000 BASEYou never know when a disability could impact your way of life. Fortunately, there’s a way to help protect your income. If an accident or sickness prevents you from earning a paycheck, disability insurance can provide a monthly benefit to help you cover your ongoing expenses.Benefits worksheetHow much coverage do I need?Monthly benefit amount for o-job accident and o-job sickness: ______________Choose a monthly benefit amount between $400 and $6,500.*If your plan includes on-job accident/sickness benefits, the benefit is 50% of the o-job amount.How long will I receive benefits?Benefit period: _______ monthsThe partial disability benefit period is three months.When will my total disability benefits start?Aer an accident: _______ days Aer a sickness: _______ daysCan you aord to not protect your paycheck? You don’t have the same lifestyle expenses as the next person. That’s why you need disability coverage that can be customized to fit your specific needs.Aer calculating your monthly expenses, your benefits counselor can help you complete the benefits worksheet.ESTIMATED MONTHLY EXPENSES AMOUNTMortgage or rent$Utilities (electric/gas, phone, water, TV, Internet)$Transportation costs (gas, car payments) $Food$Health (medical needs and prescription drugs) $Other $TOTAL$ColonialLife.com*Subject to income requirements

Individual Short-Term Disability Insurance ISTD3000 BASEYou never know when a disability could impact your way of life. Fortunately, there’s a way to help protect your income. If an accident or sickness prevents you from earning a paycheck, disability insurance can provide a monthly benefit to help you cover your ongoing expenses.Benefits worksheetHow much coverage do I need?Monthly benefit amount for o-job accident and o-job sickness: ______________Choose a monthly benefit amount between $400 and $6,500.*If your plan includes on-job accident/sickness benefits, the benefit is 50% of the o-job amount.How long will I receive benefits?Benefit period: _______ monthsThe partial disability benefit period is three months.When will my total disability benefits start?Aer an accident: _______ days Aer a sickness: _______ daysCan you aord to not protect your paycheck? You don’t have the same lifestyle expenses as the next person. That’s why you need disability coverage that can be customized to fit your specific needs.Aer calculating your monthly expenses, your benefits counselor can help you complete the benefits worksheet.ESTIMATED MONTHLY EXPENSES AMOUNTMortgage or rent$Utilities (electric/gas, phone, water, TV, Internet)$Transportation costs (gas, car payments) $Food$Health (medical needs and prescription drugs) $Other $TOTAL$ColonialLife.com*Subject to income requirements

EXCLUSIONS AND LIMITATIONS We will not pay benefits for losses that are caused by, contributed to by or occur as the result of: cosmetic surgery, felonies or illegal occupations, flying, hazardous avocations, intoxicants and narcotics, mental or nervous disorders, racing, semi-professional or professional sports, substance abuse, suicide or injuries which you intentionally do to yourself, war or armed conflict. We will not pay for losses due to you giving birth within the first nine months aer the coverage eective date of the policy. We will not pay for loss when the disability is a pre-existing condition as described in the policy.For cost and complete details, see your Colonial Life benefits counselor. Applicable to policy form ISTD3000-TX and rider form ISTD3000-ADIB-TX. This is not an insurance contract and only the actual policy and rider provisions will control.©2015 Colonial Life & Accident Insurance Company, Columbia, SC | Colonial Life insurance products are underwritten by Colonial Life & Accident Insurance Company, for which Colonial Life is the marketing brand. 7-15 | 101629-TXProduct information Total disability definitionTotally disabled or total disability means you are: unable to perform the material and substantial duties of your occupation, not, in fact, working at any occupation, and under the regular and appropriate care of a physician.How partial disability worksIf you are able to return to work part-time aer at least 14 days of being paid for a total disability, you may be able to still receive 50% of your total disability benefit.Waiver of premiumWe will waive your premium payments aer 90 consecutive days of a covered disability.Geographical limitationsIf you are disabled while outside of the United States, Canada or Mexico, you may receive benefits for up to 60 days before you have to return to the U.S. in order to continue receiving benefits.Issue ageCoverage is available from ages 17 to 74.Keep your coverage You can keep your coverage to age 75 at no additional cost, even if you change jobs, as long as you pay your premiums when they are due.PremiumYour premium is based on your age when you purchase coverage and the amount of coverage you are eligible to buy. Your premium will not change as you age.For more information, talk with your benefits counselor.

EXCLUSIONS AND LIMITATIONS We will not pay benefits for losses that are caused by, contributed to by or occur as the result of: cosmetic surgery, felonies or illegal occupations, flying, hazardous avocations, intoxicants and narcotics, mental or nervous disorders, racing, semi-professional or professional sports, substance abuse, suicide or injuries which you intentionally do to yourself, war or armed conflict. We will not pay for losses due to you giving birth within the first nine months aer the coverage eective date of the policy. We will not pay for loss when the disability is a pre-existing condition as described in the policy.For cost and complete details, see your Colonial Life benefits counselor. Applicable to policy form ISTD3000-TX and rider form ISTD3000-ADIB-TX. This is not an insurance contract and only the actual policy and rider provisions will control.©2015 Colonial Life & Accident Insurance Company, Columbia, SC | Colonial Life insurance products are underwritten by Colonial Life & Accident Insurance Company, for which Colonial Life is the marketing brand. 7-15 | 101629-TXProduct information Total disability definitionTotally disabled or total disability means you are: unable to perform the material and substantial duties of your occupation, not, in fact, working at any occupation, and under the regular and appropriate care of a physician.How partial disability worksIf you are able to return to work part-time aer at least 14 days of being paid for a total disability, you may be able to still receive 50% of your total disability benefit.Waiver of premiumWe will waive your premium payments aer 90 consecutive days of a covered disability.Geographical limitationsIf you are disabled while outside of the United States, Canada or Mexico, you may receive benefits for up to 60 days before you have to return to the U.S. in order to continue receiving benefits.Issue ageCoverage is available from ages 17 to 74.Keep your coverage You can keep your coverage to age 75 at no additional cost, even if you change jobs, as long as you pay your premiums when they are due.PremiumYour premium is based on your age when you purchase coverage and the amount of coverage you are eligible to buy. Your premium will not change as you age.For more information, talk with your benefits counselor.

Term Life InsuranceHelp protect the people who depend on youIf something happened to you, the last thing your family should have to worry about is financial burdens. Funeral expenses, medical bills and taxes could be just the beginning. How would they cover ongoing living expenses, such as a mortgage, utilities and health care?Plan for the future with term life insurance from Colonial Life & Accident Insurance Company.The advantages of term life insurance  Level death benefit.  Lower cost option compared with cash value insurance.  Coverage for specified periods of time, which can be during high-need years.  Benefit for the beneficiary that is typically free from income tax.Benefits and features  Guaranteed premiums do not increase during the term.  Coverage is guaranteed renewable to age 95 as long as premiums are paid when due.  You can convert it to cash value insurance.  Portability allows you to take it with you if you change jobs or retire.  An accelerated death benefit is included.Your cost will vary based on the level of coverage you select. Talk with your Colonial Life benefits counselor for information about what level of coverage would work best for you.TERM LIFE 1000

Term Life InsuranceHelp protect the people who depend on youIf something happened to you, the last thing your family should have to worry about is financial burdens. Funeral expenses, medical bills and taxes could be just the beginning. How would they cover ongoing living expenses, such as a mortgage, utilities and health care?Plan for the future with term life insurance from Colonial Life & Accident Insurance Company.The advantages of term life insurance  Level death benefit.  Lower cost option compared with cash value insurance.  Coverage for specified periods of time, which can be during high-need years.  Benefit for the beneficiary that is typically free from income tax.Benefits and features  Guaranteed premiums do not increase during the term.  Coverage is guaranteed renewable to age 95 as long as premiums are paid when due.  You can convert it to cash value insurance.  Portability allows you to take it with you if you change jobs or retire.  An accelerated death benefit is included.Your cost will vary based on the level of coverage you select. Talk with your Colonial Life benefits counselor for information about what level of coverage would work best for you.TERM LIFE 1000

Benefits worksheetFor use with your Colonial Life benefits counselor£ YOU $ __________________ FACE AMOUNTSelect the term period£ 10-year term£ 20-year term£ 30-year term£ SPOUSE $ ______________ FACE AMOUNTSelect the term period£ 10-year term£ 20-year term£ 30-year termSelect any optional riders:£ Spouse term life rider $ _____________ face amount for ________-year term period£ Children’s term life rider $ _____________ face amount£ Waiver of premium benefit rider£ Accidental death benefit riderHOW MUCH COVERAGE DO YOU NEED?To learn more, talk with your Colonial Life benefits counselor.EXCLUSIONS AND LIMITATIONSIf the insured commits suicide within two years (one year in CO and ND) from the coverage eective date, whether he is sane or insane (not applicable in AZ), we will not pay the death benefit. We will terminate this policy and return the premiums paid, without interest. In MO, should death occur as a result of suicide, our company is responsible only for the return of premiums paid when application is made with intent to commit suicide.You will receive a policy summary or illustration (whichever is applicable to your state) when your policy is issued if this policy has exclusions, limitations or reductions of benefits. For costs and complete details, call or write your Colonial Life benefits counselor or the company. This brochure is applicable to policy forms TERM1000, R-TERM1000-ADB, R-TERM1000-CTR, R-TERM1000-STR, R-TERM1000-WAIVER (and applicable state variations, for example: TERM1000-TX, R-TERM1000-ADB-TX-1, R-TERM1000-CTR-TX, R-TERM1000-STR-TX and R-TERM1000-WAIVER-TX-1). See your Colonial Life benefits counselor for additional information specific for your state. This coverage contains limitations and exclusions that may aect benefits payable. Product may vary by state.Cash value policy conversionYou can convert your policy to a Colonial Life cash value life insurance policy any time through age 75 (unless you have used the accelerated death benefit or waiver of premium benefit rider) with no evidence of insurability. Premiums will be based on your age at the time you convert your policy.Accelerated death benefitIf you are diagnosed with a terminal illness, you can request up to 75% of the policy’s death benefit, not to exceed $150,000. We deduct a fee only if you use the benefit, and your death benefit will then be reduced by the amount you receive. In addition, there may be tax consequences for receiving the accelerated benefit; ask your tax advisor for advice. Please refer to your policy for details.Spouse coverage optionsTwo options are available for spouse coverage at an additional cost:1. Spouse term life policy: Oers guaranteed premiums and level death benefits equivalent to those available to you – whether or not you buy a policy for yourself.2. Spouse term life rider: Add a term rider for your spouse to your policy, up to a maximum death benefit of $50,000; 10-year and 20-year are available (20-year rider only available with a 20- or 30-year term policy).Dependent coverageYou may add a children’s term life rider to cover all of your eligible dependent children with up to $10,000 in coverage each for one premium. The children’s term life rider may be added to either the primary or spouse policy, not both.Waiver of premium benefit riderThis rider waives all premiums (for the policy and any riders) if you become totally and permanently disabled before the age of 65. To be considered permanent, your total disability must continue with no interruptions for at least six consecutive months. Premiums waived by this rider do not have to be repaid. This rider is available for the spouse policy as well, subject to home oice approval.Accidental death benefit riderThis rider provides an additional benefit to the beneficiary if the insured dies as a result of an accident before age 70. The benefit doubles if the injury resulting in death occurs while insured is a fare-paying passenger on a public conveyance, such as a commercial aircra or taxicab. An additional seatbelt benefit is also payable.©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. 4-16 | 64815-10ColonialLife.com

Benefits worksheetFor use with your Colonial Life benefits counselor£ YOU $ __________________ FACE AMOUNTSelect the term period£ 10-year term£ 20-year term£ 30-year term£ SPOUSE $ ______________ FACE AMOUNTSelect the term period£ 10-year term£ 20-year term£ 30-year termSelect any optional riders:£ Spouse term life rider $ _____________ face amount for ________-year term period£ Children’s term life rider $ _____________ face amount£ Waiver of premium benefit rider£ Accidental death benefit riderHOW MUCH COVERAGE DO YOU NEED?To learn more, talk with your Colonial Life benefits counselor.EXCLUSIONS AND LIMITATIONSIf the insured commits suicide within two years (one year in CO and ND) from the coverage eective date, whether he is sane or insane (not applicable in AZ), we will not pay the death benefit. We will terminate this policy and return the premiums paid, without interest. In MO, should death occur as a result of suicide, our company is responsible only for the return of premiums paid when application is made with intent to commit suicide.You will receive a policy summary or illustration (whichever is applicable to your state) when your policy is issued if this policy has exclusions, limitations or reductions of benefits. For costs and complete details, call or write your Colonial Life benefits counselor or the company. This brochure is applicable to policy forms TERM1000, R-TERM1000-ADB, R-TERM1000-CTR, R-TERM1000-STR, R-TERM1000-WAIVER (and applicable state variations, for example: TERM1000-TX, R-TERM1000-ADB-TX-1, R-TERM1000-CTR-TX, R-TERM1000-STR-TX and R-TERM1000-WAIVER-TX-1). See your Colonial Life benefits counselor for additional information specific for your state. This coverage contains limitations and exclusions that may aect benefits payable. Product may vary by state.Cash value policy conversionYou can convert your policy to a Colonial Life cash value life insurance policy any time through age 75 (unless you have used the accelerated death benefit or waiver of premium benefit rider) with no evidence of insurability. Premiums will be based on your age at the time you convert your policy.Accelerated death benefitIf you are diagnosed with a terminal illness, you can request up to 75% of the policy’s death benefit, not to exceed $150,000. We deduct a fee only if you use the benefit, and your death benefit will then be reduced by the amount you receive. In addition, there may be tax consequences for receiving the accelerated benefit; ask your tax advisor for advice. Please refer to your policy for details.Spouse coverage optionsTwo options are available for spouse coverage at an additional cost:1. Spouse term life policy: Oers guaranteed premiums and level death benefits equivalent to those available to you – whether or not you buy a policy for yourself.2. Spouse term life rider: Add a term rider for your spouse to your policy, up to a maximum death benefit of $50,000; 10-year and 20-year are available (20-year rider only available with a 20- or 30-year term policy).Dependent coverageYou may add a children’s term life rider to cover all of your eligible dependent children with up to $10,000 in coverage each for one premium. The children’s term life rider may be added to either the primary or spouse policy, not both.Waiver of premium benefit riderThis rider waives all premiums (for the policy and any riders) if you become totally and permanently disabled before the age of 65. To be considered permanent, your total disability must continue with no interruptions for at least six consecutive months. Premiums waived by this rider do not have to be repaid. This rider is available for the spouse policy as well, subject to home oice approval.Accidental death benefit riderThis rider provides an additional benefit to the beneficiary if the insured dies as a result of an accident before age 70. The benefit doubles if the injury resulting in death occurs while insured is a fare-paying passenger on a public conveyance, such as a commercial aircra or taxicab. An additional seatbelt benefit is also payable.©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. 4-16 | 64815-10ColonialLife.com

Your cost will vary based on the level of coverage you select. Whole Life InsuranceYou can’t predict your family’s future, but you can be prepared for it.You like to think that you’ll be there for your family in the years to come. But if something happened to you, would your family have the income they need?It’s not easy to think about such serious circumstances, but it’s important to make sure your family is financially protected. You can gain peace of mind with whole life insurance from Colonial Life.Advantages of whole life insurance  Permanent coverage that stays the same throughout the life of the policy  Guaranteed level premiums that do not increase because of changes in health or age  Access to the policy’s cash value through a policy loan for emergencies  Benefit for the beneficiary that is typically tax-freeBenefits and features  Two plan options to choose what age your premium payments will end – Paid-Up at Age 70 or Paid-Up at Age 100  Stand-alone spouse policy available whether or not you buy a policy for yourself  Flexibility to keep the policy if you change jobs or retire  Built-in terminal illness accelerated death benefit that provides up to 75% of the policy’s death benefit (up to $150,000) if you’re diagnosed with a terminal illness  Immediate $3,000 claim payment that can help your designated beneficiary pay for funeral costs or other expenses  Pays cash surrender value at age 100 (when the policy endows)WHOLE LIFE (IWL5000)HealthAairs.org, End-Of-Life Medical Spending In Last Twelve Months Of Life Is Lower Than Previously Reported, July 2017.Talk with your benefits counselor for information about what level of coverage would work best for you.In the U.S., medical spending in the last 12 months of life is nearly $80,000 per person.$

Your cost will vary based on the level of coverage you select. Whole Life InsuranceYou can’t predict your family’s future, but you can be prepared for it.You like to think that you’ll be there for your family in the years to come. But if something happened to you, would your family have the income they need?It’s not easy to think about such serious circumstances, but it’s important to make sure your family is financially protected. You can gain peace of mind with whole life insurance from Colonial Life.Advantages of whole life insurance  Permanent coverage that stays the same throughout the life of the policy  Guaranteed level premiums that do not increase because of changes in health or age  Access to the policy’s cash value through a policy loan for emergencies  Benefit for the beneficiary that is typically tax-freeBenefits and features  Two plan options to choose what age your premium payments will end – Paid-Up at Age 70 or Paid-Up at Age 100  Stand-alone spouse policy available whether or not you buy a policy for yourself  Flexibility to keep the policy if you change jobs or retire  Built-in terminal illness accelerated death benefit that provides up to 75% of the policy’s death benefit (up to $150,000) if you’re diagnosed with a terminal illness  Immediate $3,000 claim payment that can help your designated beneficiary pay for funeral costs or other expenses  Pays cash surrender value at age 100 (when the policy endows)WHOLE LIFE (IWL5000)HealthAairs.org, End-Of-Life Medical Spending In Last Twelve Months Of Life Is Lower Than Previously Reported, July 2017.Talk with your benefits counselor for information about what level of coverage would work best for you.In the U.S., medical spending in the last 12 months of life is nearly $80,000 per person.$

£ YOU $ ___________________ Select the option:£ Paid-Up at Age 70£ Paid-Up at Age 100£ SPOUSE $ _______________ Select the option:£ Paid-Up at Age 70£ Paid-Up at Age 100EXCLUSIONS AND LIMITATIONSIf the insured dies by suicide, whether sane or insane, within two years (one year in ND) from the coverage eective date or the date of reinstatement, we will not pay the death benefit. We will terminate this policy and return the premiums paid without interest, minus any loans and loan interest to you. Product may vary by state. For costs and complete details of the coverage, call or write your Colonial Life benefits counselor or the company.This brochure is applicable to policy forms ICC19-IWL5000-70/IWL5000-70, ICC19-IWL5000-100/IWL5000-100, ICC19-IWL5000J/IWL5000J and rider forms ICC19-R-IWL5000-STR/R-IWL5000-STR, ICC19-R-IWL5000-CTR/R-IWL5000-CTR, ICC19-R-IWL5000-WP/R-IWL5000-WP, ICC19-R-IWL5000-ACCD/R-IWL5000-ACCD, ICC19-R-IWL5000-CI/R-IWL5000-CI, ICC19-R-IWL5000-CC/R-IWL5000-CC, ICC19-R-IWL5000-GPO/R-IWL5000-GPO and applicable state variations.Additional coverage optionsSpouse term life riderCover your spouse up to a maximum death benefit of $50,000; 10-year and 20-year spouse term riders are available.Juvenile whole life policyYou can purchase a policy while children are young and premiums are low – whether or not you buy a policy on yourself. You may also increase the coverage when the child is 18, 21 and 24 without providing proof of good health. The plan is paid-up at age 70.Children’s term life riderYou may purchase up to $20,000 in term life coverage for all of your eligible dependent children and pay one premium. The children’s term life rider may be added to either your policy or your spouse’s policy – not both.Accidental death benefit riderThe beneficiary may receive an additional benefit if the covered person dies as a result of an accident before age 70. The benefit doubles if the accidental bodily injury occurs while riding as a fare-paying passenger using public transportation, such as ride-sharing services. An additional 25% will be payable if the injury is sustained while driving or riding in a private passenger vehicle and wearing a seatbelt.Chronic care accelerated death benefit riderIf a licensed health care practitioner certifies that you have a chronic illness, you may receive an advance on all or a portion of the death benefit, available in a one-time lump sum or monthly payments. A chronic illness means you require substantial supervision due to a severe cognitive impairment or you may be unable to perform at least two of the six Activities of Daily Living (bathing, continence, dressing, eating, toileting and transferring). Premiums are waived during the benefit period.Critical illness accelerated death benefit riderIf you suer a heart attack (myocardial infarction), stroke or end-stage renal (kidney) failure, a $5,000 benefit is payable. A subsequent diagnosis benefit is included.Guaranteed purchase option riderIf you are age 50 or younger when you purchase the policy, you can add the rider, which allows you to purchase additional whole life coverage – without having to answer health questions – at three dierent points in the future. You may purchase up to your initial face amount, not to exceed a total combined maximum of $100,000 for all options.Waiver of premium benefit riderPremiums are waived (for the policy and riders) if you become totally disabled before the policy anniversary following your 65th birthday and you satisfy the six-month elimination period. Once you are no longer disabled, premium payments will resume.Benefits worksheetFor use with your benefits counselorSelect any optional riders:£ Spouse term life rider $ _____________ face amount for ________-year term period£ Children’s term life rider $ _____________ face amount£ Accidental death benefit rider£ Chronic care accelerated death benefit rider£ Critical illness accelerated death benefit rider£ Guaranteed purchase option rider£ Waiver of premium benefit riderHOW MUCH COVERAGE DO YOU NEED?To learn more, talk with your benefits counselor.ColonialLife.com6-19 | 101935£ DEPENDENT STUDENT $____________£ Paid-Up at Age 70 £ Paid-Up at Age 100 1 Loan should be repaid to protect the policy’s value. 2 Any payout would reduce the death benefit. Benefits may be taxable as income. Individuals should consult with their legal or tax counsel when deciding to apply for accelerated benefits.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.

£ YOU $ ___________________ Select the option:£ Paid-Up at Age 70£ Paid-Up at Age 100£ SPOUSE $ _______________ Select the option:£ Paid-Up at Age 70£ Paid-Up at Age 100EXCLUSIONS AND LIMITATIONSIf the insured dies by suicide, whether sane or insane, within two years (one year in ND) from the coverage eective date or the date of reinstatement, we will not pay the death benefit. We will terminate this policy and return the premiums paid without interest, minus any loans and loan interest to you. Product may vary by state. For costs and complete details of the coverage, call or write your Colonial Life benefits counselor or the company.This brochure is applicable to policy forms ICC19-IWL5000-70/IWL5000-70, ICC19-IWL5000-100/IWL5000-100, ICC19-IWL5000J/IWL5000J and rider forms ICC19-R-IWL5000-STR/R-IWL5000-STR, ICC19-R-IWL5000-CTR/R-IWL5000-CTR, ICC19-R-IWL5000-WP/R-IWL5000-WP, ICC19-R-IWL5000-ACCD/R-IWL5000-ACCD, ICC19-R-IWL5000-CI/R-IWL5000-CI, ICC19-R-IWL5000-CC/R-IWL5000-CC, ICC19-R-IWL5000-GPO/R-IWL5000-GPO and applicable state variations.Additional coverage optionsSpouse term life riderCover your spouse up to a maximum death benefit of $50,000; 10-year and 20-year spouse term riders are available.Juvenile whole life policyYou can purchase a policy while children are young and premiums are low – whether or not you buy a policy on yourself. You may also increase the coverage when the child is 18, 21 and 24 without providing proof of good health. The plan is paid-up at age 70.Children’s term life riderYou may purchase up to $20,000 in term life coverage for all of your eligible dependent children and pay one premium. The children’s term life rider may be added to either your policy or your spouse’s policy – not both.Accidental death benefit riderThe beneficiary may receive an additional benefit if the covered person dies as a result of an accident before age 70. The benefit doubles if the accidental bodily injury occurs while riding as a fare-paying passenger using public transportation, such as ride-sharing services. An additional 25% will be payable if the injury is sustained while driving or riding in a private passenger vehicle and wearing a seatbelt.Chronic care accelerated death benefit riderIf a licensed health care practitioner certifies that you have a chronic illness, you may receive an advance on all or a portion of the death benefit, available in a one-time lump sum or monthly payments. A chronic illness means you require substantial supervision due to a severe cognitive impairment or you may be unable to perform at least two of the six Activities of Daily Living (bathing, continence, dressing, eating, toileting and transferring). Premiums are waived during the benefit period.Critical illness accelerated death benefit riderIf you suer a heart attack (myocardial infarction), stroke or end-stage renal (kidney) failure, a $5,000 benefit is payable. A subsequent diagnosis benefit is included.Guaranteed purchase option riderIf you are age 50 or younger when you purchase the policy, you can add the rider, which allows you to purchase additional whole life coverage – without having to answer health questions – at three dierent points in the future. You may purchase up to your initial face amount, not to exceed a total combined maximum of $100,000 for all options.Waiver of premium benefit riderPremiums are waived (for the policy and riders) if you become totally disabled before the policy anniversary following your 65th birthday and you satisfy the six-month elimination period. Once you are no longer disabled, premium payments will resume.Benefits worksheetFor use with your benefits counselorSelect any optional riders:£ Spouse term life rider $ _____________ face amount for ________-year term period£ Children’s term life rider $ _____________ face amount£ Accidental death benefit rider£ Chronic care accelerated death benefit rider£ Critical illness accelerated death benefit rider£ Guaranteed purchase option rider£ Waiver of premium benefit riderHOW MUCH COVERAGE DO YOU NEED?To learn more, talk with your benefits counselor.ColonialLife.com6-19 | 101935£ DEPENDENT STUDENT $____________£ Paid-Up at Age 70 £ Paid-Up at Age 100 1 Loan should be repaid to protect the policy’s value. 2 Any payout would reduce the death benefit. Benefits may be taxable as income. Individuals should consult with their legal or tax counsel when deciding to apply for accelerated benefits.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.

Getting startedThe easiest way to manage your business with us is through ColonialLife.com. To sign up for the website, click Register at the top right of the home page and follow the instructions. Consider your optionsAt Colonial Life, our goal is to give you an excellent customer experience that is simple, modern and personal. For your convenience, you can choose how you interact with us. For the quickest service, we recommend using our website, which lets you do the following:  Review, print or download a copy of your policy/certificate by clicking on the My Correspondence tab.  Update contact information or add family member profile information for use when filing online claims.  Access service forms to make changes to your policy, such as a beneficiary change.  Submit your claim using our eClaims system.  Check the status of your claim and view claims correspondence.  Access claim forms.Policyholder Service GuideeClaims are quick and easyWith the eClaims feature on ColonialLife.com, you can file most claims online by simply answering a few questions and uploading your supporting documentation. You’re able to spend less time on paperwork, and we’re able to process your claim faster.  From Colonial Life.com, file claims from any device. It’s fast, easy and available 24/7.  Select direct deposit to receive your benefit payment faster.  Easily submit additional documents.Paper claims  If you don’t want to file online, download the form you need by visiting the Claims Center page on ColonialLife.com and clicking on claim and service forms.  You may fax your claim to 1-800-880-9325.  Follow the instructions, tips and videos to complete and submit your claim.ColonialLife.comContact us Online ColonialLife.com Log in and click on Contact UsTelephone 1-800-325-4368Hearing-impaired customers 803-798-4040If you do not have a TDD, call Voiance Telephone Interpretation Services. 844-495-61058-17 | 43233-39Underwritten by Colonial Life & Accident Insurance Company, Columbia, SC ©2017 Colonial Life & Accident Insurance Company. All rights reserved. Colonial Life is a registered trademark and marketing brand of Colonial Life & Accident Insurance Company.

Getting startedThe easiest way to manage your business with us is through ColonialLife.com. To sign up for the website, click Register at the top right of the home page and follow the instructions. Consider your optionsAt Colonial Life, our goal is to give you an excellent customer experience that is simple, modern and personal. For your convenience, you can choose how you interact with us. For the quickest service, we recommend using our website, which lets you do the following:  Review, print or download a copy of your policy/certificate by clicking on the My Correspondence tab.  Update contact information or add family member profile information for use when filing online claims.  Access service forms to make changes to your policy, such as a beneficiary change.  Submit your claim using our eClaims system.  Check the status of your claim and view claims correspondence.  Access claim forms.Policyholder Service GuideeClaims are quick and easyWith the eClaims feature on ColonialLife.com, you can file most claims online by simply answering a few questions and uploading your supporting documentation. You’re able to spend less time on paperwork, and we’re able to process your claim faster.  From Colonial Life.com, file claims from any device. It’s fast, easy and available 24/7.  Select direct deposit to receive your benefit payment faster.  Easily submit additional documents.Paper claims  If you don’t want to file online, download the form you need by visiting the Claims Center page on ColonialLife.com and clicking on claim and service forms.  You may fax your claim to 1-800-880-9325.  Follow the instructions, tips and videos to complete and submit your claim.ColonialLife.comContact us Online ColonialLife.com Log in and click on Contact UsTelephone 1-800-325-4368Hearing-impaired customers 803-798-4040If you do not have a TDD, call Voiance Telephone Interpretation Services. 844-495-61058-17 | 43233-39Underwritten by Colonial Life & Accident Insurance Company, Columbia, SC ©2017 Colonial Life & Accident Insurance Company. All rights reserved. Colonial Life is a registered trademark and marketing brand of Colonial Life & Accident Insurance Company.