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This Benefit Summary is to highlight your Benefits. Don’t use this document to understand your exact coverage. If this Benefit Summary conflictswith the Summary Plan Description (SPD), that document governs. Review your SPD for an exact description of the services and supplies that areand are not covered, those which are excluded or limited, and other terms and conditions of coverage.UnitedHealthcare Level Funded | Oregon | Choice Plus | HP5000257524B | CP RX5 ADVBChoice Plus plan details, all in one place.Use this benefit summary to learn more about this plan’s benefits, ways you can get help managing costs and how you may get more out of this health plan.Check out what’s included in the plan Choice PlusNetwork coverage onlyYou can usually save money when you receive care for covered health care services fromnetwork providers.Network and out-of-network benefitsYou may receive care and services from network and out-of-network providers andfacilities — but staying in the network can help lower your costs.Primary care physician (PCP) requiredWith this plan, you need to select a PCP — the doctor who plays a key role in helpingmanage your care. Each enrolled person on your plan will need to choose a PCP.Referrals requiredYou’ll need referrals from your PCP before seeing a specialist or getting certain healthcare services.Preventive care covered at 100%There is no additional cost to you for seeing a network provider for preventive care.Pharmacy benefitsWith this plan, you have coverage that helps pay for prescription drugs and medications.Tier 1 providersUsing Tier 1 providers may bring you the greatest value from your health care benefits.These PCPs and medical specialists meet national standard benchmarks for quality careand cost savings.Freestanding centersYou may pay less when you use certain freestanding centers — health care facilities thatdo not bill for services as part of a hospital, such as MRI or surgery centers.Health savings account (HSA)With an HSA, you’ve got a personal bank account that lets you put money aside, tax-free.Use it to save and pay for qualified medical expenses. 1

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Here's a more in-depth look at how Choice Plus works.Medical BenefitsIn Network Out-of-NetworkAnnual Medical DeductibleIndividual $5,000 $10,000Family $10,000 $20,000All individual deductible amounts will count toward the family deductible, but an individual will not have to pay more than the individual deductible amount.*After the Annual Medical Deductible has been met.You're responsible for paying 100% of your medical expenses until you reach your deductible. For certain covered services, you may be required to pay a fixed dollar amount - your copay.Annual Out-of-Pocket LimitIndividual $6,900 $20,000Family $13,800 $40,000All individual out-of-pocket maximum amounts will count toward the family out-of-pocket maximum, but an individual will not have to pay more than the individual out-of-pocket maximum amount.Once you’ve met your deductible, you start sharing costs with your plan - coinsurance. You continue paying a portion of the expense until you reach your out-of-pocket limit. From there, your plan pays 100% of allowed amounts for the rest of the plan year.What You Pay for ServicesCopays ($) and Coinsurance (%) for Covered Health Care ServicesNetworkOut-of-NetworkPreventive Care ServicesPreventive Care Services No copay 50%*Certain preventive care services are provided as specified by the Patient Protection and Affordable Care Act (ACA), with no cost-sharing to you. These services are based on your age, gender and other health factors. UnitedHealthcare also covers other routine services that may require a copay, co-insurance or deductible.Includes services such as Routine Wellness Checkups, Immunizations, Breast Pumps, Mammography and Colorectal Cancer Screenings.Office Services - Sickness & InjuryPrimary Care Physician $25 copay* 50%*Additional copays, deductible, or co-insurance may apply when you receive other services at your physician’s office. For example, surgery and lab work.Telehealth is covered at the same cost share as in the office.Specialist $75 copay* 50%*Additional copays, deductible, or co-insurance may apply when you receive other services at your physician’s office. For example, surgery and lab work.Telehealth is covered at the same cost share as in the office.*After the Annual Medical Deductible has been met.¹Prior Authorization may be Required. Refer to SPD. 2

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What You Pay for ServicesCopays ($) and Coinsurance (%) for Covered Health Care ServicesNetworkOut-of-NetworkUrgent Care Center Services $50 copay* 50%*Additional copays, deductible, or co-insurance may apply when you receive other services at the urgent care facility. For example, surgery and lab work.Virtual Care Services No copay Not coveredNetwork Benefits are available only when services are delivered through a Designated Virtual Network Provider. You can find a Designated Virtual Visit Network Provider by contacting us at myuhc.com® or the telephone number on your ID card. Access to Virtual Visits and prescription services may not be available in all states or for all groups.Emergency CareAmbulance Services - Emergency AmbulanceAir Ambulance No copay* No copay*Ground Ambulance No copay* No copay*Ambulance Services - Non-Emergency Ambulance¹Air Ambulance No copay* No copay*Ground Ambulance No copay* 50%*Dental Services - Accident Only No copay* 50%*Emergency services by an Out-of-Network provider will be considered at the Network benefit Level.Emergency Health Care Services - Outpatient¹ $300 copay* $300 copay*Notification is required if it results in confinement to an Out-of-Network Hospital.Inpatient CareHabilitative Services - Inpatient The amount you pay is based on where the covered health care service is provided.Hospital - Inpatient Stay¹ No copay* 50%*Skilled Nursing Facility/Inpatient Rehabilitation Facility Services¹No copay* 50%*Limited to 60 days per year.Outpatient CareAcupuncture Services $25 copay* 50%*Limited to 10 treatments per year.*After the Annual Medical Deductible has been met.¹Prior Authorization may be Required. Refer to SPD. 3

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What You Pay for ServicesCopays ($) and Coinsurance (%) for Covered Health Care ServicesNetworkOut-of-NetworkHabilitative Services - OutpatientManipulative treatment services $25 copay* 50%*Other habilitative services No copay* 50%*Limits will be the same as, and combined with those stated under Rehabilitation Services - Outpatient Therapy and Manipulative Treatment.Home Health Care¹ No copay* 50%*Limited to 30 visits per year.One visit equals up to four hours of skilled care services. This visit limit does not include any service which is billed only for the administration of intravenous infusion.Lab, X-Ray and Diagnostic - Outpatient - Lab Testing¹ No copay* 50%*Limited to 18 Definitive Drug Tests per year.Limited to 18 Presumptive Drug Tests per year.Lab, X-Ray and Diagnostic - Outpatient - X-Ray and other Diagnostic Testing¹No copay* 50%*Major Diagnostic and Imaging - Outpatient¹ No copay* 50%*Physician Fees for Surgical and Medical Services No copay* 50%*Rehabilitation Services - Outpatient Therapy and Manipulative TreatmentManipulative treatment services $25 copay* 50%*Other rehabilitation services No copay* 50%*Limited to 20 visits of Manipulative Treatments per year.Limited to 30 combined visits of physical therapy, occupational therapy, speech therapy, cardiac therapy, post cochlear therapy, cognitive therapy and pulmonary therapy per year.Limits are combined with Habilitative Services - Outpatient.Surgery - Outpatient¹ No copay* 50%*Therapeutic Treatments - Outpatient¹ No copay* 50%*Therapeutic treatments include, but are not limited to dialysis, intravenous chemotherapy, intravenous infusion, medical education services and radiation oncology.Supplies and ServicesDiabetes Self-Management Items¹ The amount you pay is based on where the covered health care service is provided under Durable Medical Equipment (DME), Orthotics and Supplies or in the Prescription Drug Benefits Section.Diabetes Self-Management and Training/Diabetic Eye Exams/Foot Care¹The amount you pay is based on where the covered health care service is provided.Durable Medical Equipment (DME), Orthotics and Supplies¹ No copay* 50%**After the Annual Medical Deductible has been met.¹Prior Authorization may be Required. Refer to SPD. 4

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What You Pay for ServicesCopays ($) and Coinsurance (%) for Covered Health Care ServicesNetworkOut-of-NetworkEnteral Nutrition No copay* 50%*Hearing Aids No copay* 50%*Limited to $5,000 every 36 months ages 18 and over.Limited to 1 Bone Anchored Hearing Aid per lifetime.Limited to 1 hearing aid per ear every 36 months under the age of 18.Limited to a single purchase per hearing impaired ear every 36 months.Ostomy Supplies No copay* 50%*Pharmaceutical Products - Outpatient No copay* 50%*Depending on the pharmaceutical product prior authorization may be required.This includes medications given at a doctor's office, or in a covered person's home.Prosthetic Devices¹ No copay* 50%*PregnancyPregnancy - Maternity Services¹ The amount you pay is based on where the covered health care service is provided except that an Annual Deductible will not apply for a newborn child whose length of stay in the Hospital is the same as the mother's length of stay.Mental Health Care & Substance Related and Addictive Disorder ServicesInpatient No copay* 50%*Outpatient $75 copay* 50%*Partial Hospitalization No copay* 50%*Limited to 60 days combined for residential treatment facility and skilled nursing facility per year.Other ServicesCellular and Gene Therapy The amount you pay is based on where the covered health care service is provided.For Network Benefits, Cellular or Gene Therapy services must be received from a Designated Provider.Clinical Trials¹ The amount you pay is based on where the covered health care service is provided.Gender Dysphoria¹ The amount you pay is based on where the covered health care service is provided or in the Prescription Drug Benefits Section.Hospice Care¹ No copay* 50%*Reconstructive Procedures¹ The amount you pay is based on where the covered health care service is provided.Transplantation Services No copay* Not coveredCoverage is only available when services are performed at a Centers of Excellence facility, except for cornea transplants.*After the Annual Medical Deductible has been met.¹Prior Authorization may be Required. Refer to SPD. 5

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Pharmacy Benefits** Only certain Prescription Drug Products are available through mail order; please visit myuhc.com® or call Customer Care at the telephone number on the back of your ID card for more information. You will be charged aretail Copayment and/or Coinsurance for 31 days or 2 times for 60 days based on the number of days supply dispensed for any Prescription Order or Refills sent to the mail order pharmacy. To maximize your Benefit, askyour Physician to write your Prescription Order or Refill for a 90-day supply, with refills when appropriate, rather than a 30-day supply with three refills.***Retail: up to a 90 day supply. You will be charged a retail Copayment and/or Coinsurance for 31 days, 2 times for 60 days, or 3 times for 90 days based on the number of days supply dispensed for any PrescriptionOrder or Refills obtained at a retail pharmacy.Your Copayment and/or Coinsurance is determined by the tier to which the Prescription Drug List (PDL) Management Committee has assigned the Prescription Drug Product. All Prescription Drug Products on thePrescription Drug List are assigned to Tier 1, Tier 2, Tier 3 or Tier 4.If you are a member, you can find individualized information on your benefit coverage, determine tier status, check the status of claims and search for network pharmacies by logging into your account on myuhc.com® orcalling the Customer Care number on your ID card. If you are not a member, you can view prescription information at welcometouhc.com > Benefits > Pharmacy Benefits.Pharmacy Plan DetailsPharmacy Network BroadPrescription Drug List AdvantageIn NetworkAnnual Pharmacy DeductibleIndividual See the Annual Medical Deductible sectionFamily See the Annual Medical Deductible sectionAnnual Deductible - Network and Out-of-NetworkThe Pharmacy Deductible is the amount you pay for pharmacy expenses per year before you begin to receive Pharmacy Benefits.Up to a 31-day supply Up to a 90-day supplyPrescription Drug Product Tier LevelIn-Network Retail Pharmacy***Out-of-Network Retail PharmacyIn-Network Mail Order Pharmacy**Tier 1 $$10* $10* $25*Tier 2 $$$35* $35* $87.50*Tier 3 $$$$70* $70* $175*Tier 4 $$$$$150* $150* $375*Specialty Prescription Drug Product Tier LevelIn-Network Specialty PharmacyOut-of-Network Specialty PharmacySpecialty Mail Order**Tier 1 $$10* $10* Not applicableTier 2 $$$150* $150* Not applicableTier 3 $$$$350* $350* Not applicableTier 4 $$$$$500* $500* Not applicable 6

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Other important information about your benefits.Medical ExclusionsServices your plan generally does NOT cover. It is recommended that you review your SPD for an exact description of the services and suppliesthat are covered, those which are excluded or limited, and other terms and conditions of coverage.• Bariatric Surgery • Cosmetic Surgery• Dental Care (Adult)• Infertility Treatment• Long-Term Care• Non-emergency care when traveling outside the U.S.• Private-Duty Nursing• Routine Eye Care (Adult)• Routine Foot Care• Weight Loss ProgramsOutpatient Prescription Drug BenefitsFor Prescription Drug Products dispensed at an In-Network Retail Pharmacy, you are responsible for paying the lowest of the following: 1) Theapplicable Copayment and/or Coinsurance; 2) The In- Network Retail Pharmacy Usual and Customary Charge for the Prescription Drug Product;and 3) The Prescription Drug Charge for that Prescription Drug Product. For Prescription Drug Products from an In-Network Mail Order Pharmacy,you are responsible for paying the lower of the following: 1) The applicable Copayment and/or Coinsurance; and 2) The Prescription Drug Chargefor that Prescription Drug Product. For an out-of-Network Retail Pharmacy, your reimbursement is based on the Out-of-Network ReimbursementRate, and you are responsible for the difference between the Out-of-Network Reimbursement Rate and the out-of-Network Pharmacy’s Usual andCustomary Charge.See the Copayment and/or Coinsurance stated in the Benefit Information table for amounts. We will not reimburse you for any non-covered drugproduct.For a single Copayment and/or Coinsurance, you may receive a Prescription Drug Product up to the stated supply limit. Some products are subjectto additional supply limits based on criteria that we have developed. Supply limits are subject, from time to time, to our review and change.Specialty Prescription Drug Products supply limits are as written by the provider, up to a consecutive 31-day supply of the Specialty PrescriptionDrug Product, unless adjusted based on the drug manufacturer’s packaging size, or based on supply limits, or as allowed under the Smart FillProgram. Supply limits apply to Specialty Prescription Drug Products obtained at a Preferred Specialty Network Pharmacy, an out-of-NetworkPharmacy, a mail order Network Pharmacy or a Designated Pharmacy.Certain Prescription Drug Products for which Benefits are described under the Prescription Drug Rider are subject to step therapy requirements. Inorder to receive Benefits for such Prescription Drug Products you must use a different Prescription Drug Product(s) first. You may find out whether aPrescription Drug Product is subject to step therapy requirements by contacting us at myuhc.com or the telephone number on your ID card.Before certain Prescription Drug Products are dispensed to you, your Physician, your pharmacist or you are required to obtain prior authorizationfrom us or our designee to determine whether the Prescription Drug Product is in accordance with our approved guidelines and it meets thedefinition of a Covered Health Care Service and is not an Experimental or Investigational or Unproven Service. We may also require you to obtainprior authorization from us or our designee so we can determine whether the Prescription Drug Product, in accordance with our approvedguidelines, was prescribed by a Specialist.If you require certain Prescription Drug Products, we may direct you to a Designated Pharmacy with whom we have an arrangement to providethose Prescription Drug Products. If you are directed to a Designated Pharmacy and you choose not to obtain your Prescription Drug Product fromthe Designated Pharmacy, the Prescription Drug Product is not eligible for benefits .Certain Preventative Care Medications may be covered at zero costshare. You can get more information by contacting us at myuhc.com or thetelephone number on your ID card.Benefits are provided for certain Prescription Drug Products dispensed by an In-Network Mail Order Pharmacy . The Outpatient Prescription DrugSchedule of Benefits will tell you how In-Network Mail Order Pharmacy supply limits apply. Please contact us at myuhc.com or the telephonenumber on your ID card to find out if Benefits are provided for your Prescription Drug Product and for information on how to obtain yourPrescription Drug Product through an In-Network Mail Order Pharmacy . 8

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Other important information about your benefits.Pharmacy ExclusionsThe following exclusions apply. In addition see your SPD for additional exclusions and limitations that may apply.• A Pharmaceutical Product for which Benefits are provided in your Summary Plan Description.• A Prescription Drug Product with either: an approved biosimilar, a biosimilar and Therapeutically Equivalent to another covered Prescription DrugProduct.• Any Prescription Drug Product to the extent payment or benefits are provided or available from the local, state or federal government (forexample, Medicare).• Any product dispensed for the purpose of appetite suppression or weight loss.• Any product for which the primary use is a source of nutrition, nutritional supplements, or dietary management of disease, and prescriptionmedical food products even when used for the treatment of Sickness or Injury, except as required by state mandate.• Certain New Prescription Drug Products and/or new dosage forms until the date they are reviewed and placed on a tier by our PDL ManagementCommittee.• Certain Prescription Drug Products for tobacco cessation.• Certain Prescription Drug Products for which there are Therapeutically Equivalent alternatives available.• Certain Prescription Drug Products that are FDA approved as a package with a device or application, including smart package sensors and/orembedded drug sensors.• Certain compounded drugs.• Diagnostic kits and products.• Drugs available over-the-counter.• Drugs which are prescribed, dispensed or intended for use during an Inpatient Stay.• Durable Medical Equipment, including insulin pumps and related supplies for the management and treatment of diabetes, for which Benefits areprovided in your Summary Plan Description. Prescribed and non-prescribed outpatient supplies. This does not apply to diabetic supplies andinhaler spacers specifically stated as covered.• Experimental or Investigational or Unproven Services and medications.• General vitamins, except Prenatal vitamins, vitamins with fluoride, and single entity vitamins when accompanied by a Prescription Order or Refill.• Medications used for cosmetic purposes.• Prescription Drug Products dispensed outside the United States, except as required for Emergency treatment.• Prescription Drug Products when prescribed to treat infertility.• Prescription Drug Products, including New Prescription Drug Products or new dosage forms, that we determine do not meet the definition of aCovered Health Care Service.• Publicly available software applications and/or monitors that may be available with or without a Prescription Order or Refill. 9

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Does it qualify?If you have an FSA, you have likely wondered whether a particular item is eligible or not. Prescription sunglasses? Over-the-counter medicine? And, recent changes via the CARES Act have expanded the list of qualified items. You can use the app while at the pharmacy to scan a product’s bar code to see if it qualifies as a medical expense.Add your bank account for faster reimbursementYou can add or update information to have reimbursements deposited directly into your bank account. Direct deposit information added through the PSA mobile app goes through a real-time verification process and becomes effective the next business day.Download it todayThe PSA app is available for download from your device’s app store. You’ll find it by searching “myPacificSource Admin (PSA).” Note that there are two apps with similar names. The other one, called “myPacificSource,” is for PacificSource Health Plans, and includes a member ID, a doctor or hospital finder, benefits information, and more.Once you’ve downloaded the app, you’ll need your username and password from the PSA web page: PSA.Consumer.PacificSource.com. The app also enables you to use your fingerprint to log in, if your device supports that function.

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UnitedHealthcare does not treat members diﬀerently because of sex, age, race, color, disability or national origin. If you think you weren’t treated fairly because of your sex, age, race, color, disability or national origin, you can send a complaint to the Civil Rights Coordinator:Online: UHC_Civil_Rights@uhc.comMail: Civil Rights Coordinator UnitedHealthcare Civil Rights Grievance P.O. Box 30608, Salt Lake City, UT 84130You must send the complaint within 60 days of when you found out about it. A decision will be sent to you within 30 days. If you disagree with the decision, you have 15 days to ask us to look at it again. If you need help with your complaint, please call the toll-free phone number listed on your ID card, TTY 711, Monday through Friday, 8 a.m. to 8 p.m. You can also ﬁle a complaint with the U.S. Dept. of Health and Human Services. Online: https://ocrportal.hhs.gov/ocr/portal/lobby.jsfComplaint forms are available at: http://www.hhs.gov/ocr/office/file/index.html.Phone: Toll-free 1-800-368-1019, 1-800-537-7697 (TDD)Mail: U.S. Dept. of Health and Human Services, 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C. 20201 We provide free services to help you communicate with us such as letters in others languages or large print. You can also ask for an interpreter. To ask for help, please call the toll-free member phone number listed on your health plan ID card.ATTENTION: If you speak English, language assistance services, free of charge, are available to you. Please call the toll-free phone number listed on your identiﬁcation card.Administrative services provided by United HealthCare Services, Inc. or their affiliates, and UnitedHealthcare Service LLC in NY. Stop-loss insurance is underwritten by UnitedHealthcare Insurance Company or their affiliates, including UnitedHealthcare Life Insurance Company in NJ, and UnitedHealthcare Insurance Company of New York in NY.B2C EI1670806.1 4/23 © 2023 United HealthCare Services, Inc. All Rights Reserved. 22-1665601

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This Benefit Summary is to highlight your Benefits. Don’t use this document to understand your exact coverage. If this Benefit Summary conflictswith the Summary Plan Description (SPD), that document governs. Review your SPD for an exact description of the services and supplies that areand are not covered, those which are excluded or limited, and other terms and conditions of coverage.UnitedHealthcare Level Funded | Oregon | Choice Plus | P3000i80LX21B | RX4 ADVBChoice Plus plan details, all in one place.Use this benefit summary to learn more about this plan’s benefits, ways you can get help managing costs and how you may get more out of this health plan.Check out what’s included in the plan Choice PlusNetwork coverage onlyYou can usually save money when you receive care for covered health care services fromnetwork providers.Network and out-of-network benefitsYou may receive care and services from network and out-of-network providers andfacilities — but staying in the network can help lower your costs.Primary care physician (PCP) requiredWith this plan, you need to select a PCP — the doctor who plays a key role in helpingmanage your care. Each enrolled person on your plan will need to choose a PCP.Referrals requiredYou’ll need referrals from your PCP before seeing a specialist or getting certain healthcare services.Preventive care covered at 100%There is no additional cost to you for seeing a network provider for preventive care.Pharmacy benefitsWith this plan, you have coverage that helps pay for prescription drugs and medications.Tier 1 providersUsing Tier 1 providers may bring you the greatest value from your health care benefits.These PCPs and medical specialists meet national standard benchmarks for quality careand cost savings.Freestanding centersYou may pay less when you use certain freestanding centers — health care facilities thatdo not bill for services as part of a hospital, such as MRI or surgery centers.Health savings account (HSA)With an HSA, you’ve got a personal bank account that lets you put money aside, tax-free.Use it to save and pay for qualified medical expenses. 1

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Here's a more in-depth look at how Choice Plus works.Medical BenefitsIn Network Out-of-NetworkAnnual Medical DeductibleIndividual $3,000 $6,000Family $6,000 $12,000All individual deductible amounts will count toward the family deductible, but an individual will not have to pay more than the individual deductible amount.*After the Annual Medical Deductible has been met.You're responsible for paying 100% of your medical expenses until you reach your deductible. For certain covered services, you may be required to pay a fixed dollar amount - your copay.Annual Out-of-Pocket LimitIndividual $8,150 $16,300Family $16,300 $32,600All individual out-of-pocket maximum amounts will count toward the family out-of-pocket maximum, but an individual will not have to pay more than the individual out-of-pocket maximum amount.Once you’ve met your deductible, you start sharing costs with your plan - coinsurance. You continue paying a portion of the expense until you reach your out-of-pocket limit. From there, your plan pays 100% of allowed amounts for the rest of the plan year.What You Pay for ServicesCopays ($) and Coinsurance (%) for Covered Health Care ServicesNetworkOut-of-NetworkPreventive Care ServicesPreventive Care Services No copay 50%*Certain preventive care services are provided as specified by the Patient Protection and Affordable Care Act (ACA), with no cost-sharing to you. These services are based on your age, gender and other health factors. UnitedHealthcare also covers other routine services that may require a copay, co-insurance or deductible.Includes services such as Routine Wellness Checkups, Immunizations, Breast Pumps, Mammography and Colorectal Cancer Screenings.Office Services - Sickness & InjuryPrimary Care PhysicianAll other covered persons $25 copay 50%*Covered persons less than age 19 No copay 50%*Additional copays, deductible, or co-insurance may apply when you receive other services at your physician’s office. For example, surgery and lab work.Telehealth is covered at the same cost share as in the office.*After the Annual Medical Deductible has been met.¹Prior Authorization may be Required. Refer to SPD. 2

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What You Pay for ServicesCopays ($) and Coinsurance (%) for Covered Health Care ServicesNetworkOut-of-NetworkSpecialist $75 copay 50%*Additional copays, deductible, or co-insurance may apply when you receive other services at your physician’s office. For example, surgery and lab work.Telehealth is covered at the same cost share as in the office.Urgent Care Center Services $50 copay 50%*Additional copays, deductible, or co-insurance may apply when you receive other services at the urgent care facility. For example, surgery and lab work.Virtual Care Services No copay Not coveredNetwork Benefits are available only when services are delivered through a Designated Virtual Network Provider. You can find a Designated Virtual Visit Network Provider by contacting us at myuhc.com® or the telephone number on your ID card. Access to Virtual Visits and prescription services may not be available in all states or for all groups.Emergency CareAmbulance Services - Emergency AmbulanceAir Ambulance 20%* 20%*Ground Ambulance 20%* 20%*Ambulance Services - Non-Emergency Ambulance¹Air Ambulance 20%* 20%*Ground Ambulance 20%* 50%*Dental Services - Accident Only 20%* 50%*Emergency services by an Out-of-Network provider will be considered at the Network benefit Level.Emergency Health Care Services - Outpatient¹ You pay a $300 per occurrence copay per visit prior to and in addition to paying any Annual Deductible and any coinsurance amount. 20%*You pay a $300 per occurrence copay per visit prior to and in addition to paying any Annual Deductible and any coinsurance amount. 20%*Notification is required if it results in confinement to an Out-of-Network Hospital.Inpatient CareHabilitative Services - Inpatient The amount you pay is based on where the covered health care service is provided.Hospital - Inpatient Stay¹ 20%* 50%*Skilled Nursing Facility/Inpatient Rehabilitation Facility Services¹20%* 50%*Limited to 60 days per year.*After the Annual Medical Deductible has been met.¹Prior Authorization may be Required. Refer to SPD. 3

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What You Pay for ServicesCopays ($) and Coinsurance (%) for Covered Health Care ServicesNetworkOut-of-NetworkOutpatient CareAcupuncture Services $25 copay 50%*Limited to 10 treatments per year.Habilitative Services - OutpatientManipulative treatment services $25 copay 50%*Other habilitative services 20%* 50%*Limits will be the same as, and combined with those stated under Rehabilitation Services - Outpatient Therapy and Manipulative Treatment.Home Health Care¹ 20%* 50%*Limited to 30 visits per year.One visit equals up to four hours of skilled care services. This visit limit does not include any service which is billed only for the administration of intravenous infusion.Lab, X-Ray and Diagnostic - Outpatient - Lab Testing¹ 20%* 50%*Limited to 18 Definitive Drug Tests per year.Limited to 18 Presumptive Drug Tests per year.Lab, X-Ray and Diagnostic - Outpatient - X-Ray and other Diagnostic Testing¹20%* 50%*Major Diagnostic and Imaging - Outpatient¹ 20%* 50%*Physician Fees for Surgical and Medical Services 20%* 50%*Rehabilitation Services - Outpatient Therapy and Manipulative TreatmentManipulative treatment services $25 copay 50%*Other rehabilitation services 20%* 50%*Limited to 20 visits of Manipulative Treatments per year.Limited to 30 combined visits of physical therapy, occupational therapy, speech therapy, cardiac therapy, post cochlear therapy, cognitive therapy and pulmonary therapy per year.Limits are combined with Habilitative Services - Outpatient.Surgery - Outpatient¹ 20%* 50%*Therapeutic Treatments - Outpatient¹ 20%* 50%*Therapeutic treatments include, but are not limited to dialysis, intravenous chemotherapy, intravenous infusion, medical education services and radiation oncology.*After the Annual Medical Deductible has been met.¹Prior Authorization may be Required. Refer to SPD. 4

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What You Pay for ServicesCopays ($) and Coinsurance (%) for Covered Health Care ServicesNetworkOut-of-NetworkSupplies and ServicesDiabetes Self-Management Items¹ The amount you pay is based on where the covered health care service is provided under Durable Medical Equipment (DME), Orthotics and Supplies or in the Prescription Drug Benefits Section.Diabetes Self-Management and Training/Diabetic Eye Exams/Foot Care¹The amount you pay is based on where the covered health care service is provided.Durable Medical Equipment (DME), Orthotics and Supplies¹ 20%* 50%*Enteral Nutrition 20%* 50%*Hearing Aids 20%* 50%*Limited to $5,000 every 36 months ages 18 and over.Limited to 1 Bone Anchored Hearing Aid per lifetime.Limited to 1 hearing aid per ear every 36 months under the age of 18.Limited to a single purchase per hearing impaired ear every 36 months.Ostomy Supplies 20%* 50%*Pharmaceutical Products - Outpatient 20%* 50%*Depending on the pharmaceutical product prior authorization may be required.This includes medications given at a doctor's office, or in a covered person's home.Prosthetic Devices¹ 20%* 50%*PregnancyPregnancy - Maternity Services¹ The amount you pay is based on where the covered health care service is provided except that an Annual Deductible will not apply for a newborn child whose length of stay in the Hospital is the same as the mother's length of stay.Mental Health Care & Substance Related and Addictive Disorder ServicesInpatient 20%* 50%*Outpatient $75 copay 50%*Partial Hospitalization 20%* 50%*Limited to 60 days combined for residential treatment facility and skilled nursing facility per year.Other ServicesCellular and Gene Therapy The amount you pay is based on where the covered health care service is provided.For Network Benefits, Cellular or Gene Therapy services must be received from a Designated Provider.Clinical Trials¹ The amount you pay is based on where the covered health care service is provided.*After the Annual Medical Deductible has been met.¹Prior Authorization may be Required. Refer to SPD. 5

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Pharmacy Benefits** Only certain Prescription Drug Products are available through mail order; please visit myuhc.com® or call Customer Care at the telephone number on the back of your ID card for more information. You will be charged aretail Copayment and/or Coinsurance for 31 days or 2 times for 60 days based on the number of days supply dispensed for any Prescription Order or Refills sent to the mail order pharmacy. To maximize your Benefit, askyour Physician to write your Prescription Order or Refill for a 90-day supply, with refills when appropriate, rather than a 30-day supply with three refills.***Retail: up to a 90 day supply. You will be charged a retail Copayment and/or Coinsurance for 31 days, 2 times for 60 days, or 3 times for 90 days based on the number of days supply dispensed for any PrescriptionOrder or Refills obtained at a retail pharmacy.Your Copayment and/or Coinsurance is determined by the tier to which the Prescription Drug List (PDL) Management Committee has assigned the Prescription Drug Product. All Prescription Drug Products on thePrescription Drug List are assigned to Tier 1, Tier 2, Tier 3 or Tier 4.If you are a member, you can find individualized information on your benefit coverage, determine tier status, check the status of claims and search for network pharmacies by logging into your account on myuhc.com® orcalling the Customer Care number on your ID card. If you are not a member, you can view prescription information at welcometouhc.com > Benefits > Pharmacy Benefits.Pharmacy Plan DetailsPharmacy Network BroadPrescription Drug List AdvantageIn NetworkAnnual Pharmacy DeductibleIndividual You do not have to pay a pharmacy deductibleFamily You do not have to pay a pharmacy deductibleUp to a 31-day supply Up to a 90-day supplyPrescription Drug Product Tier LevelIn-Network Retail Pharmacy***Out-of-Network Retail PharmacyIn-Network Mail Order Pharmacy**Tier 1 $$10 $10 $25Tier 2 $$$35 $35 $87.50Tier 3 $$$$75 $75 $187.50Tier 4 $$$$$250 $250 $625Specialty Prescription Drug Product Tier LevelIn-Network Specialty PharmacyOut-of-Network Specialty PharmacySpecialty Mail Order**Tier 1 $$10 $10 Not applicableTier 2 $$$150 $150 Not applicableTier 3 $$$$350 $350 Not applicableTier 4 $$$$$500 $500 Not applicable 7

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This Benefit Summary is to highlight your Benefits. Don’t use this document to understand your exact coverage. If this Benefit Summary conflictswith the Summary Plan Description (SPD), that document governs. Review your SPD for an exact description of the services and supplies that areand are not covered, those which are excluded or limited, and other terms and conditions of coverage.UnitedHealthcare Level Funded | Oregon | Choice Plus | P1000i80LX21B | RX4 ADVBChoice Plus plan details, all in one place.Use this benefit summary to learn more about this plan’s benefits, ways you can get help managing costs and how you may get more out of this health plan.Check out what’s included in the plan Choice PlusNetwork coverage onlyYou can usually save money when you receive care for covered health care services fromnetwork providers.Network and out-of-network benefitsYou may receive care and services from network and out-of-network providers andfacilities — but staying in the network can help lower your costs.Primary care physician (PCP) requiredWith this plan, you need to select a PCP — the doctor who plays a key role in helpingmanage your care. Each enrolled person on your plan will need to choose a PCP.Referrals requiredYou’ll need referrals from your PCP before seeing a specialist or getting certain healthcare services.Preventive care covered at 100%There is no additional cost to you for seeing a network provider for preventive care.Pharmacy benefitsWith this plan, you have coverage that helps pay for prescription drugs and medications.Tier 1 providersUsing Tier 1 providers may bring you the greatest value from your health care benefits.These PCPs and medical specialists meet national standard benchmarks for quality careand cost savings.Freestanding centersYou may pay less when you use certain freestanding centers — health care facilities thatdo not bill for services as part of a hospital, such as MRI or surgery centers.Health savings account (HSA)With an HSA, you’ve got a personal bank account that lets you put money aside, tax-free.Use it to save and pay for qualified medical expenses. 1

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Here's a more in-depth look at how Choice Plus works.Medical BenefitsIn Network Out-of-NetworkAnnual Medical DeductibleIndividual $1,000 $2,000Family $2,000 $4,000All individual deductible amounts will count toward the family deductible, but an individual will not have to pay more than the individual deductible amount.*After the Annual Medical Deductible has been met.You're responsible for paying 100% of your medical expenses until you reach your deductible. For certain covered services, you may be required to pay a fixed dollar amount - your copay.Annual Out-of-Pocket LimitIndividual $4,500 $9,000Family $9,000 $18,000All individual out-of-pocket maximum amounts will count toward the family out-of-pocket maximum, but an individual will not have to pay more than the individual out-of-pocket maximum amount.Once you’ve met your deductible, you start sharing costs with your plan - coinsurance. You continue paying a portion of the expense until you reach your out-of-pocket limit. From there, your plan pays 100% of allowed amounts for the rest of the plan year.What You Pay for ServicesCopays ($) and Coinsurance (%) for Covered Health Care ServicesNetworkOut-of-NetworkPreventive Care ServicesPreventive Care Services No copay 50%*Certain preventive care services are provided as specified by the Patient Protection and Affordable Care Act (ACA), with no cost-sharing to you. These services are based on your age, gender and other health factors. UnitedHealthcare also covers other routine services that may require a copay, co-insurance or deductible.Includes services such as Routine Wellness Checkups, Immunizations, Breast Pumps, Mammography and Colorectal Cancer Screenings.Office Services - Sickness & InjuryPrimary Care PhysicianAll other covered persons $25 copay 50%*Covered persons less than age 19 No copay 50%*Additional copays, deductible, or co-insurance may apply when you receive other services at your physician’s office. For example, surgery and lab work.Telehealth is covered at the same cost share as in the office.*After the Annual Medical Deductible has been met.¹Prior Authorization may be Required. Refer to SPD. 2

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Pharmacy Benefits** Only certain Prescription Drug Products are available through mail order; please visit myuhc.com® or call Customer Care at the telephone number on the back of your ID card for more information. You will be charged aretail Copayment and/or Coinsurance for 31 days or 2 times for 60 days based on the number of days supply dispensed for any Prescription Order or Refills sent to the mail order pharmacy. To maximize your Benefit, askyour Physician to write your Prescription Order or Refill for a 90-day supply, with refills when appropriate, rather than a 30-day supply with three refills.***Retail: up to a 90 day supply. You will be charged a retail Copayment and/or Coinsurance for 31 days, 2 times for 60 days, or 3 times for 90 days based on the number of days supply dispensed for any PrescriptionOrder or Refills obtained at a retail pharmacy.Your Copayment and/or Coinsurance is determined by the tier to which the Prescription Drug List (PDL) Management Committee has assigned the Prescription Drug Product. All Prescription Drug Products on thePrescription Drug List are assigned to Tier 1, Tier 2, Tier 3 or Tier 4.If you are a member, you can find individualized information on your benefit coverage, determine tier status, check the status of claims and search for network pharmacies by logging into your account on myuhc.com® orcalling the Customer Care number on your ID card. If you are not a member, you can view prescription information at welcometouhc.com > Benefits > Pharmacy Benefits.Pharmacy Plan DetailsPharmacy Network BroadPrescription Drug List AdvantageIn NetworkAnnual Pharmacy DeductibleIndividual You do not have to pay a pharmacy deductibleFamily You do not have to pay a pharmacy deductibleUp to a 31-day supply Up to a 90-day supplyPrescription Drug Product Tier LevelIn-Network Retail Pharmacy***Out-of-Network Retail PharmacyIn-Network Mail Order Pharmacy**Tier 1 $$10 $10 $25Tier 2 $$$35 $35 $87.50Tier 3 $$$$75 $75 $187.50Tier 4 $$$$$250 $250 $625Specialty Prescription Drug Product Tier LevelIn-Network Specialty PharmacyOut-of-Network Specialty PharmacySpecialty Mail Order**Tier 1 $$10 $10 Not applicableTier 2 $$$150 $150 Not applicableTier 3 $$$$350 $350 Not applicableTier 4 $$$$$500 $500 Not applicable 7

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Insurance issued by Principal Life Insurance Company, 711 High Street, Des Moines, IA 50392GP62509-17 1086779 - 10001 Page 1 of 4 06/2024Policyholder: PATTERSON NURSERYSALES, INC.Group dental insuranceBenefit summary forall membersYour coverage renews every November 1This summary was created on 10/15/2024 and shows benefits availableat that time.What's available to me?Dental insurance helps pay for all, or a portion, of the costs associated with dental care, from routinecleanings to root canals.EligibilityEligible employeesAll active, full-time employeesCalendar-year deductible Coinsurance your policy paysIn-network Out-of-network In-network Out-of-networkPreventive$0 $0 100% 100%Basic$50 $50 80% 80%Major$50 $50 50% 50%Additional provisionsFamily deductible3 times the per person deductible amountCombined deductibleYour in-network deductiblesfor basic and major services are combined.Your out-of-network deductibles for basic and major are combined.Your services applied to the in-network deductible will apply to the out-of-networkdeductible and vice versa.Combined maximumYour calendar year maximum for preventive, basic, and major in-network servicesare combined.Your calendar year maximum for preventive, basic, and major out-of-networkservices are combined. In-network calendar year maximums are $1,500 per personor out-of-network calendar year maximums are $1,500 per person.Your services applied to the in-network maximum will apply to the out-of-networkmaximum and vice versa.MaximumaccumulationIncludedPlan typeUnscheduled

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Insurance issued by Principal Life Insurance Company, 711 High Street, Des Moines, IA 50392GP62509-17 1086779 - 10001 Page 2 of 4 06/2024Who can buy coverage?• You may buy coverage if you're an active, full-time employee. Seasonal, temporary, or contractemployees aren't eligible.o If you’re on regularly scheduled day off, holiday, vacation day, jury duty, funeral leave, or personal timeoff, you’re still considered actively at work, as long as you’re fulfilling your regular duties and wereworking the day immediately prior to your time off.o You must enroll within 31 days of being eligible. If you don’t, you’ll have to wait until the next openenrollment period, or qualifying event.Additional eligibility requirements may apply.Which procedures are covered, and how often?PreventiveRoutine examsOnce per six monthsRoutine cleaningsOnce per six monthsBitewing X-raysOnce per calendar yearFull mouth X-raysOnce every 60 monthsFluorideOnce per six months (covered only for dependent children under age 18)SealantsCovered only for dependent children under age 18; once per tooth each 36monthsHarmful habit applianceCovered only for dependent children under age 18BasicEmergency examsOnce per six monthsPeriodontal maintenanceIf three months have passed since active surgical periodontal treatment;subject to routine cleaning frequency limitFillings Replacement fillings every 24 monthsComposite (tooth colored) Covered on posterior teethOral surgerySimple and complexGeneral anesthesia / IVsedationCovered only for specific proceduresSimple endodontics Root canal therapy for anterior teethComplex endodontics Root canal therapy for molar teethNon-surgical periodontics,including scaling and rootplaningOnce per quadrant per 24 monthsPeriodontal surgicalproceduresOnce per quadrant per 36 months

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Insurance issued by Principal Life Insurance Company, 711 High Street, Des Moines, IA 50392GP62509-17 1086779 - 10001 Page 3 of 4 06/2024MajorCrownsEach 84 months per tooth if tooth cannot be restored by a fillingCore buildupEach 84 months per toothImplantsEach 84 months per toothBridges84 months old (initial placement / replacement)Dentures 60 months old (initial placement / replacement)Repairs Partial denture, bridge, crown, relines, rebasing, tissue conditioning andadjustment to bridge/denture, within policy limitationsAdditional benefitsPrevailing charge When you receive care from an out-of-network-provider, benefits will be basedon the 90thpercentile of the usual and customary charges.Maximum accumulationSome of your unused annual benefit maximum can be carried over to the nextyear. To qualify, you must have had a dental service performed within thecalendar year and used less than the maximum threshold. The threshold isequal to the lesser of 50% of the out-of-network maximum benefit or $1,000. Ifthe qualification is met, 50% of the threshold is carried over to next year'smaximum benefit. Individuals with fourth quarter effective dates will startqualifying for rollover at the beginning of the next calendar year. You canaccumulate no more than four times the carry over amount. The entireaccumulation amount will be forfeited if no dental service is submitted within acalendar yearPeriodontal program If you’re pregnant or have diabetes or heart disease, you may receive scalingand root planing covered at 100% (if dentally necessary), or one additionalcleaning (routine or periodontal) subject to deductible and coinsurance.Second opinion program You may be eligible for second opinions from dental providers at 100%. Thisprogram makes sure you get the best advice to make an informed decisionabout your care.Cancer treatment oralhealth programIf you have cancer and are undergoing chemotherapy or head/neck radiationtherapy, you may receive up to three fluoride treatments every 12 monthscovered at 100% plus one additional routine cleaning.General anesthesiaprogramIf you have autism, Down syndrome, cerebral palsy, muscular dystrophy, orspina bifida you may receive general anesthesia or intravenous sedationcoverage. Services must be administered in a dental office. All othercontractual limitations apply.How do I find a network dentist?When you receive services from a dentist in our network, your cost may be lower. Network dentists agree tolower their fees for dental services and not charge you the difference. You’ll have access to the Principal PlanDental network, with more than 117,000 dentists nationwide. Visit principal.com/dentist to find a dentist orcall 800-247-4695.

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principal.comThis is a summary of dental coverage insured by or with administrative services provided by Principal LifeInsurance Company. This outline is a brief description of your coverage. It is not an insurance contract or acomplete statement of the rights, benefits, limitations and exclusions of the coverage. If there is a discrepancybetween the policy and this document, the actual policy provision prevails. For complete coverage details,refer to the booklet.© 2024 Principal Financial Services, Inc., Principal, Principal and symbol design and Principal Financial Group are trademarks and servicemarks of Principal Financial Services, Inc., a member of the Principal Financial Group.Insurance issued by Principal Life Insurance Company, 711 High Street, Des Moines, IA 50392GP62509-17 1086779 - 10001 Page 4 of 4 06/2024What if my dentist isn't in the network?You can refer your dentist to our network. Please submit the dentist’s name and information by calling800-247-4695, or submitting a form at principal.com/refer-dental-provider.What are the limitations and exclusions of my coverage?• Missing tooth provision –This means the initial placement of bridges, partials, dentures, and implantservices to replace teeth missing before this coverage starts may not be covered. If the policy youremployer purchased replaces coverage with another carrier, continuous coverage under the prior planmay be applied and you may be eligible for coverage to replace teeth missing before this coverage started.Your effective date with your current employer, along with the employer's effective date with Principal areused to determine coverage. MIssing tooth provision doesn’t apply to pediatric essential benefits.• Frequency limitations for services are calculated to the month and exact date from the last date of serviceor placement date.There are additional limitations to your coverage. Please review your booklet for more information. Westrongly recommend submitting a predetermination to determine benefits.U 1 P 1YesU 1 P 2NoU 2 P 1YesU 2 P 2NoU 3 P 1YesU 3 P 2No

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Vision Benefit SummaryPowered by UnitedHealthcare Vision NetworkCustomer Service and Provider Locator: (800) 638-3120myuhcvision.comPlan SH107UnitedHealthcare Vision has been trusted for more than 50 years to deliver affordable, innovative vision care solutions to the nation’s leading employers through experienced, customer-focused people and the nation’s most accessible, diversified vision care network.Exam with MaterialsBenefit FrequencyComprehensive Exam(s)Once every 12 monthsComprehensive Exam(s) for persons with diabetesTwice every 12 monthsEyeglass LensesOnce every 12 monthsFramesOnce every 24 monthsContact Lenses instead of EyeglassesOnce every 12 monthsIn-Network ServicesCopaysExam(s)$ 10.00Eyeglasses (lenses and frame)$ 25.00Contact lenses instead of Eyeglasses$ 25.00Retinal Screening for persons with diabetes$ 0.00Frame Benefit - for frames that exceed the allowance, an additional 30% discount may be applied to the overage¹Private Practice Provider$ 150.00 retail frame allowanceRetail Chain Provider$ 150.00 retail frame allowanceLens Options - this list highlights the discounted cost on our most popular lens options. Exact pricing may vary; confirm cost with your provider prior to purchase.Standard Scratch Coating$0Scratch Warranty$10Tint$14UV Coating$16Photochromic$67Anti-Reflective Tier I$30Anti-Reflective Tier II$50Anti-Reflective Tier III$75Anti-Reflective Tier IV$95Roll and Polish Edges$13Progressive Tier I$55Progressive Tier II$100Progressive Tier III$150Progressive Tier IV$200Progressive Tier V$250High Index (<1.66)$53High Index (1.66-1.73)$63Polycarbonate for Adults$33Polycarbonate for Dependent Children$0Contact Lens Benefit²Elective contact lensesAllowance is applied toward the purchase of contact lenses. Contact lens copay is waived.$150.00Elective contact lens fitting and evaluationAllowance is applied toward the contact lens fitting/evaluation fees.$40.00Necessary contact lenses³Covered in full after copay (if applicable).

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Children's and Maternity Eye Care BenefitMembers age 0-12 and members pregnant or breastfeeding are eligible for a 2nd exam 60 days after the initial 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 $125.00Contact Lens Fitting and EvaluationUp To $0.00Necessary Contacts instead of Eyeglasses³Up To $210.00DiscountsLaser 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 services. 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.Contact LensOrder extra contact lenses at uhccontacts.com for 10% off.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.Blue Light EyesafeUnitedHealthcare Vision has collaborated with Eyesafe® to provide members with a 20% discount off the retail price on blue-light screen filters for their devices. Members can receive the discount by visiting myuhcvision.com and clicking on the Eyesafe link.¹30% discount available at most participating in-network provider locations. May exclude certain frame manufacturers. Please verify 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 certain conditions. 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 are subject to change.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.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.READ YOUR PLAN CAREFULLY - THIS BENEFIT SUMMARY PROVIDES A VERY BRIEF DESCRIPTION OF THE IMPORTANT FEATURES OF YOUR PLAN. THIS IS NOT THE INSURANCE CONTRACT. YOUR FULL RIGHTS AND BENEFITS ARE EXPRESSED IN THE ACTUAL PLAN DOCUMENTS THAT ARE AVAILABLE TO YOU UPON YOUR REQUEST TO US.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.06.TX, VPOL.13.TX or VPOL.18.TX and associated COC form number VCOC.INT.06.TX, VCOC.CER.13.TX or VCOC.18.TX. Plans sold in Virginia use policy form number VPOL.06.VA, VPOL.13.VA or VPOL.18.VA and associated COC form number VCOC.INT.06.VA, VCOC.CER.13.VA or VCOC.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 our national lab network.04/23 © 2023 United HealthCare Services, Inc. *SH107NCA-03C (v5.5)

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Basic Life Benefit SummaryThe Accidental Death and Dismemberment (AD&D) portion is automatically included with Basic Life and provides the employee with additional insurance coverage for the loss of life or injuries sustained in an accident on or off the job.*Coverage Benefit DescriptionFlat Amount$15,000 The Life Insurance Benefit Amount.Guarantee IssueAmount of benefit guaranteed. Benefits over this amount are subject to proof of good health. Evidence of Insurability must be submitted and approved.Refer to table belowAccelerated BenefitIncludedThis benefit provides an advanced payout of benefits for covered persons who are terminally ill and not expected to live for more than one year. The benefit pays 50% not to exceed $50,000 of life insurance to the employee.Waiver of PremiumIncludedIf eligible employee becomes totally disabled before age 60, life premiums will be waived and life coverage continued until age 65 [annual proof of disability required].Age Reduction Schedule65%@65, 50%@70The benefits will be reduced to 65% of original amount at age 65 and 50% of the original amount at age 70.Premium ContributionNon-Contributory is when the employer pays 100% of the premium.Non-Contributoryü Accelerated Death Benefit, Waiver of Premium and Conversion are included. Guarantee IssueEligible Lives Guarantee Issue Maximum Plan Maximum2 to 56 to 910 to 1920 to 5051 to 99100 to 199200 to 300$25,000$50,000$50,000$100,000$175,000$175,000$175,000$50,000$175,000$175,000$250,000$350,000$350,000$500,000- Amounts are based on your employer group size and plan benefit levelsCreated on: 06/15/2021 MPS-01; v3.0© 2020 United HealthCare Services, Inc.

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- Wealth Management Account: An enhanced benefit payment process. Life claim proceeds in excess of $5,000can, at the beneficiary's election, be deposited into an Optum Bank Wealth Management Account (WMA).Beneficiaries receive an FDIC-insured, beneficiary-owned, interest earning account with convenient access to theirclaim proceeds via debit card or checkbook.***- Will & Trust Preparation Services: Provides information on will & trust preparation and services. For moreinformation, please call 800-773-0888 or visit www.CLClegalforms.com. Services provided by CLC.Additional Notes:- *The Accidental Death and Dismemberment Benefit is equal to the Life Benefit; refer to the Certificate of Coverage for thecomplete AD&D Benefit schedule. Coverage includes a Seat Belt Benefit.- **Beneficiary Services offered thru United Behavioral Health, a company of UnitedHealth Group.- ***Eligibility for automatic deposit into an Optum Bank Wealth Management Account is subject to qualifying conditions evaluatedby Optum Bank and UnitedHealthcare at the time of claim review to include limited availability in certain states. For moreinformation please contact your UnitedHealthcare representative. Optum Bank, Member FDIC, is part of the financial services unitof OptumHealth, a health and wellness company serving more than 60 million people. Optum is a UnitedHealth Group(NYSE:UNH) company.- Limitations for AD&D: Disease, bodily or mental infirmity, suicide or intentionally self-inflicted injury, commission of an assault orfelony, war, use of any drug unless prescribed by physician, driving while intoxicated, engaging in any hazardous activities, ortravel in a private aircraft. Additional exclusions may apply depending upon the plan design of the employer.- Benefit provisions, exclusions and limitations may vary as a result of state specific requirements.- Individual coverage will continue, upon timely payment of premium, unless terminated because the Covered Person's insuranceunder the Policy terminates, or the dependent no longer meets the specific eligibility requirements stated in the Policy or the Policyterminates.- The Policy will continue, upon timely payment of premium, unless we cancel because the Policyholder did not meet his obligationsstated in the Policy, including providing information needed to administer the Policy, or the participation level drops below the levelstated in the Policy.- Premiums may vary by age.- UnitedHealthcare Life and Disability products are provided by UnitedHealthcare Insurance Company and certain products inCalifornia by Unimerica Life Insurance Company. Life and Disability products are provided on policy forms LASD-POL (05/03) et al.and UHCLD-POL 2/2008 et al., in Texas on forms LASD-POL-TX (05/03) and UHCLD-POL 2/2008-TX and in Virginia onLASD-POL (05/03) and UHCLD-POL 2/2008. The policies have exclusions, limitations, reductions of benefits, and terms underwhich the policy may be continued in force or discontinued. For costs and complete details of the coverage, call or write yourinsurance agent or the company. Some products are not available in all states. UnitedHealthcare Insurance Company is located inHartford, CT and Unimerica Life Insurance Company in Milwaukee, WI.- This Benefit Summary is intended only to highlight benefits and should not be relied upon to fully determine coverage. Morecomplete descriptions of benefits and the terms under which they are provided are contained in the Certificate of Coveragereceived upon enrollment in the plan. If this Benefit Summary conflicts in any way with the Policy issued to the employer, thePolicy shall prevail.Value-Added Services (All features may not apply. Some states may have restrictions.)- Beneficiary Services: Provides beneficiaries with services for grief consultation, financial/legal assistance andreferral to community resources. For more information, call 866-302-4480.· Toll-free line available 24/7 as well as referrals for face-to-face counseling. Specialists provide in-depthconsultation, information and referral to community resources such as grief support groups. Includes access toa national network of credentialed clinicians for grief and loss counseling. Beneficiaries receive twocomplimentary sessions.**· Financial and Legal Services. Telephonic access to financial consultants for assistance with financialdecision-making. Includes access to a network of 22,000 attorneys for either a 30-minute telephonic or anin-person consultation. You may retain the same attorney for representation at a discount to their hourly rate.Access to legal services facilitated by CLC, Inc.· Communication Support. We provide a "Beneficiary Kit" with informational resources to help beneficiarieswith the emotional and financial process that follows the loss of a loved one.- Travel Assistance: Assists domestic and foreign travelers with a variety of emergency travel-related services, suchas medical assistance, emergency transportation and pre-trip information. Includes access to Emergency ResponseCenter via toll-free or collect telephone call; available 24/7 from anywhere in the world. Covers up to 90 days on anyone trip when traveling 100+ miles from home or office. For more information, please call 1-410-453-6330 or visitthe online Member Center at http:members.uhcglobal.com. You will need to provide policy number: 358231.Services provided by UnitedHealthcare Global, a subsidiary of UnitedHealth Group.Created on: 06/15/2021 MPS-01; v3.0© 2020 United HealthCare Services, Inc.

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Patterson Nursery Sales Flexible Spending Account Summary January 1, 2024 – December 31, 2024 A Flexible Spending Account (FSA) is a type of plan that allows you to receive certain benefits on a pretax basis. Think of it as a tax-free and interest-free loan to yourself. The pretax contributions may be used for qualified healthcare and childcare expenses for you and your tax dependents. They also allow you to pay for your group’s sponsored insurance premiums on a pretax basis. Contributing to Your FSA Component Maximum Pay Period Election Minimum Annual Election Maximum Annual Election General Purpose Health FSA $ 133.33 $100 $3,200 Dependent Daycare Expenses $ 208.33 $100 $5,000 if married & filing a joint return or a single parent $2,500 if married but filing separately The Plans: The following FSA components are available through your employer.Premium Component o Your employer will deduct your portion of the group-sponsored insurance plans, including premiums for medical, dental, vision,hospitalization, accident insurance, and/or other qualified benefits from your gross salary on a pre-tax basis. This reduces incometaxes and results in an increase in take home pay and lower taxable salary.Health FSA Component – includes the following account(s) Health Related Expense Account (HRE) - the General Purpose FSA o If you’re eligible for your employer’s health plan, you can set up an HRE account. With an HRE account, you can save pre-taxmoney for healthcare expenses, including medical, dental, and vision expenses that are either not covered or only partiallycovered by your insurance plan.o These expenses are for your tax dependents. Examples include: you, your spouse, or child(ren), whether or not they are coveredon your employer’s group insurance plan.o When you have a qualified change in status—such as if you add or remove dependents from your insurance plan—you canincrease or decrease your electionDependent Care Assistance Plan (DCAP) Component Dependent Daycare Expense Account (DCE) o Our Dependent Daycare Expense Account (DCE) allows you to save pre-tax dollars to pay for dependent care. This is specificallyfor expenses for a child up to age 13 or disabled taxable dependent who is unable to care for themselves, including elder careexpenses.o When you have a qualified change in status—such as if your spouse’s employment changes—you can increase or decrease howmuch you put into your account.o In many cases, this account will be more beneficial to you than the federal tax credit.

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2 Claims Reimbursement Reimbursement Time Frame Reimbursements may be requested during the plan year or after it ends. Your claim submission period ends 90 days after the plan year ends. This is known as a run-out period. All eligible reimbursement claims for services you received between January 1, 2024 and December 31, 2024 must be submitted by March 31, 2025 for reimbursement. Submitting Claims There are several ways you can submit expenses for reimbursement. If you’re reimbursed for a claim and it is later determined that the expense was not eligible for reimbursement, you will be liable for repaying the money to your FSA. Additional information is listed below. Manual Claims We offer several ways you can submit your claims for reimbursement: 1. Submit your claim online using our PSAConsumer portal: https://psa.consumer.pacificsource.com 2. Submit your claim via our Mobile App: myPacificSource Admin (PSA) 3. Mail or fax a Request for Reimbursement Form. You’ll find the form at PSA.PacificSource.com/ Forms_Flex.aspx Prepaid Benefit Card A Prepaid Benefits Debit Card gives you an easy, automatic way to pay for qualified healthcare expenses. When you enroll in the health FSA, you will automatically receive two benefits cards. Simply swipe your benefits card as you would a credit/debit card (and select “credit” rather than “debit”). When you use the card to make a purchase or payment, it deducts funds directly from your FSA. Date of service is important! It’s assumed the date of service is the day the card is swiped. If you are paying for a prior service, only use your card if the service date is within your current plan year. Prior year services need to be submitted as manual claims for reimbursement. Replacements or additional cards can be purchased for $10 per set of two cards. When you use your debit card, you should request an itemized receipt for reimbursement in case we need you to substantiate a charge. (You must save all expense documentation, such as itemized receipts, per IRS regulations.) You may occasionally receive a notice if your transaction is ineligible or needs additional documentation. You will be required to submit the documentation, refund the account, or “offset” the expense as indicated in the notice. If the transaction issue hasn’t been resolved within the allotted time, the card will be suspended. Amounts for transactions that aren’t properly documented or that have been deemed ineligible may be included as wages on your W-2. Funds Remaining After the Plan Ends If the plan year ends before you’ve used all of your Health FSA funds, you’re allowed to have up to $640 carry over to the next FSA plan year. If you have more than the $640 remaining, you’ll lose those additional funds, along with all other account balances. Carryover funds will be automatically rolled after the prior plan year and claims submission period ends. You may request an early roll by contacting Customer Service. What Happens if I Terminate Employment during the Plan Year? If you terminate employment or lose eligibility, your participation in the plan will end with your final payroll contribution. You may be eligible to continue the Health FSA under COBRA or by making an additional pre-tax contribution out of your last paycheck.

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How to use your prepaid benet cardCLB1415_0424The prepaid benefit card that comes with your FSA or HRA account may look like a regular debit or credit card, but it’s not.Using your card comes with some additional responsibilities beyond a normal debit or credit card. Your card is only for IRS-approved eligible expenses, and swiping it is just the first step in using it. You’ll sometimes be required to submit documentation to verify the eligibility of the expenses you pay for with your card.Follow these 3 steps whenever you use your card1. Always ask for an itemized receipt that MUST include the following:• The service provider’s name • The date of service or purchase• A description of the service or eligible expense• The amount paid by your health insurance• The patient responsibility—this is the amount you oweTip: It’s helpful to get a receipt emailed or texted to you, so you can easily submit it in the consumer portal. Alternatively, you can take a picture of your paper receipt with your phone.2. A few days after you swipe your card, visit the PSA consumer portal.• Log in at PacSrc.co/psa-portal • First time signing in? Use the username and password instructions from your welcome letter to log in under the “Existing User” section. For login assistance, call our Customer Service team at 800-422-7038.• Look under “Tasks” to see if you need to submit your itemized receipt or explanation of benefits.• Check for any new communications from PSA in the “Message Center.”3. If you submitted something, revisit the portal or app a few days later to see if what you submitted was accepted or if any more actions are required. Download and use the FSA and HRA mobile app from PacSrc.co/psa-appMessage CenterTasksExisting User

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When to use your cardIf you’re seeing a medical provider for a routine visit, and you’re only being charged a copay, you should use your card at the time of service. Also use your card for prescription and approved over-the-counter items. The transaction should automatically approve, and you won’t need to supply anything more. But, it’s always a good idea to keep a copy of your receipt and follow the 3 steps on the previous page, in case your purchase isn’t auto-approved.If your treatment charges include anything more than a copay, it’s always best to wait until after your health insurance company has paid its portion of the bill before you use your card to pay your portion.Card suspensionYour card may become suspended. Common reasons include not responding to requests for documentation or incomplete documentation.You may not realize your card is suspended until you try to use your card and a charge is denied. This can be inconvenient and embarrassing, but it’s a sign your account needs attention.Rest assured that any funds left in your account are not affected by card suspension.To find out why your card was suspended, and to start using it, refer to the tasks or messages in your PSA consumer portal or app, or call PSA customer service at 800-422-7038, TTY: 711. We accept all relay calls.Benet card FAQDo I really need to get a receipt, even if I’m just using the card for a copay at my doctor’s office or at a pharmacy? Yes, always get an itemized receipt when using your card. The itemized receipt must include the provider’s name, date of service, a description of the service, the amount paid by insurance, and the patient responsibility amount.My dental or vision provider is requiring I pay before or at the time of service. Can I use my card? Yes, but be aware that the provider will estimate how much your insurance company will pay, and the insurance company may end up paying more than anticipated. If this happens, that amount will need to be refunded by your provider. Or your provider will refund you and you’ll need to refund your FSA or HRA account. You can refund your account using the PSA consumer portal or app.The money in my account is my money. How can you deny a charge I make with the card? The money in your account is conditional. We’re required by the IRS to ensure all purchases are eligible under your FSA or HRA plan. When our system is unable to automatically verify eligibility, we ask you for more information.I submitted a receipt. Why are you asking for more documentation? Sometimes a provider will give you an incomplete receipt. If the documentation you submitted to us doesn’t include the required details, we’ll ask for a more complete receipt or an Explanation of Benefits statement from your health insurance company. Your documentation must include the provider’s name, date of service, a description of the service, the amount paid by insurance, and the patient responsibility amount.Can I use my card to buy supplements? Sometimes. Supplements can be eligible, if you can provide a letter of medical necessity including a diagnosis code or the medical reason for needing the supplements. Many over-the-counter products are FSA-eligible, such as cold and pain relief medications, feminine care, and thermometers. A list of eligible expenses for general purpose health FSA accounts can be found at PacSrc.co/fsa-eligible-expenses (PDF).Why can’t I use my card to pay for a doctor bill from the previous year? You must spend your dollars during the same plan year as the date of service.My receipt shows that I used my card at a provider’s office. Why do you need a description of what I spent the money on? Not all services or goods sold at a provider’s office are eligible. For instance, teeth whitener from a dental office is not an eligible expense. A list of eligible expenses for general purpose health FSA accounts can be found at PacSrc.co/fsa-eligible-expenses (PDF).Questions? We’re here to help.800-422-7038, T T Y: 711 We accept all relay calls.PSACustomerService@PacificSource.com

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Monthly maintenance fee Other account fees $2.50* per ATM transaction. In addition to our fee, the bank/ATM you use to withdraw funds may charge you their own fee. $20.00* per outbound transfer or rollover to another HSA custodian. $1.50 printed statement fee. If you do not choose online delivery for your account statements, we may charge this fee for every statement we mail to you. Note: there is no charge for online statement delivery. $1.00 – there is no fee waiver threshold Includes use of: •Optum Financial payment card – to pay charges directly•Online bill payment and mobile access•Receipt vault – allows you to upload and store images of receipts onlineMonthly investment fee Investment threshold $3.00 $2,000 – The balance in your HSA must remain at or exceed the Investment Threshold each time a new investment is made. Schedule of fees Optum Bank®, Member FDIC, wants you to understand the fees associated with your health savings account (HSA). In the chart below, we’ve outlined the fees and how they may apply to your account. Standard fees Investment account† © 2023 Optum, Inc. All rights reserved. †Investments are not FDIC-insured, are not guaranteed by Optum Bank and may lose value. Betterment Investment Fee: 0.50% per year on your invested balance. Accrued on daily basis, and charged quarterly, and deducted from Betterment account. Schwab Health Savings Brokerage Account: $0.00. There is no monthly maintenance fee for Schwab HSBA, zero commissions, and no fee for online trades. Transaction fees apply to certain investments and for Broker-Assisted trades.

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For more information, talk with your benefits counselor.ColonialLife.comGroup Hospital Indemnity InsurancePlan 1 (HSA-Compliant)PA: “Hospital Confinement Admission” benefit replaces the “Hospital Confinement” benefitTHIS INSURANCE PROVIDES LIMITED BENEFITS.Insureds in California must be covered by comprehensive health insurance before applying for Hospital Confinement Indemnity Insurance.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; or (h) war. 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 certificateeective date. (n) This limitation applies to the following benefits, if applicable: Hospital Confinement, Daily Hospital Confinement, Inpatient Mental and Nervous, Rehabilitation Unit Confinement and Specified Critical Illness.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 formGMB7000-P and certificate form GMB7000-C (including state abbreviations where applicable, such as policy forms GMB7000-P-AU-TX and GMB7000-P-EE-TX, and certificate forms GMB7000-C-AU-TX and GMB7000-C-EE-TX). For cost and complete details of coverage, call or write your Colonial Life benefits counselor or the company. This form is not complete without form #101733.GMB7000 – PLAN 1 | 6-21 | 101917-2Group 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 insured£ Daily 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.Health savings account (HSA) compatibleThis plan is compatible with HSA guidelines and any other HSA plan that a covered family member may participate in. It may also be oered to employees who do not have HSAs.Colonial Life & Accident Insurance Company’s Group Medical Bridge oers an HSA-compatible plan in most states.Underwritten 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.1500.00

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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. 1212757-ORGROUP ACCIDENT (GAC4100) — PREFERRED PLAN

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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

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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)Options checked below have been chosen by your employer to enhance your Group Accident Coverage.  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 ................................ $250(Maximum once per insured per calendar year, with an accompanying police report) Gunshot wound benetThis benet can help pay your medical expenses if you receive a non-fatal gunshot wound. It offers you a lump sum for a covered injury regardless of any other insurance you may have and includes on/off-job coverage.• Gunshot wound .............................$_________This benet covers a non-fatal gunshot wound from a conventional rearm that requires treatment by a doctor and overnight hospitalization within 24 hours of the injury. If you are shot more than once in a 24-hour period, we can pay benets only for the rst wound.

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Contact your Colonial Life benets counselor to learn more.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, incarceration, racing, semi-professional or professional sports, sickness, suicide or self-inicted injuries, war, or armed conict. 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-OR and certicate form GAC4100-C-OR. 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 | 1212757-ORColonialLife.com1212757-OR

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ColonialLife.com 1284160-ORHEALTH 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, incarceration, racing, semiprofessional or professional sports, sickness, suicide or self-inicted injuries, war, or armed conict.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-OR and certicate form GAC4100-C-OR. 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 | 1284160-OR

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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• Spouse $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• Spouse $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 1284100-ORGROUP ACCIDENT (GAC4100) – AD&D BENEFITS

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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.ColonialLife.com1284100-ORHEALTH 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, incarceration, racing, semi-professional or professional sports, sickness, suicide or self-inicted injuries, war, or armed conict.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-OR and certicate form GAC4100-C-OR. 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 | 1284100-OR

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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%Permanent paralysis due to a covered accident100%Stroke100%Sudden cardiac arrest100%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:387100-ORelect from $5,000 to $30,000

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ColonialLife.com8-20 | 387100-OR1. 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 BENEFITSEXCLUSIONS 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: alcoholism or drug addiction; felonies, 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 was treated by a doctor, received advice from a doctor or had taken medication prescribed by a doctor within a six-month period immediately preceding the coverage eective date shown on the Certificate Schedule.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 form GCI6000-P-OR and certificate form GCI6000-C-OR. 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 six 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 forspouse or domesticpartner and eligibledependent childrenat 50% of yourcoverage amount Cover your eligibledependent children atno additional cost Receive coverageregardless of medicalhistory, withinspecified limits Works alongsideyour health savingsaccount (HSA) Benefits payableregardless of otherinsurance387100-OR

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Additional benets and servicesBuilt-in accelerated death benet provides an advance of up to 75% of the death benet, to a maximum of $150,000, if diagnosed with a terminal illness.3Health Advocate Employee Assistance Program (EAP) provides 24-hour personal support and referral service, including a medical bill saver service. Face-to-face sessions and video counseling with mental health professionals are available.4• Online: ColonialLife.com/EAP • Telephone: 1-888-645-1772Life planning services offer nancial and legal counseling services, as well as grief support and referral for up to 12 months after a claim.4Get the most out of your coveragePortability: You may be able to continue your coverage if you change jobs or retire. Conversion: After the group term period ends, you may be eligible to convert to a whole life policy without health questions. Waiver of premium: Your premium payments may be eligible for waiver if you become disabled. To learn more, talk with your Colonial Life benets counselor.1 Spouse and dependent coverage will not be effective if they are currently totally disabled. Being totally disabled means the inability to perform two or more activities of daily living, being conned to a hospital or similar institution, or being unable to attend school outside the home (for a dependent child age 5 up to age 26). In ID, NH and TX, the denition of total disability does not include Activities of Daily Living (ADL) requirements. The ability to work does not determine disability. You can pay premiums on insurance for your dependents with no health questions asked. Coverage isn’t effective until the earlier of the date they are no longer totally disabled or two years after the date that coverage would have otherwise become effective for the spouse or dependent child. This provision does not apply to newborn children born while dependent insurance is in effect.2 The maximum benet is 50% of your benet in NE.3 Terminal illness means an injury or sickness that results in the covered person having a life expectancy of 12 months or less and from which there is no reasonable prospect of recovery. A life expectancy of 24 months or less in IL, KS, MA, TX and WA. Accelerated death benet payments will reduce the amount the policy pays upon the recipient’s death, may adversely affect the recipient’s eligibility for Medicaid or other government benets or entitlements, and may be taxable. Recipients should consult their tax attorney or advisor before utilizing accelerated benet payments.4 The Employee Assistance Program and Life Planning Services, provided by Health Advocate, are available with Colonial Life & Accident Insurance Company Group Term Life offering. Terms and availability of service are subject to change. The service provider does not provide legal advice; please consult your attorney for guidance. Services are not valid after coverage terminates. State-mandated limitations for legal services in WA apply. Please contact the company for full details.BENEFIT AGE REDUCTION SCHEDULEWhen a covered person reaches age 70, but not 75, the amount of insurance will be:• 65% of the amount of insurance prior to age 70; or• 65% of the amount of insurance applied for on or after age 70 but before age 75.When a covered person reaches age 75 or more, the amount of insurance will be:• 50% of the amount of insurance prior to the rst reduction; or• 50% of the amount of insurance the employee applied for on or after age 75.Once the benet reduction schedule begins, there will be no further increases in insurance for a covered person. If the proposed insured is age 70, but not age 75 at the time of enrollment, the amount of insurance applied for will be reduced by 65%. If the proposed insured is age 75 or older at the time of enrollment, the amount applied for will be reduced by 50%.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 GTL1.0-P and certicate form GTL1.0-C (including state abbreviations where used, for example: GTL1.0-P-TX and GTL1.0-C-TX). For cost and complete details of coverage, call or write your Colonial Life benets counselor or the company.ColonialLife.comUnderwritten by Colonial Life & Accident Insurance Company, Columbia, SC.© 2024 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 3-24 | 100272-7

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Group Term Life InsuranceAccidental Death & Dismemberment Insurance (AD&D)This coverage can provide benets for a covered accidental death or dismemberment. Benets can be used for any purpose, including to help pay costs related to recovery or rehabilitation.What is my AD&D full benet amount? ____________________The AD&D full benet amount is equal to your group term life insurance death benet amount.What is payable under the AD&D benet?If the loss is: % of full amount payableLoss of life 100%Loss or loss of use of both hands or both feet or sight of both eyes100%Loss or loss of use of one hand and one foot 100%Loss or loss of use of one hand and sight of one eye 100%Loss or loss of use of one foot and sight of one eye 100%Loss of speech and hearing 100%Loss or loss of use of one hand or one foot 50%Loss of sight of one eye 50%Loss of speech or hearing 50%Loss or loss of use of thumb and index nger on the same hand25%What other benets are included? Seatbelts and airbags: Pays a benet if the cause of death or dismemberment is a car accident and the covered person was using a seatbelt or airbag.Family coverageAD&D is available to you with your group term life coverage, as well as all your covered family members.To learn more, talk with your Colonial Life benets counselor.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 GTL1.0-P and certicate form GTL1.0-C (including state abbreviations where used for example: GTL1.0-P-TX and GTL1.0-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.© 2024 Colonial Life & Accident Insurance Company. All rights reserved. Colonial Life is a registered trademark and marketing brand of Colonial Life & Accident Insurance Company.ColonialLife.com GROUP TERM LIFE AD&D BENEFIT FOR EMPLOYEES 1-24 | 100265-3

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Whole Life Plus Insurance*You can’t predict your family’s future, but you can prepare for it.Help give your family more peace of mind and coverage for nal expenses with Colonial Life Individual Whole Life Plus insurance.Benets and features Choose the age when your premium payments end — Paid-Up at Age 70 or Paid-Up at Age 100 Stand-alone spouse policy available even without buying a policy for yourself Ability to keep the policy if you change jobs or retire Built-in terminal illness accelerated death benet that provides up to 75% of the policy’s death benet (up to $150,000) if you’re diagnosed with a terminal illness1 Immediate $3,000 claim payment that can help your designated beneciary pay for funeral costs or other expenses Provides cash surrender value at age 100 (when the policy endows)Additional coverage optionsSpouse term riderCover your spouse with a death benet up to $50,000, for 10 or 20 years.Juvenile Whole Life Plus policyPurchase a policy (Paid-Up at Age 70) while children are young and premiums are low — whether or not you buy a policy for yourself. You may also increase the coverage when the child is 18, 21 and 24 without proof of good health. Children’s term riderYou may purchase up to $20,000 in term life insurance coverage for all of your eligible dependent children and pay one premium. The children’s term rider may be added to either your policy or your spouse’s policy — not both.Advantages of Whole Life Plus insurance• Permanent life insurance coverage that stays the same through the life of the policy• Premiums will not increase due to changes in health or age.• Accumulates cash value based on a nonforfeiture interest rate of 3.75%2• Policy loans available, which can be used for emergencies• Benet for the beneciary that is typically tax-freeYour cost will vary based on the amount of coverage you select.WHOLE LIFE PLUS (IWL5000)

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Additional coverage options (Continued)Accelerated death benet for long term care services rider3Talk with your benets counselor for more details.Accidental death benet riderAn additional benet may be payable if the covered person dies as a result of an accident before age 70, and doubles if the injury occurs while riding as a fare-paying passenger using public transportation. An additional 25% is payable if the injury occurs while driving or riding in a private passenger vehicle and wearing a seatbelt.Chronic care accelerated death benet riderIf a licensed health care practitioner certies that you have a chronic illness, you may receive an advance on all or a portion of the death benet, available in a one-time lump sum or monthly payments.1 Talk with your benets counselor for more details.Critical illness accelerated death benet riderIf you suffer a heart attack, stroke or end-stage renal (kidney) failure, a $5,000 benet is payable.1 A subsequent diagnosis benet is included.Guaranteed purchase option riderThis rider allows you to purchase additional whole life coverage — without having to answer health questions — at three different points in the future. The rider may only be added if you are age 50 or younger when you purchase the policy. 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 benet riderPolicy and rider premiums are waived 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, premiums will resume.Benets worksheetFor use with your benets counselorHow much coverage do you need? 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 100 DEPENDENT STUDENT $ ____________________________ Select the option: Paid-Up at Age 70 Paid-Up at Age 100Select any optional riders: Spouse term rider $ _____________ face amount for _________-year term period Children’s term rider $ ______________ face amount Accelerated death benet for long term care services rider Accidental death benet rider Chronic care accelerated death benet rider Critical illness accelerated death benet rider Guaranteed purchase option rider Waiver of premium benet riderTo learn more, talk with your benets counselor.ColonialLife.com* Whole Life Plus is a marketing name of the insurance policy led as “Whole Life Insurance” in most states.1 Any payout would reduce the death benet. Benets may be taxable as income. Individuals should consult with their legal or tax counsel when deciding to apply for accelerated benets. 2 Accessing the accumulated cash value reduces the death benet by the amount accessed, unless the loan is repaid. Cash value will be reduced by any outstanding loans against the policy.3 The rider is not available in all states. This life insurance does not specically cover funeral goods or services and may not cover the entire cost of your funeral at the time of your death. The beneciary of this life insurance may use the proceeds for any purpose, unless otherwise directed.EXCLUSIONS AND LIMITATIONS: If the insured dies by suicide, whether sane or insane, within two years (one year in ND) from the coverage effective date or the date of reinstatement, we will not pay the death benet. We will terminate this policy and return the premiums paid without interest, minus any loans and loan interest to you. This information is not intended to be a complete description of the insurance coverage available. The policy or its provisions may vary or be unavailable in some states. The policy has exclusions and limitations which may affect any benets payable. Applicable to policy forms ICC19-IWL5000-70/IWL5000-70, ICC19-IWL5000-100/IWL5000-100, ICC19-IWL5000J/IWL5000J and rider forms ICC23-IWL5000-LTC/IWL5000-LTC, 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 (including state abbreviations where applicable). For cost and complete details of the 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 8-23 | 642298-2

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Filing online means never waiting for mail or dealing with fax machines and complex paper forms . Our guided question wizard walks you through the process and checks for missing information that could cause delays. Opting for direct deposit can also get approved payments to you up to a week faster than paper check. NEED TO FILE A CLAIM?Here’s what you can do on Colonial Life for Policyholders:Update yourpersonal info& preferencesFile claimswith a simple,guided form Opt for instant alerts by email or textView claim statusor policy details anytimeCheck your claim status by logging into your account at ColonialLife.com/access. You can also sign up for text or email alerts so you know instantly if status changes or more information is needed. For your convenience, you can login anytime with a mobile device to photograph and upload documents with your camera.AFTER YOU FILE:Find out how simple your claims and beneﬁts experience can be by learning more about the Colonial Life for Policyholders portal. Just visit ColonialLife.com to see what this online account administration platform can do for you.LEARN MOREBECOME A MEMBER TODAY:Go to ColonialLife.com/access to register.Click “create an account”, ﬁll out the required information and click Submit.Enjoy faster service and improved beneﬁts awareness.123THE PORTALOFFERS YOU:Faster service than calling/emailingConﬁrmation when a claim has been submittedSimpliﬁed bill payment and managementAnswers to frequently asked questions and live chat assistance if you don’t see what you are looking for.Colonial Life for Policyholders PortalA faster, simpler way to manage your beneﬁtsColonial Life for Policyholders is an online portal created with you in mind. It’s the most convenient and ecient way to ﬁle a claim and manage your beneﬁts. Colonial Life products are underwritten by Colonial Life & Accident Insurance Company, Columbia, SC. ©2022 Colonial Life & Accident Insurance Company. All rights reserved. Colonial Life is a registered trademark and marketing brand of Colonial Life & Accident Insurance Company.43233-41Set up directdeposit forapproved payments