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2023-2024 Benefits Guide
HOWTOENROLLYouwillbeabletocompleteyourenrollmentbyfollowingthestepslistedbelow. ENROLLMENTOPTIONS 01You canenrollindependently throughouronline EnrollmentPlatform. Logininstructionsareincludedon the nextpage.02Youcan clickthelinkthatwasemailed/texttoyouand scheduleatimeto havea benefitscounselor callyouatyourchosentime,reviewyouroptions,andenrollyou overthephone.
_________________________________EMPLOYEE BENEFITS: HOWTO LOGINTOBERNIE PORTALACCOUNTBelow are the instructions for how to login both with and without an email address:How to login with email:Go to: https://www.bernieportal.com/en/loginEmployee default logins:Username: email addressPassword: Selecttheforgotpasswordoption ifyou donotrememberorhavenotsetoneupbefore.ORHow to login without email:https://www.bernieportal.com/en/emplovercode/loginEmployee code logins:2-digit code: 2-digit birth month (Example:March=03)4-digit code: last 4 of socialEmployer code:____________Pegaso Energy Servicesccc7b4
BenefitPre-TaxorPostTaxWhopaysthecost?WhydoIpayforsomebenefitswithbefore-taxmoney?Whilenotallbenefitsqualifyforpre-taxcontribution,thereisadefiniteadvantagetopayingforthosethatdo:Takingthemoneyoutbeforeyourtaxesarecalculatedlowerstheamountofyourtaxableincome.Therefore,youpaylessintaxes.HowYourBenefitsWorkFull-timeemployeesareeligibleformostbenefitson_____________________________________ofhire.MakingChangesGenerally,youcanonlychangeyourbenefitschoicesduringtheannualBenefitsEnrollmentPeriod.However,youcanchangeyourbenefitschoicesduringtheyearifyouhavealifeeventchange.Lifeeventchangesincludebutarenotlimitedto:· Marriage· Divorce· Birth,adoption,orplacementforadoptionofaneligiblechild· Deathofyourspouseorcoveredchild· Changeinyouoryourspouse’sworkstatusthatresultsincancellationofyourbenefits· BecomingeligibleforMedicareorMedicaidduringtheyearIfyouhavealifeeventchange,youmustnotifyHumanResourceswithin31daysofthechange(forexample,amarriageorbirthcertificate).Ifyoudo notnotifyHumanResourceswithin31days,youwillhavetowaituntilthenextannualOpenEnrollmentperiodtomakebenefitschangesunlessyouhaveanotherlifeeventchange.Anychangesyoumaketoyourbenefitchoicesmustbedirectlyrelatedtothelifeeventchange.the first day of the month following 60 daysPre-TaxPre-TaxPre-TaxHealth InsuranceDental InsuranceLong Term DisabilityVision InsuranceVoluntary Life InsurancePegaso Energy thriveson balance – balancing professional andpersonalworlds– balancingworkandrest– whilealwaysbalancingcostandvalue.Wealsounderstandthatbalancemustbeindividualized.What isrightforonepersonmaynotbeappropriateforanother.Itisourgoaltoofferchoicesallowingyoutotailoryourbenefitsplanspecificallytowhatisbestforyouandyourfamilymembers.YourChoices__Pegaso Energy _ Provides acompletepackageofbenefitsaimedatproviding flexibleinsurance protectionandprogramstomeetyourever-changingneeds.__Pegaso Energy _ sharesthecostofsomebenefitswithyou,whilemakingadditionalbenefitsavailablethatyoupayforifyouchoosetoenroll.Thepartofthebenefitcoststhatyouareresponsibleforwillbeautomaticallydeductedfromyourpaycheck,eitherbeforeorafteryourtaxesarecalculated.AccidentCritical Illness Post-TaxPost-TaxPost-Tax Post-TaxEmployer Shared Employer Shared Employer SharedEmployee Paid Employee PaidEmployee Paid Employee PaidPost-TaxShort Term DisabilityEmployee Paid Hospital Post-Tax Employee Paid
PortabilityIfyouleavethecompany,someofyourbenefitsendandsomeofyourbenefitsareportable.Thismeansyoucantakethemwithyouifyouleave,aslongasyoucontinuetopaythepremiumsyourself.Onceterminated,youwillbenotifiedthroughthemailifanyofyourbenefitsareportable.WhenCoverageEndsBenefitsendonthelastdayofthemonthfollowingterminationorwhenyouceasetomeeteligibilityguidelines. NOTES:____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Continuing Your CoverageUndercertaincircumstances,youmay continue yourhealthcarecoveragewhenitwouldotherwiseend.Thisiscalled___________________.______________________Cobraappliestotheseplans:· HealthInsurance· DentalInsurance· VisionInsuranceWhencan I continue coverage under____________________?Youand/oryourdependentsareeligibletocontinuehealthcarecoverageunder________________________If coverageislostbecause:· Your employment endsforanyreasonother than“grossmisconduct”.· Yourworkhours are significantlyreduced.· Youdie.· Youbecome entitled toandenrollinMedicarepriortolosingcoverage.· Youdivorceorbecomelegallyseparatedfromyourspouse.· Yourdependentlosesdependentstatus.CobraCobraCobraLooking ahead……Nowlet’s lookateachbenefitthatmakesupthe Pegaso Energy Services benefitsprogram.Inthefollowingpages,you’lllearnmoreaboutthevaluablebenefitsyouremployeroffers.You’llalsoseehowchoosingtherightcombinationofbenefitscanhelpprotectyouandyourfamily’shealth.
In OutDeductibleN/A N/AFamily DeductibleN/A N/ACoinsurance100% 100%Out-Of-Pocket$5,000 / $10,000 $10,000 / $20,000Office Visit$15 to $100 $300 Specialty Doctor Office Visit$15 to $100 $300 Inpatient Hospital Services$500 Copay $500 CopayPreventative Lab & X-Ray$0 Copay $0 CopayAdvanced Imagining$100 to $725 Copay $2,175 Urgent Care$50 Copay $150 CopayEmergency Room$500 Copay $500 CopayRX20/60/90/240/270/300 N/APCPEmployee OnlyEmployee + SpouseEmployee + Child(ren)Employee + FamilyNoEmployees Bi-Weekly Deduction$0.00$236.59$209.22$353.68NEWSurest C5000
2022 Surest Standard Plan Designs - TexasProperty of Bind Benefits, Inc. d/b/a Surest, Do not distribute without written permission. © 2022. Patent Pending.In-Network Out-of-NetworkDeductible NoneCoinsurance (Plan Paid) 100%OOP Limit Individual $5,000 $10,000OOP Limit Family $10,000 $20,000Preventive Care $0 $150Virtual CareVirtual Visit (Doctor on Demand) $0 Not CoveredOffice Visit $15 to $100 $300Urgent Care $50 $150Emergency Room $500 $500Ambulance $225 $225Observation Stay $500 $500MaternityPrenatal and Postnatal Care $0 $150Delivery $900 to $1,700 $5,100Procedures (Office, Outpatient and Inpatient) $40 to $3,000 Up to $9,000Bariatric Surgery Not Covered Not CoveredGender Dysphoria Surgery Covered CoveredOther outpatient hospital services $250 $750Other inpatient hospital stay (inc. admission from ER) $2,000 $6,000Rehabilitative Therapies $10 to $85 Up to $255Ex: Chiropractic $25 $75Ex: Physical Therapy $10 to $70 $210Complex Imaging (Ex: MRI, CT, etc.) $100 to $725 $2,175Routine Diagnostic Test (Ex: X-ray, Lab, Ultrasound) $0 $0Advanced Tests $25 to $825 Up to $2,475Ex: Sleep Study $100 to $700 $2,100Medical Infusions and Chemotherapy $50 to $2,950 Up to $8,850Therapeutic Treatments $70 to $1,850 Up to $5,550Durable Medical Equipment (including hearing aids) $0 to $1,000 Up to $2,000Fertility Treatment $100 to $1,500 Not CoveredMental Health & Substance Use DisorderIn an office setting (inc. ABA therapy) $15 $150Mental Health Telehealth $15 $150Partial day treatment $110 $330In an inpatient setting $2,000 $6,000In an outpatient setting $110 $330Residential $1,500 $4,500Retail Pharmacy - 30 day supplyTier 1 $20 Not CoveredTier 2 $60 Not CoveredTier 3 $90 Not CoveredRetail Pharmacy - 90 day supplyTier 1 $50 Not CoveredTier 2 $150 Not CoveredTier 3 $225 Not CoveredSpecialty Retail PharmacyTier 1 $240 Not CoveredTier 2 $270 Not CoveredTier 3 $300 Not CoveredPlan C5000Category Plan Design ElementOverall ProvisionsMedical CoveragePharmacy Coverage (OptumRx)
2022 Surest Standard Plan Designs - TexasProperty of Bind Benefits, Inc. d/b/a Surest, Do not distribute without written permission. © 2022. Patent Pending.In-Network Out-of-NetworkPlan C5000Category Plan Design ElementOOP Limit Cross ApplicationIn-Network copays accumulate to Out-of-Network OOP LimitOut-of-Network copays do not accumulate to In-Network OOP LimitOOP Limit AccumulatorERISA Plan Year accumulatorERISA Plan Year accumulatorOut of Network Reimbursement N/A 110% of Medicare Fee ScheduleEmergency Services OOP accumulatorIn-network copays accumulate to In-Network OOP LimitOut-of-network copays accumulate to the In-Network OOP LimitTherapy Visit Limits:Acupuncture 60 visit limit per person per plan year**Chiropractic60 visit limit per person per plan year**Physical Therapy 60 visit limit per person per plan year**Occupational Therapy 60 visit limit per person per plan year**Speech Therapy 60 visit limit per person per plan year**Home Health Care 120 visit limit per person per plan year**Skilled Nursing Facility 120 day limit per person per plan year***Place of Service - the Price (Copays) for some medical services and procedures are determined by the clinical setting in which the individual actually receives the care (“Place of Service”). For example, minor surgery in an office will incur an Office Visit price (copay), whereas minor surgery received in a hospital will incur an Outpatient Hospital Services and Surgery price (copay).**All visit and stay limits are per covered person per plan year and combined in-network and out-of-network.Insurance coverage for fully insured plans is provided by All Savers Insurance Company (for FL, GA, OH, UT and VA) or by UnitedHealthcare Insurance Company (for AZ, AR, KS, MI, MN, MO, OK, PA, SC, TN and TX). These policies have exclusions, limitations, and terms under which the policy may be continued in force or discontinued. For costs and complete details of the coverage, contact either your broker or the company. Administrative services provided by Bind Benefits, Inc. d/b/a Surest, its affiliate UnitedHealthCare Services, Inc., or by Bind Benefits, Inc. d/b/a Surest Administrators Services, in CA.Other Benefit Notes
EN-2026 FOR EMPLOYEES (06-21) Unum | Dental InsurancePegaso Energy ServicesWhat else is included?Pregnancy benefitAn extra cleaning for expecting mothers in their 2nd or 3rd trimester.Wellness benefitsOral cancer screenings for patients 40 and older with high risk factors.Unumdentalcare.comUse unumdentalcare.com and the mobile app search for providers, manage your benefits and learn about good dental health. Features include easy access to ID Cards, claims history and coverage information.Carryover benefitsMembers who take care of their teeth, but use only part of their annual maximum benefit during a benefit period are rewarded with extra benefits in future years! Carryover benefits will be accrued and stored in the insured’s carryover account to be used in the next benefit year.The limits for this policy/certificate are:Passive PPOCarryover benefit $250Threshold limit $500Carryover account limit$1,000Unum Dental™ Dental Insurance can help you pay for dental exams, cleanings and other services.Why is this coverage so valuable?Routine dental care keeps your mouth and whole body healthy.Your plan is backed by Unum’s commitment to excellence in customer service.Personalized website and mobile app to manage your benefits including claims information, ID cards and more.There’s no waiting period for preventive and basic services.How does it work?Good dental care is critical to your overall well-being. With Unum Dental insurance, you can get the attention your teeth need — at a cost you can afford.Unum Dental allows you to see any dentist you choose. To get the most from your benefits and reduce out-of-pocket costs, choose an in-network provider by utilizing our large national network. These providers have agreed to file your claims and uphold the highest quality standards. You can find in-network providers at unumdentalcare.com.
EN-2026 FOR EMPLOYEES (06-21) Unum | Dental InsuranceDental carryover benet and how it worksEach benefit year a member must have: • One cleaning, • One regular exam, and • Total dental claims for preventive, basic and major covered procedures paid during the year below the threshold limit. • If all three criteria above are met, a portion of the annual maximum will carry over to the next year.Other Specifications: • Each covered family member receives their own carryover benefit. • Group carryover benefit rider must be in effect for one benefit year before any members can utilize carryover benefits. • A member must be on the plan for a minimum of three months before accruing carryover benefits. • Carryover benefit may be used toward preventive, basic and major covered services only • A member’s carryover account will be eliminated, and the accrued carryover benefits lost if the insured has a break in coverage for any length of time or any reason.Dependent childrenDependent age guidelines vary by state. Please refer to your policy certificate or contact customer service at (888) 400-9304.Services not listedIf you expect to require a dental service not included on this brochure, it may still be covered. Please contact customer service at (888) 400-9304 to confirm your exact benefits.Alternate treatmentUnum covers the least expensive most commonly used and accepted American Dental Association treatments. Plan members may elect a more expensive treatment, but will be responsible for the cost difference resulting from the more expensive procedure.Coverage details and costsOverview Passive PPOBenefit Year Maximum*$1,000Deductible**$50 per benefit yearMaximum 3 per familyPlan Coinsurance In-network Non-networkClass A Preventive100% 100%Class B Basic80% 80%Class C Major50% 50%Class D Orthodontics50% 50%*Applies to Class A, B and C Services, if applicable **Waived for Class A (applies to Class B and C Services) Dental CoveragePassive PPOMonthly cost†You$34.28You and your spouse$67.23You and your children$91.56Family$135.12†Rates guaranteed for 12 months from the effective date.
EN-2026 FOR EMPLOYEES (06-21) Unum | Dental InsuranceCovered Procedures & Waiting PeriodsPassive PPOCLASS A PREVENTIVE SERVICESWaiting Period: None •Routine exams (2 per 12 months) • Prophylaxis (2 per 12 months) – (1 additional cleaning or periodontal maintenance per 12 months, if member is in 2nd or 3rd trimester of pregnancy) • Bitewing x-rays (maximum of 4 films; 1 per 12 months) • Fluoride treatment for children up to age 16 (1 per 12 months) • Sealants for children up to age 16 (permanent molars, 1 per 36 months) • Space MaintainersCLASS B BASIC SERVICESWaiting Period: None •Emergency Treatment (1 per 12 months) • Full mouth/panoramic x-rays (1 per 36 months) • Simple restorative services (fillings) – Posterior composite restorations • Simple extractionsCLASS C MAJOR SERVICESWaiting Period: None •Oral Surgery (extractions and impacted teeth) • Anesthesia (subject to review, covered with complex oral surgery) • Repair of crown, denture or bridge • Inlays and onlays • Non-Surgical periodontics • Surgical periodontics (gum treatments) • Periodontal maintenance (2 per 12 month in combination with prophylaxis) • Endodontics (root canals) • Crowns, bridges, dentures and implantsCLASS D ORTHODONTICSWaiting Period: 12 months •Separate Lifetime Maximum: $1,000 • Up to 25% of lifetime allowance may be payable on initial banding • Dependent children to age 19 onlyRefer to your certificate of coverage for the services covered under your plan.
Exclusions and LimitationsThe following dental services are not covered unless stated otherwise in the Certificate of Coverage:• any treatment which is elective or primarily cosmetic in nature and not generally recognized as a generally accepted dental practice by the American Dental Association, as well as any replacement of prior elective or cosmetic restorations;• replacement of a removable device or appliance that is lost, missing or stolen, and for the replacement of removable appliances that have been damaged due to abuse, misuse, or neglect. This may include but not be limited to removable partial dentures or dentures;• replacement of any permanent or removeable device or appliance unless the device or appliance is no longer functional and is older than the limitation in the Schedule of Covered Procedures. This may include but not be limited to bridges, dentures and crowns;• any appliance, service, or procedure performed for the purpose of splinting, to alter vertical dimension or to restore occlusion;• any appliance, service or procedure performed for the purpose of correcting attrition, abrasion, erosion, abfraction, bite registration, or bite analysis;• charges for implants (except noted above), removal of implants, precision or semi-precision attachments, denture duplication, or dentures and any associated surgery, or other customized services or attachments;• services provided for any type of temporomandibular joint (TMJ) dysfunction, muscular, skeletal deficiencies involving TMJ or related structures, myofascial pain.Limitations:• Multiple restorations on one surface are payable as one surface. Multiple surfaces on a single tooth will not be paid as separate restorations. On any given day, more than 8 periapical x-rays or a panoramic film in conjunction with bitewings will be paid as a full mouth radiograph. Pre-estimates are recommended for any treatment expected to exceed $300. A Network Access plan is available. THIS POLICY PROVIDES LIMITED BENEFITS This brochure is not intended to be a complete description of the insurance coverage available. The policies or their provisions may vary or be unavailable in some states. The policies have exclusions and limitations which may affect any benefits payable. For complete details of coverage and availability, please refer to Policy Form Series Dental 20-GDN or contact your Unum Dental representative. Underwriten by Starmount Life Insurance Company, Baton Rouge, LA.© 2021 Unum Group. All rights reserved. Unum is a registered trademark and marketing brand of Unum Group and its insuring subsidiaries. EN-2026 FOR EMPLOYEES (06-21)unum.com
EN-376255 FOR EMPLOYEES (4-21) Pegaso Energy ServicesUnum Vision® Powered by EyeMedMore flexibility, choice and savingsHow much does it cost? Monthly premiumYou $6.79You and your spouse $13.59You and your children $15.25Family $23.82Plan features:Members have the freedom to choose any provider from EyeMed’s Insight Network. Our network offers the right mix of independent, national retail and regional retail providers like Lens Crafters, Pearle Vision, Target Optical and many more. Members can also purchase glasses and contact lenses online at Glasses.com and ContactsDirect.com.Covered benefits:Exam: Each member is entitled to a comprehensive vision exam. An exam co-pay applies and is outlined in the grid at right.Materials: Each member has coverage for covered services and materials. Purchases are subject to benefit frequencies and co-pays. Plan features include:• Frame benefit: You may choose any frame within a provider’s collection, subject to the retail frame allowance listed at right. If the cost is greater than the plan’s benefits, you are responsible for the difference.• Eyeglass lens benefit: Standard plastic (CR-39 Plastic Material) single vision, bifocal, trifocal, and specialty lenses are generally covered after any applicable materials copay. If covered by plan allowance, you are responsible for any cost greater than the plan’s benefit.• Contact lens benefit: Members electing contact lenses instead of eye glass lenses may apply the contact lens allowance to any lenses in the provider’s collection. If the cost is greater than the plan’s benefits, you are responsible for the difference. Laser vision correction: Discounts are available with participating surgery providers across the country (not an insured benefit)EyeMed benefits:Vision Care ServicesIn-network Member CostOut-of-network ReimbursementsExam (1 per 12 months)$10 co-pay Up to $40Retinal Imaging BenefitUp to $39 Not coveredStandard Plastic Lenses (1 per 12 months)Single Vision$25 co-pay Up to $30Bifocal$25 co-pay Up to $50Trifocal$25 co-pay Up to $70Lenticular$25 co-pay Up to $70Standard Progressive $90 co-pay Up to $50Premium Progressive LensPremium Progressive Tier 1$110 co-pay Up to $50Premium Progressive Tier 2$120 co-pay Up to $50Premium Progressive Tier 3$135 co-pay Up to $50Premium Progressive Tier 4 $90 co-pay (80% of charge less than $120 allowance)Up to $50Lens OptionsPolycarbonate Lenses (under age 19)Covered Up to $32Frames (1 per 24 months)Members may select any frame available$150 allowance Up to $105Contact Lenses (1 per 12 months) In lieu of eyeglass lensesElective$150 allowance Up to $150Non-ElectiveCovered Up to $210Standard Contact Lens Fitting Exam Fee*Up to $40 Not covered*The standard contact lens fitting exam fee applies to a new or existing contact lens user who wears spherical disposable, daily wear, or extended wear lenses only.
EN-376255 FOR EMPLOYEES (4-21) Vision InsuranceUnum Vision Powered by EyeMed members will receive the following discounts on materials at in-network providers only:• 40% off for a complete second pair of glasses.• 20% off non-prescription sunglasses.• 20% off remaining balance beyond plan coverage.Laser Vision Correction NetworkMembership provides access to preferred pricing. Transactions are handled directly between members and providers. Refractive surgery is an elective procedure and may involve potential risks to patients. This is not an insured benefit. Unum cannot and does not guarantee the outcome of any refractive surgical procedure or a total elimination of the need for glasses or contacts. Providers may not be available in all metropolitan areas. Login to www.eyemedvisioncare.com/unum for a list of participating laser vision correction providers.Hearing Savings Plan included at no additional cost to the member!Unum offers a Hearing Savings Plan at no additional cost, to all of its Unum Vision Powered by EyeMed members. Partnering with Amplifon, the Hearing Savings Plan provides:• 40% off hearing exams at thousands of convenient locations nationwide• Discounted set pricing on thousands of hearing aids, including those with the newest, most advanced technology• Low price guarantee – if you find the same product at a lower price elsewhere, Amplifon will beat it by 5%• 60-day hearing aid trial period with no restocking fees• Free batteries for 2 years with initial purchase• 3-year warranty plus loss and damage coverageDependent children: Dependent age guidelines vary by state. Please refer to your policy certificate or contact customer service at (855) 652-8686.Services not listed: If you expect to require a vision service not included on this brochure, it may still be covered. Refer to the member portal at www.eyemedvisioncare.com/unum, to confirm your exact benefits. This is a primary vision care benefit and is intended to cover only eye examinations and/or corrective eyewear. Medical or surgical treatment of eye disease or injury is not provided under this plan. Coverage may not exceed the lesser of actual cost of covered services and materials or the limits of the policy.No benefits will be paid for services, materials connected with, or charges arising from:Orthoptic or vision training, subnormal vision aids and any associated supplemental testing; Aniseikonic lenses; Medical and/or surgical treatment of the eye, eyes or supporting structures; services provided as a result of any Workers’ Compensation law, or similar legislation, or required by any governmental agency or program whether federal, state or subdivisions thereof; any Vision Examination, or any corrective eyewear required by a Policyholder as a condition of employment; Safety eyewear; Plano (non-prescription) lenses; Non-prescription sunglasses; Two pair of glasses in lieu of bifocals; Services or materials provided by any other group benefit plan providing vision care; Services rendered after the date an Insured Person ceases to be covered under the Policy, except when Vision Materials ordered before coverage ended are delivered, and the services rendered to the Insured Person are within 31 days from the date of such order; Lost or broken lenses, frames, glasses, or contact lenses will not be replaced except in the next Benefit Frequency when Vision Materials would next become available.Member receives a 20% discount on items not covered by the plan at EyeMed In-Network locations. Discount does not apply to EyeMed Provider’s professional services, or contact lenses. Plan discounts cannot be combined with any other discounts or promotional offers. In certain states, members may be required to pay the full retail rate and not the negotiated discount rate with certain participating providers. Please see EyeMed’s online provider locator to determine which participating providers have agreed to the discounted rate. Discounts on vision materials may not be applicable to certain manufacturers’ products EyeMed Vision Care reserves the right to make changes to the products on each tier and the member out-of-pocket costs. Fixed pricing is reflective of brands at the listed product level. All providers are not required to carry all brands at all levels. Service and amounts listed above are subject to change at any time. Fees charged by a Provider for services other than a covered benefit must be paid in full by the Insured Person to the Provider. Such fees or materials are not covered under the Policy. Benefit allowances provide no remaining balance for future use within the same Benefit Frequency.A Network Access plan is available.THIS POLICY PROVIDES LIMITED BENEFITS This brochure is not intended to be a complete description of the insurance coverage available. The policies or their provisions may vary or be unavailable in some states. The policies have exclusions and limitations which may affect any benefits payable. For complete details of coverage and availability, please refer to Policy Form Series VI-2002, VI-2007 and VI-2019 or contact your Unum Vision representative.Starmount Life Insurance Company8485 Goodwood Boulevard • Baton Rouge, LA 70806PH: (855) 652-8686Vision plans are marketed by Unum, administered and underwritten by Starmount Life Insurance Company, Baton Rouge, LA.© 2021 Unum Group. All rights reserved. Unum is a registered trademark and marketing brand of Unum Group and its insuring subsidiaries.
Ratesfortheselinesareloadedintheonlineenrollmentplatformandexplainedinmoredetailonthefollowingpages.VoluntaryGroupTermLife/AD&DVoluntaryGroupTermLifeInsuranceisalsoavailableforyou,yourspouse,andyourdependentchildrenthrough_________________.Asanemployee,youmaypurchaseTermLifeInsuranceforyourselfinbenefitamountsbetween$10,000and_____________,in$10,000increments.GuaranteedIssuedYoucanpurchaseupto______________withouthavingtoansweramedicalquestionnaire.Ifyouchoosenottoenrollwhenyouarefirstofferedtheopportunityandchoosetoenrollatalatertime,youwillhavetocompleteamedicalquestionnaireandaresubjecttothecarrier’sapproval/denial.CriticalIllnesswithCancerCoverageEverydaythousandsofpeoplearediagnosedwithaseriousillness,suchascancerorarestrickenwithaheartattack,stroke,orotherunexpectedmedicalconditions.Thecostsassociatedwithseriousillnesses–evenforindividualswithmedicalinsurance–canbeastronomical.Thisplancanhelpovercomesomeofthecostsrelatedtosuddenillnessesthatarenotcoveredbymedicalinsurance.Youmayalsopurchasecoverageonyourspouse(age18–70)andyourdependentchildren(undertheageof26,whoareunmarriedandyourdependent.Diagnosishastotakeplaceafterthepolicyeffectivedate.UpondiagnosisofacoveredCriticalIllness,thecoveredindividualwillreceive100%ofthelumpsumbenefitamountelected. Ratesfortheseplansareloadedintheonlineenrollmentplatformandexplainedinmoredetailonthefollowingpages.AccidentInsuranceAccidentsareunexpected,asarethevariousexpenditures associated withthem.Whilemosthealthinsurancecoversmajorexpenses,itdoesnot covereveryrelatedcost.Youcouldface office visitcopays,deductibles,andtransportation/lodgingcosts – all costyou weren’t expecting. The AccidentInsurancegivesyoutheprotectionfortheunexpected.Theplanpaysyouabenefitthat can beappliedtoexpendituressurroundinganaccident,includingbutnotlimitedtoambulance,emergencyroom treatment,doctor’svisits,andsurgeryrelatedtotheaccident.Italsopaysbenefitsforcommonaccidentalinjuries,suchasburns,concussions,emergencydentalwork,dislocations,fractures,andmuchmore.Theamountofbenefityoureceive dependsonthenatureoftheinjuryorthetypeofserviceyoureceive. And thesebenefitsarepaidinadditiontoanymedicalinsuranceyoumighthave.ShortTerm/LongTerm DisabilityInsuranceHowdoyouseeyourselffiveyearsfromnow? Or ten?Chances are,you don’t seeyourself disabled. Butasurprisingnumberofpeopledofindthemselvesinjuredorsickandunabletowork – even if onlyforashorttime.Butwouldamonthseemlikeashorttimeifyouhadnoincome?Youremployeroffers plans thatwillhelpyoupayforyourhousehold expensesifyoubecome disabled andcannotwork.Theseplansmaybepurchasedwithout answeringhealthquestionsaslongasyouenrollwhenyouarefirsthired orthefirstyeartheplanisoffered.Enrollmentatanyothertimewill require medicalevidenceofinsurability.UNUM$500,000$50,000
EN-1976 FOR EMPLOYEES (4-21) 440971Pegaso Energy ServicesTerm Life and Accidental Death & Dismemberment (AD&D) Insurancecan provide money for your family if you die or are diagnosed with a terminal illness.Who can get Term Life coverage?If you are actively at work at least 32 hours per week, you may apply for coverage for:You: Choose from $10,000 to $500,000 in $10,000 increments, up to 5 times your earnings.If you previously purchased coverage, you can increase it up to $70,000, your guaranteed issue amount, with no health questions. If you previously declined coverage, you may have to answer some health questions.Your spouse:Get up to $250,000 of coverage in $5,000 increments. Spouse coverage cannot exceed 100% of the coverage amount you purchase for yourself.If you previously purchased coverage for your spouse, they can increase their coverage up to $25,000, their guaranteed issue amount, with no health questions or exams, if eligible (see delayed effective date). If you previously declined spouse coverage, some health questions may be required.Your children:Get up to $20,000 of coverage in $2,000 increments if eligible (see delayed effective date). One policy covers all of your children until their 26th birthday.The maximum benefit for children live birth to 6 months is $1,000.How does it work?You choose the amount of coverage that’s right for you, and you keep coverage for a set period of time, or “term.” If you die during that term, the money can help your family pay for basic living expenses, final arrangements, tuition and more.AD&D Insurance is also available, which pays a benefit if you survive an accident but have certain serious injuries. It pays an additional amount if you die from a covered accident.Why is this coverage so valuable?If you previously purchased coverage, you can increase it up to $70,000 to meet your growing needs — with no health questions or exams.What else is included? A ‘Living’ Benefit — If you are diagnosed with a terminal illness with less than 12 months to live, you can request 100% of your life insurance benefit (up to $250,000) while you are still living. This amount will be taken out of the death benefit, and may be taxable. These benefit payments may adversely affect the recipient’s eligibility for Medicaid or other government benefits or entitlements, and may be taxable. Recipients should consult their tax attorney or advisor before utilizing living benefit payments.Waiver of premium — Your cost may be waived if you are totally disabled for a period of time.Portability — You may be able to keep coverage if you leave the company, retire or change the number of hours you work.Employees or dependents who have a sickness or injury having a material effect on life expectancy at the time their group coverage ends are not eligible for portability.Who can get Term Life coverage?If you are actively at work at least 32 hours per week, you may apply for coverage for:You: Choose from $10,000 to $500,000 in $10,000 increments, up to 5 times your earnings.If you previously purchased coverage, you can increase it up to $70,000, your guaranteed issue amount, with no health questions. If you previously declined coverage, you may have to answer some health questions.Your spouse:Get up to $250,000 of coverage in $5,000 increments. Spouse coverage cannot exceed 100% of the coverage amount you purchase for yourself.If you previously purchased coverage for your spouse, they can increase their coverage up to $25,000, their guaranteed issue amount, with no health questions or exams, if eligible (see delayed effective date). If you previously declined spouse coverage, some health questions may be required.Your children:Get up to $20,000 of coverage in $2,000 increments if eligible (see delayed effective date). One policy covers all of your children until their 26th birthday.The maximum benefit for children live birth to 6 months is $1,000.Who can get Accidental Death & Dismemberment (AD&D) coverage?You: Get up to $500,000 of AD&D coverage for yourself in $10,000 increments to a maximum of 5 times your earnings.Your spouse:Get up to $250,000 of AD&D coverage for your spouse in $5,000 increments, if eligible (see delayed effective date).Your children:Get up to $20,000 of coverage for your children in $2,000 increments if eligible (see delayed effective date).No questions or health exams required for AD&D coverage.
EN-1976 FOR EMPLOYEES (4-21) 440971Term Life and Accidental Death & Dismemberment (AD&D) InsuranceHow much coverage can I get?1. Enter the coverage amount you want.2. Divide by the amount shown.3. Multiply by the rate. Use the rate table (at right) to find the rate based on age.(Choose the age you will be when your coverage becomes effective on 04/01/2022. To determine your spouse rate, choose the age the employee will be when coverage becomes effective on 04/01/2022.)4. Enter your cost.Billed amount may vary slightly.If you apply for coverage above the guaranteed issue amount, you will be asked health-related questions which may affect your ability to get the larger coverage amount. In order to purchase coverage for your dependents, you must buy coverage for yourself. Coverage amounts cannot exceed 100% of your coverage amounts. Calculate your costs1 2 3 4Employee $______,000 ÷ $10,000 = $________ X $______ = $_______Spouse $______,000 ÷ $5,000 = $________ X $______ = $_______Child $______,000 ÷ $2,000 = $________ X $______ = $_______Total costSpouse monthly ratePer $5,000 of coverageCost$0.650$0.650$0.800$1.050$1.500$2.450$3.850$5.500$7.000$10.000$17.000$17.000Employee monthly rateAgePer $10,000 of coverageCost15-24 $1.30025-29 $1.30030-34 $1.60035-39 $2.10040-44 $3.00045-49 $4.90050-54 $7.70055-59 $11.00060-64 $14.00065-69 $20.00070-74 $34.00075+ $34.000Child monthly rate$0.400 per $2,000 of coverage1. Enter the AD&D coverage amount you want.2. Divide by the amount shown.3. Multiply by the rate. Use the AD&D rate table (at right) to find the rate.4. Enter your cost.AD&D monthly ratesCoverage amount RateEmployee per $10,000 of coverage $0.600Spouse per $5,000 of coverage $0.300Child per $2,000 of coverage $0.120AD&D1 2 3 4Employee $______,000 ÷ $10,000 = $________ X $0.600 = $_______Spouse $______,000 ÷ $5,000 = $________ X $0.300 = $_______Child $______,000 ÷ $2,000 = $________ X $0.120 = $_______Total cost
EN-1976 FOR EMPLOYEES (4-21) 440971Exclusions and limitationsActively at workEligible employees must be actively at work to apply for coverage. Being actively at work means on the day the employee applies for coverage, the individual must be working at one of his/her company’s business locations; or the individual must be working at a location where he/she is required to represent the company. If applying for coverage on a day that is not a scheduled workday, the employee will be considered actively at work as of his/her last scheduled workday. Employees are not considered actively at work if they are on a leave of absence or lay off.An unmarried handicapped dependent child who becomes handicapped prior to the child’s attainment age of 26 may be eligible for benefits. Please see your plan administrator for details on eligibility.Employees must be U.S. citizens or legally authorized to work in the U.S. to receive coverage. Employees must be actively employed in the United States with the Employer to receive coverage. Employees must be insured under the plan for spouses and dependents to be eligible for coverage.Exclusions and limitationsLife insurance benefits will not be paid for deaths caused by suicide occurring within 24 months after the effective date of coverage. The same applies for increased or additional benefits. AD&D specific exclusions and limitations:Accidental death and dismemberment benefits will not be paid for losses caused by, contributed to by, or resulting from:• Disease of the body; diagnostic, medical or surgical treatment or mental disorder as set forth in the latest edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM)• Suicide, self-destruction while sane, intentionally self-inflicted injury while sane or self-inflicted injury while insane• War, declared or undeclared, or any act of war• Active participation in a riot• Committing or attempting to commit a crime under state or federal law• The voluntary use of any prescription or non-prescription drug, poison, fume or other chemical substance unless used according to the prescription or direction of your or your dependent’s doctor. This exclusion does not apply to you or your dependent if the chemical substance is ethanol.• Intoxication – ‘Being intoxicated’ means your or your dependent’s blood alcohol level equals or exceeds the legal limit for operating a motor vehicle in the state or jurisdiction where the accident occurred.Delayed effective date of coverageInsurance coverage will be delayed if you are not an active employee because of an injury, sickness, temporary layoff, or leave of absence on the date that insurance would otherwise become effective.Delayed Effective Date: if your spouse or child has a serious injury, sickness, or disorder, or is confined, their coverage may not take effect. Payment of premium does not guarantee coverage. Please refer to your policy contract or see your plan administrator for an explanation of the delayed effective date provision that applies to your plan.Age ReductionCoverage amounts for Life and AD&D Insurance for you and your dependents will reduce to 65% of the original amount when you reach age 65, and will reduce to 50% of the original amount when you reach age 70. Coverage may not be increased after a reduction.Termination of coverageYour coverage and your dependents’ coverage under the policy ends on the earliest of:• The date the policy or plan is cancelled• The date you no longer are in an eligible group• The date your eligible group is no longer covered• The last day of the period for which you made any required contributions• The last day you are actively employed (unless coverage is continued due to a covered layoff, leave of absence, injury or sickness), as described in the certificate of coverageIn addition, coverage for any one dependent will end on the earliest of:• The date your coverage under a plan ends• The date your dependent ceases to be an eligible dependent• For a spouse, the date of a divorce or annulment• For dependents, the date of your deathUnum will provide coverage for a payable claim that occurs while you and your dependents are covered under the policy or plan.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 benefits payable. For complete details of coverage and availability, please refer to Policy Form C.FP-1 et al or contact your Unum representative.Term Life and Accidental Death & Dismemberment (AD&D) InsuranceLife Planning Financial & Legal Resources services, provided by HealthAdvocate, are available with select Unum insurance offerings. Terms and availability of service are subject to change. Service provider does not provide legal advice; please consult your attorney for guidance. Services are not valid after coverage terminates. Please contact your Unum representative for details.Unum complies with state civil union and domestic partner laws when applicable.Underwritten by: Unum Life Insurance Company of America, Portland, Maine© 2021 Unum Group. All rights reserved. Unum is a registered trademark and marketing brand of Unum Group and its insuring subsidiaries.
EN-1977 (6-20) FOR EMPLOYEES440972Pegaso Energy ServicesPegaso Energy ServicesShort Term Disability Insurance can pay you a weekly benefit if you have a covered disability that keeps you from working.How does it work?If a covered illness or injury keeps you from working, Short Term Disability Insurance can replace part of your income while you recover. As long as you remain disabled, you can receive payments for up to 12 weeks. You’re generally considered disabled if you’re unable to do important parts of your job — and your income suffers as a result. Why is this coverage so valuable?You can use the money however you choose. It can help you pay for your rent or mortgage, groceries, out-of-pocket medical expenses and more.What’s covered? This insurance may cover a variety of conditions and injuries. Here are Unum’s top reasons for short term disability claims:1 • Normal pregnancy• Injuries (excluding back)• Joint disorders• Cancer• Digestive disordersThis plan does not cover pre-existing conditions. See the disclosure section to learn more.1 Unum internal data, 2018. Note: Causes are listed in ranked order.Consider your weekly expensesFood $_______Transportation _______ (gas, car payments, repairs)Child care/elder care _______Mortgage/rent _______Utilities _______ (electric, water, cable, phone)Medical costs _______ (co-pays, medications)Insurance _______ (health, life, car, home)Total weekly expenses $_______
EN-1977 (6-20) FOR EMPLOYEES 440972Short Term Disability InsuranceHow much coverage can I get?! If you didn’t get coverage when you were first eligible, you’ll have to answer medical questions now. If you’re newly eligible, you are guaranteed coverage now with no medical questions. If you already have coverage, you can increase it up to the maximum available with no medical questions. New coverage may be subject to pre-existing condition limitations.Elimination period (EP)This is the number of days that must pass between your first day of a covered disability and the day you can begin to receive your disability benefits.Your benefits would begin after you become disabled for 7 days.Benefit duration (BD)The maximum number of weeks you can receive benefits while you’re disabled. You have a 12 week benefit duration.Calculate your costYou*You are eligible for coverage if you are an active employee in the United States working a minimum of 32 hours per week.Coverage amounts Cover 60% of your weekly income, up to a maximum benefit of $1,500 per week. The weekly benefit may be reduced or offset by other sources of income. *See the Legal Disclosures for more information• For step 2:Enter your rate from the Rate Chart, based on your age.(Choose the age you will be when your coverage becomes effective on 04/01/2022.)Billed amount may vary slightly. Your rate is based on your age and will increase as you move to the next age band. * The maximum covered annual income is $130,000.Age Rates15-24 $0.23825-29 $0.26530-34 $0.35935-39 $0.43240-44 $0.55345-49 $0.69250-54 $0.96755-59 $1.20760-64 $1.55165+ $1.886Disability worksheet1Calculate your weekly disability benefit.$________ ÷ 52 = $________ x 60% =$__________Max weekly benefit available (if the amount exceeds the plan max of $1,500, enter $1,500.Your annualearningsYour weeklyearnings(Max % ofincome covered)2Calculate your cost per paycheck.$________÷ 10 = $________ x $_______ = $________ x 12 = $_______ ÷ 12 = $__________Your weeklybenefit amountYour rate Your monthly costYour annual costNumber of paychecks per yearYour cost per paycheck
EN-1977 (6-20) FOR EMPLOYEES 440972Exclusions and limitationsActive employeeYou are considered in active employment, if on the day you apply for coverage, you are being paid regularly by Pegaso Energy Services for the required minimum hours each week and you are performing the material and substantial duties of your regular occupation.Delayed effective date of coverageInsurance coverage will be delayed if you are not an active employee because of an injury, sickness, temporary layoff, or leave of absence on the date that insurance would otherwise become effective.Definition of disabilityYou are considered disabled when Unum determines that, due to sickness or injury:• You are limited from performing the material and substantial duties of your regular occupation and you are not working; or• You are working but you have lost 20% or more in weekly earnings.You must be under the regular care of a physician in order to be considered disabled. The loss of a professional or occupational license or certification does not, in itself, constitute disability. Unless the policy specifies otherwise, as part of the disability claims evaluation process, Unum will evaluate your occupation based on how it is normally performed in the national economy, not how work is performed for a specific employer, at a specific location or in a specific region.Pre-existing conditionsYou have a pre-existing condition if: • You received medical treatment, consultation, care or services including diagnostic measures for the condition, or took prescribed drugs or medicines for it in the 3 months just prior to your effective date of coverage; and• The disability begins in the first 12 months after your effective date of coverage. Deductible sources of incomeYour disability benefit may be reduced by deductible sources of income and any earnings you have while you are disabled, including such items as group disability benefits or other amounts you receive or are entitled to receive:• Workers’ compensation or similar occupational benefit laws• State compulsory benefit laws• Automobile liability insurance policy• Motor vehicle insurance policy or plan• No fault motor vehicle plan• Legal judgments and settlements• Salary continuation or sick leave plans, if applicable• Other group or association disability programs or insurance• Social Security or similar governmental programs Exclusions and limitationsBenefits will not be paid for disabilities caused by, contributed to by, or resulting from:• War, declared or undeclared or any act of war• Active participation in a riot• Intentionally self-inflicted injuries;• Loss of professional license, occupational license or certification;• Commission of a crime for which you have been convicted;• Any period of disability during which you are incarcerated;• Any occupational injury or sickness (this will not apply to a partner or sole proprietor who cannot be covered by law under workers’ compensation or any similar law);• Excluded pre-existing conditions (see definition).The loss of a professional or occupational license does not, in itself, constitute disability.Termination of coverageYour coverage under the policy ends on the earliest of the following:• The date the policy or plan is cancelled• The date you no longer are in an eligible group• The date your eligible group is no longer covered• The last day of the period for which you made any required contributions• The last day you are in active employment except as provided under the covered layoff or leave of absence provision.Unum will provide coverage for a payable claim that occurs while you are covered under the policy or plan.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 benefits payable. For complete details of coverage and availability, please refer to Policy Form C.FP-1 et al., or contact your Unum representative.Underwritten by:Short Term Disability InsuranceUnum Life Insurance Company of America, Portland, Maine© 2020 Unum Group. All rights reserved. Unum is a registered trademark and marketing brand of Unum Group and its insuring subsidiaries.
EN-1978 (6-20) FOR EMPLOYEES 440972Pegaso Energy ServicesLong Term Disability Insurance can replace part of your income if a disability keeps you out of work for a long period of time.How does it work?This coverage can pay a monthly benefit if you have a covered illness or injury and you can’t work for a few months — or even longer.You’re generally considered disabled if you’re unable to do important parts of your job — and your income suffers as a result. Why is this coverage so valuable?You can use the money however you choose. It can help you pay for your rent or mortgage, groceries, out-of-pocket medical expenses and more.What else is included?Work-life balance EAP Get access to professional help for a range of personal and work-related issues, including counselor referrals, financial planning and legal support.Worldwide emergency travel assistance One phone call gets you and your family immediate help anywhere in the world, as long as you’re traveling 100 or more miles from home. However, a spouse traveling on business for his or her employer is not covered.Survivor benefit If you die while you’ve been disabled and receiving benefits for at least 180 days, your family could get a benefit equal to 3 months of your gross disability payment. Waiver of premium If you’re disabled and receiving benefit payments, Unum waives your cost until you return to work.1 Unum internal data, 2018. Note: Causes are listed in ranked order.What’s covered? This insurance may cover a variety of conditions and injuries. Here are Unum’s top reasons for long term disability claims:1 • Cancer• Back disorders• Injuries• Cardiovascular• Joint disordersThis plan does not cover pre-existing conditions. See the disclosure section to learn more.Consider your monthly expensesFood $_______Transportation _______ (gas, car payments, repairs)Child care/elder care _______Mortgage/rent _______Utilities _______ (electric, water, cable, phone)Medical costs _______ (co-pays, medications)Insurance _______ (health, life, car, home)Total monthly expenses $_______
EN-1978 (6-20) FOR EMPLOYEES440972Long Term Disability InsuranceHow much coverage can I get?! If you didn’t get coverage when you were first eligible, you’ll have to answer medical questions now. If you’re newly eligible, you are guaranteed coverage now with no medical questions. If you already have coverage, you can increase it up to the maximum available with no medical questions. New coverage may be subject to pre-existing condition limitations. Elimination period (EP)Your elimination period is 90 days. This is the number of days that must pass after a covered accident or illness before you can begin to receive benefits.Benefit duration (BD)This is the maximum length of time you can receive benefits while you’re disabled. You can receive benefits up to the Social Security (SS) normal retirement age.Billed amount may vary slightly. Your rate is based on your age and will increase as you move to the next age band. • Use $200,000 if your annual earnings exceed this amount. This is the maximum coverage amount offered in this plan. • Multiply by your rate.Use the rate table to find the rate based on your age. (Choose the age you will be when your coverage becomes effective effective on 04/01/2022.)Calculate your costYou*You are eligible for coverage if you are an active employee in the United States working a minimum of 32 hours per week. Coverage amounts Cover 60% of your monthly income, up to a maximum payment of $10,000. The monthly benefit may be reduced or offset by other sources of income. *See the Legal Disclosures for more information.Age Rates15-24 $0.18025-29 $0.21030-34 $0.38035-39 $0.65040-44 $1.45045-49 $1.65050-54 $2.30055-59 $2.50060-64 $2.60065-69 $1.90070+ $1.550Disability worksheet1Enter your annual earnings and calculate your maximum monthly benefit available.$________ ÷ 12 = $_______ x 60% = $__________Your annual earningsYour monthly earnings(Max % of income covered) Max monthly benefit available 2Calculate your cost per paycheck $_______÷ 100 = $_______ x $_____ = $_______ ÷ 12 = $__________Your annual earningsRate Number of paychecks per yearTotal cost per paycheck
EN-1978 (6-20) FOR EMPLOYEES440972Exclusions and limitationsActive employeeYou are considered in active employment, if on the day you apply for coverage, you are being paid regularly by Pegaso Energy Services for the required minimum hours each week and you are performing the material and substantial duties of your regular occupation.Delayed effective date of coverageInsurance coverage will be delayed if you are not an active employee because of an injury, sickness, temporary layoff, or leave of absence on the date that insurance would otherwise become effective.Benefit duration (BD)The duration of your benefit payments is based on your age when your disability occurs. Your Long Term Disability benefits are payable while you continue to meet the definition of disability. Please refer to your plan document for the duration of benefits under this policy.Definition of disabilityYou are considered disabled when Unum determines that you are under the regular care of a physician, and:• You are limited from performing the duties required of your regular occupation due to sickness or injury and are not working; or• You are working and you have a 20% or more loss in monthly earnings due to sickness or injury.After benefits have been paid for 24 months, your plan’s definition of disability changes. At that time you are considered disabled when Unum determines that, due to the same sickness or injury, you cannot perform the duties of any occupation that you are qualified to do based on your education, training or experience.You must be under the regular care of a physician in order to be considered disabled.The loss of a professional or occupational license or certification does not, in itself, constitute disability.“Substantial and material acts” means the important tasks, functions and operations that are generally required by employers from those engaged in your usual occupation and that cannot be reasonably omitted or modified.Unless the policy specifies otherwise, as part of the disability claims evaluation process, Unum will evaluate your occupation based on how it is normally performed in the national economy, not how work is performed for a specific employer, at a specific location or in a specific region.Pre-existing conditionsYou have a pre-existing condition if:• You received medical treatment, consultation, care or services including diagnostic measures for the condition, or took prescribed drugs or medicines for it in the 3 months just prior to your effective date of coverage; and• The disability begins in the first 12 months after your effective date of coverage.Deductible sources of incomeYour disability benefit may be reduced by deductible sources of income and any earnings you have while you are disabled, including such items as group disability benefits or other amounts you receive or are entitled to receive:• Workers’ compensation or similar occupational benefit laws, including a temporary disability benefit under a workers’ compensation law• State compulsory benefit laws• Automobile liability insurance policy• No fault motor vehicle plan• Third-party settlements• Other group insurance plans• A group plan sponsored by your employer• Governmental retirement system• Salary continuation or sick leave plans, if applicable• Retirement payments• Social Security or similar governmental programsExclusions and limitationsBenefits will not be paid for disabilities caused by, contributed to by, or resulting from:• Intentionally self-inflicted injuries;• Active participation in a riot;• War, declared or undeclared or any act of war;• Commission of a crime for which you have been convicted;• Loss of professional license, occupational license or certification; or• Pre-existing conditions (See the disclosure section to learn more).The loss of a professional or occupational license does not, in itself, constitute disability.Unum will not pay a benefit for any period of disability during which you are incarcerated.The lifetime cumulative maximum benefit for all disabilities due to mental illness is 24 months. Disabilities based primarily on self-reported symptoms are limited to 24 months. Only 24 months of benefits will be paid for any combination of such disabilities even if the disabilities are not continuous and/or are not related. Payments can continue beyond 24 Long Term Disability Insurancemonths only if you are confined to a hospital or institution as a result of the disability.Termination of coverageYour coverage under the policy ends on the earliest of the following:• The date the policy or plan is cancelled• The date you no longer are in an eligible group• The date your eligible group is no longer covered• The last day of the period for which you made any required contributions• The last day you are in active employment except as provided under the covered layoff or leave of absence provision.Unum will provide coverage for a payable claim that occurs while you are covered under the policy or plan.Social Security advocacy services are provided by GENEX Services, Inc. or The Advocator Group, LLC. Referral to one of our advocacy partners is determined by Unum.Worldwide emergency travel assistance services are provided by Assist America, Inc. Work-life balance employee assistance program services are provided by HealthAdvocate. Services are available with select Unum insurance offerings. Terms and availability of service are subject to change and prior notification requirements. Service providers do not provide legal advice; please consult your attorney for guidance. Services are not valid after coverage terminates. Please contact your Unum representative for details.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 benefits payable. For complete details of coverage and availability, please refer to Policy Form C.FP-1 et al. or contact your Unum representative.Underwritten by:Unum Life Insurance Company of America, Portland, Maine© 2020 Unum Group. All rights reserved. Unum is a registered trademark and marketing brand of Unum Group and its insuring subsidiaries.
Unum | Critical Illness Insurance EN-2050 FOR EMPLOYEES (8-22) Pegaso Energy ServicesWhy should I buy coverage now? • It’s more affordable when you buy it through your employer and the premiums are conveniently deducted from your paycheck. • Coverage is portable. You may take the coverage with you if you leave the company or retire. You’ll be billed at home. Be Well BenefitEvery year, each family member who has Critical Illness coverage can also receive a payment for getting a covered Be Well Benefit screening test, such as:• Annual exams by a physician include sports physicals, well-child visits, dental and vision exams• Screenings for cancer, including pap smear, colonoscopy• Cardiovascular function screenings• Screenings for cholesterol and diabetes• Imaging studies, including chest X-ray, mammography• Immunizations including HPV, MMR, tetanus, influenzaWho can get coverage?You:Choose $10,000, $20,000 or $30,000 of coverage with no medical underwriting to qualify if you apply during this enrollment.Your spouse:Spouses can only get 50% of the employee coverage amount as long as you have purchased coverage for yourself.Your children:Children from live birth to age 26 are automatically covered at no extra cost. Their coverage amount is 50% of yours. They are covered for all the same illnesses plus these specific childhood conditions: cerebral palsy, cleft lip or palate, cystic fibrosis, Down syndrome and spina bifida. The diagnosis must occur after the child’s coverage effective date.How does it work?If you’re diagnosed with an illness that is covered by this insurance, you can receive a lump sum benefit payment. You can use the money however you want.Why is this coverage so valuable? • The money can help you pay out-of-pocket medical expenses, like co-pays and deductibles. • You can use this coverage more than once. Even after you receive a payout for one illness, you’re still covered for the remaining conditions and for the reoccurrence of any critical illness with the exception of skin cancer. The reoccurrence benefit can pay 100% of your coverage amount. Diagnoses must be at least 180 days apart or the conditions can’t be related to each other.What’s covered?Critical illnesses• Heart attack• Stroke• Major organ failure• End-stage kidney failure• Coronary artery disease Major (50%): Coronary artery bypass graft or valve replacement Minor (10%): Balloon angioplasty or stent placementCancer conditions• Invasive cancer — all breast cancer is considered invasive• Non-invasive cancer (25%)• Skin cancer — $500Progressive diseases Supplemental conditions• Amyotrophic Lateral Sclerosis (ALS)• Dementia, including Alzheimer’s disease• Multiple Sclerosis (MS)• Parkinson’s disease• Functional loss• Loss of sight, hearing or speech• Benign brain tumor• Coma• Permanent Paralysis• Occupational HIV, Hepatitis B, C or D• Infectious Diseases (25%)Please refer to the certificate for complete definitions about these covered conditions. Coverage may vary by state. See exclusions and limitations. Critical Illness Insurance
Unum | Critical Illness Insurance EN-2050 FOR EMPLOYEES (8-22) Active employment: You are considered in active employment if, on the day you apply for coverage, you are being paid regularly for the required minimum 30 hours each week and you are performing the material and substantial duties of your regular occupation. Insurance coverage will be delayed if you are not in active employment because of an injury, sickness, temporary layoff, or leave of absence on the date that insurance would otherwise become effective. New employees have a 30 day waiting period to be eligible for coverage. Please contact your plan administrator to confirm your eligibility date.If enrolling, and eligible for Medicare (age 65+; or disabled) the Guide to Health Insurance for People with Medicare is available at www.medicare.gov/sites/default/files/2022-03/02110-medigap-guide-health-insurance.pdf. Monthly costsAgeEmployee coverage: $10,000 Spouse coverage: $5,000 Be Well benefit: $50Employee Spouseunder 25 $3.48 $2.6825 - 29 $4.18 $3.0330 - 34 $5.38 $3.6335 - 39 $6.58 $4.2340 - 44 $9.18 $5.5345 - 49 $13.48 $7.6850 - 54 $20.98 $11.4355 - 59 $29.68 $15.7860 - 64 $43.28 $22.5865 - 69 $63.98 $32.9370 - 74 $94.48 $48.1875 - 79 $129.68 $65.7880 - 84 $175.68 $88.7885+ $273.38 $137.63Monthly costsAgeEmployee coverage: $20,000 Spouse coverage: $10,000 Be Well benefit: $75Employee Spouseunder 25 $6.96 $5.3625 - 29 $8.36 $6.0630 - 34 $10.76 $7.2635 - 39 $13.16 $8.4640 - 44 $18.36 $11.0645 - 49 $26.96 $15.3650 - 54 $41.96 $22.8655 - 59 $59.36 $31.5660 - 64 $86.56 $45.1665 - 69 $127.96 $65.8670 - 74 $188.96 $96.3675 - 79 $259.36 $131.5680 - 84 $351.36 $177.5685+ $546.76 $275.26Monthly costsAgeEmployee coverage: $30,000 Spouse coverage: $15,000 Be Well benefit: $100Employee Spouseunder 25 $10.44 $8.0425 - 29 $12.54 $9.0930 - 34 $16.14 $10.8935 - 39 $19.74 $12.6940 - 44 $27.54 $16.5945 - 49 $40.44 $23.0450 - 54 $62.94 $34.2955 - 59 $89.04 $47.3460 - 64 $129.84 $67.7465 - 69 $191.94 $98.7970 - 74 $283.44 $144.5475 - 79 $389.04 $197.3480 - 84 $527.04 $266.3485+ $820.14 $412.89
Unum | Critical Illness Insurance EN-2050 FOR EMPLOYEES (8-22) Your paycheck deduction will include the cost of coverage and the Be Well Benefit. Actual billed amounts may vary.Date of diagnosis must be after the coverage effective date.Exclusions and limitationsWe will not pay benefits for a claim that is caused by, contributed to by, or occurs as a result of any of the following: • committing or attempting to commit a felony; being engaged in an illegal occupation or activity; injuring oneself intentionally or attempting or committing suicide, whether sane or not; active participation in a riot, insurrection, or terrorist activity. This does not include civil commotion or disorder, injury as an innocent bystander, or injury for self-defense; participating in war or any act of war, whether declared or undeclared; combat or training for combat while serving in the armed forces of any nation or authority, including the National Guard, or similar government organizations; voluntary use of or treatment for voluntary use of any prescription or non-prescription drug, alcohol, poison, fume, or other chemical substance unless taken as prescribed or directed by the Insured’s Physician; being intoxicated; and a Date of Diagnosis that occurs while an Insured is legally incarcerated in a penal or correctional institution.Additionally, no benefits will be paid for a Date of Diagnosis that occurs prior to the Coverage Effective Date.End of employee coverageIf you choose to cancel your coverage your coverage ends on the first of the month following the date you provide notification to your employer. Otherwise, your coverage ends on the earliest of the: date this policy is canceled by Unum or your employer; date you are no longer in an eligible group; date your eligible group is no longer covered; date of your death; last day of the period any required premium contributions are made; or last day you are in active employment. However, as long as premium is paid as required, coverage will continue in accordance with the Continuation of your Coverage during Absences provision or if you elect to continue coverage for you, your Spouse, and Children under Portability of Critical Illness Insurance.Unum will provide coverage for a payable claim that occurs while you are covered under this certificate.THIS INSURANCE PROVIDES LIMITED BENEFITSThis 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 imitations which may affect any benefits payable. For complete details of coverage and availability, please refer to Policy Form GCIP16-1 or the Certificate Form GCIC16-1 or contact your Unum representative.Underwritten by: Unum Insurance Company, Portland, Maine© 2022 Unum Group. All rights reserved. Unum is a registered trademark and marketing brand of Unum Group and its insuring subsidiaries.
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EN-2073 FOR EMPLOYEES (10-22) Unum | Accident InsurancePegraso Energy ServicesWho can get coverage? Accident InsuranceHow does it work?Accident Insurance pays a set benefit amount based on the type of injury you have and the type of treatment you need. It covers accidents that occur off the job. And it includes a range of incidents, from common injuries to more serious events.Why is this coverage so valuable?It can help you with out-of-pocket costs that your medical plan doesn’t cover, like co-pays and deductibles. You’ll have base coverage without medical underwriting. The cost is conveniently deducted from your paycheck. You can keep your coverage if you change jobs or retire. You’ll be billed directly.YouIf you’re actively at work*Your spouseCan get coverage as long as you have purchased coverage for yourself.Your childrenDependent children from birth until their 26th birthday, regardless of marital or student status.*Employees must be legally authorized to work in the United States and actively working at a U.S. location to receive coverage. See Schedule of benefits for a complete listing of what is covered. What’s included?Be Well BenefitEvery year, each family member who has Accident coverage can also receive $50 for getting a covered Be Well screening test, such as: • Annual exams by a physician include sports physicals, well-child visits, dental and vision exams • Screenings for cancer, including pap smear, colonoscopy • Cardiovascular function screenings • Screenings for cholesterol and diabetes • Imaging studies, including chest X-ray, mammography • Immunizations including HPV, MMR, tetanus, influenzaOrganized Sports BenefitEach family member that has Accident coverage is eligible for a 10% increase in payable benefits within the Injury and Treatment schedule of benefit categories. See disclosures and schedule of benefits for more information.How much does it cost?Your monthly premium Option 1You$11.01You and your spouse$19.95You and your children$28.49Family$37.43
Unum | Accident InsuranceEN-2073 FOR EMPLOYEES (10-22)SCHEDULE OF BENEFITSAccidental Death and DismembermentAD&D Employee $50,000Spouse $25,000Children $12,500Common Carrier Benefit can pay if the insured individual is injured as a fare-paying passenger on a common carrier (examples include mass transit trains, buses and planes) Employee $50,000Spouse $25,000Children $12,500Dismemberment Both Feet $50,000Both Hands $50,000One Foot $25,000One Hand $25,000Thumb and Index Finger of the same Hand $12,500Coma Coma $10,000Home & Vehicle Modifications Home & Vehicle Modifications $1,500Loss of Use Hearing (one ear) $12,500Hearing $12,500Sight of one Eye $25,000Sight of both Eyes $50,000Speech $25,000Paralysis Uniplegia $12,500Hemi/Paraplegia $25,000Triplegia $37,500Quadriplegia $50,000HospitalizationAdmission $1,000Admission – Hospital ICU (added to Admission)$1,000Daily Stay $300Daily Stay – Hospital ICU (added to Daily Stay)$300Short Stay $200InjuryInjury due to felony & sexual assault$150Organized Sports 10%BurnsInjury2nd Degree Burns - At least 5%, but less than 20% of skin surface$5002nd Degree Burns - 20% or greater of skin surface$1,0003rd Degree Burns - Less than 5% of skin surface$2,0003rd Degree Burns - At least 5%, but less than 20% of skin surface$5,0003rd Degree Burns - 20% or greater of skin surface$10,000ConcussionConcussion $200Connective Tissue DamageOne Connective Tissue (tendon, ligament, rotator cuff, muscle)$90Two or more Connective Tissues (tendon, ligament, rotator cuff, muscle)$150DislocationsKnee joint (other than patella)$1,650Ankle bone or bones of the foot (other than toes)$1,650Hip joint $3,375Collarbone (sternoclavicular)$825Elbow joint $500Hand (other than Fingers) $500Lower Jaw $500Shoulder $500Wrist joint $500Collarbone (acromioclavicular and separation)$325Finger or Toe (Digit) $150Kneecap (patella) $500Incomplete Dislocation - Payable as a % of the applicable Dislocations benefit25%Eye InjuryEye Injury $200FracturesSkull (except bones of Face or Nose), Depressed$4,500Hip or Thigh (femur) $3,375Skull (except bones of Face or Nose), Non-depressed$2,250Vertebrae, body of (other than Vertebral Processes)$1,350Leg (mid to upper tibia or fibula)$1,350Pelvis $1,350InjuryBones of the Face or Nose (other than Lower Jaw, Mandible or Upper Jaw, Maxilla)$675Upper Arm between Elbow and Shoulder (humerus)$675Upper Jaw, Maxilla (other than alveolar process)$675Ankle (lower tibia or fibula)$450Collarbone (clavicle, sternum) or Shoulder Blade (scapula)$450Foot or Heel (other than Toes)$450Forearm (olecranon, radius, or ulna), Hand, or Wrist (other than Fingers)$450Kneecap (patella) $450Lower Jaw, Mandible (other than alveolar process)$450Vertebral Processes $450Rib $450Tailbone (coccyx), Sacrum $450Finger or Toe (Digit) $225Chip Fracture - Payable as a % of the applicable Fractures benefit25%Same bone maximum incurred per accident1 FractureMaximum payable multiplier for multiple bones2 TimesInternal InjuriesInternal Injuries $200LacerationsNo Repair $50Repair Less than 2 inches $150Repair At least 2 inches but less than 6 inches$300Repair 6 inches or greater $600Loss of a DigitOne Digit (other than a Thumb or Big Toe)$750One Digit (a Thumb or Big Toe)$1,125Two or more Digits $1,500Knee CartilageKnee Cartilage (Meniscus) Injury$150Ruptured or Herniated DiscOne Disc $150Two or more Discs $250RecoveryAcquired Brain Injury $25At-Home Care $100Physician Follow-Up Visits $75
Unum | Accident InsuranceEN-2073 FOR EMPLOYEES (10-22)SCHEDULE OF BENEFITSRecoveryPhysician Follow-Up Maximum Visits2Prescription Drug $25Prescription Benefit Incidence per covered accident1 Per InsuredRehabilitation or Subacute Rehabilitation Unit$100Behavior Health Therapy $20Behavior Health Therapy visits15Telehealth Service $25Telemedicine Medical Service$25Therapy Services (chiro, speech, PT, occ, acupuncture/alternative)$20Therapy Services Maximum Days15SurgeryDislocationsDislocation, Surgical Repair - Payable as a % of the applicable Injury benefit100%AnesthesiaEpidural or Regional Anesthesia$100General Anesthesia $250Connective TissueExploratory without Repair $100Repair for One Connective Tissue$800Repair for Two or more Connective Tissues$1,200Eye SurgeryEye Surgery, Requiring Anesthesia$300FracturesFractures, Surgical Repair - Payable as a % of the applicable Injury benefit100%Surgical Repair same bone maximum incurred per accident1 FractureSurgical Repair same bone maximum payable multiplier for multiple bones2 TimesGeneral SurgeryAbdominal, Thoracic, or Cranial$1,500Exploratory $150Incidence per covered accident1 Per InsuredHernia SurgeryHernia Surgery $150Knee CartilageSurgeryKnee Cartilage (Meniscus) Exploratory without Repair$150Knee Cartilage (Meniscus) with Repair$750Outpatient Surgical FacilityOutpatient Surgical Facility$300Ruptured or Herniated Disc SurgeryExploratory without Repair $125One Disc $675Two or more Discs $1,000TreatmentOrganized Sports 10%AmbulanceAir $1,000Ground $300Durable Medical EquipmentTier 1 (arm sling, cane, medical ring cushion)$50Tier 2 (bedside commode, cold therapy system, crutches)$100Tier 3 (back brace, body jacket, continuous passive movement, electric scooter)$200Emergency Dental RepairDental Crown $350Dental Extraction $115Filling or Chip Repair $90ImagingTier 1: X-rays or Ultrasound$50Tier 2: Bone Scan, CAT, CT, EEG, MR, MRA, or MRI$100Medical Imaging Incidence allowance covered accident per Tier1 Per Insured Per TierLodgingLodging (per night) $150Prosthetic DeviceOne Device or Limb $750Two or more Devices or Limbs$1,500Skin GraftsFor Burns - Payable as a % of the applicable Burn benefit50%Not Burns - Less than 20% of skin surface$250Not Burns - 20% or greater of skin surface$500TreatmentEmergency Room Treatment $200TreatmentInjections to Prevent or Limit Infection (tetanus, rabies, antivenom, immune globulin)$50Pain Management Injections (epidural, cortisone, steroid)$100Transfusions $400Transportation (per trip) $100Family Care $50Pet Boarding (per day) $30•
EN-2073 FOR EMPLOYEES (10-22)Unum | Accident InsuranceOrganized Sports BenefitThis increased benefit payment will be applied if the covered Accident occurs while playing an organized sport that required formal registration to participate and is officiated by someone certified to act in that capacity. Active employmentYou are considered in active employment if, on the day you apply for coverage, you are being paid regularly for the required minimum 20 hours each week and you are performing the material and substantial duties of your regular occupation. Insurance coverage will be delayed if you are not in active employment because of an injury, sickness, temporary layoff, or leave of absence on the date that insurance would otherwise become effective. New employees have a 30 day waiting period to be eligible for coverage. Please contact your plan administrator to confirm your eligibility date. If enrolling, and eligible for Medicare (age 65+; or disabled) the Guide to Health Insurance for People with Medicare is available at www.medicare.gov/sites/default/files/2022-03/02110-medigap-guide-health-insurance.pdf.Effective date of coverageCoverage becomes effective on the first day of the month in which payroll deductions begin.Exclusions and limitations We will not pay benefits for a claim that is caused by, contributed to by, or occurs as the result any of the following:• committing or attempting to commit a felony;• being engaged in an illegal occupation or activity;• injuring oneself intentionally or attempting or committing suicide, whether sane or not;• active participation in a riot, insurrection, or terrorist activity. This does not include civil commotion or disorder, Injury as an innocent bystander, or Injury for self-defense;• participating in war or any act of war, whether declared or undeclared;• combat or training for combat while serving in the armed forces of any nation or authority, including the National Guard, or similar government organizations;• a Covered Loss that occurs while an Insured is legally incarcerated in a penal or correctional institution;• elective procedures, cosmetic surgery, or reconstructive surgery unless it is a result of trauma, infection, or other diseases;• an occupational injury; • any Sickness, bodily infirmity, or other abnormal physical condition or Mental or Nervous Disorders, including diagnosis, treatment, or surgery for it;• Infection. This exclusion does not apply when the infection is due directly to a cut or wound sustained in a Covered Accident;• experimental or investigational procedures;• operating any motorized vehicle while intoxicated;• operating, learning to operate, serving as a crew member of any aircraft or hot air balloon, including those which are not motor-driven, unless flying as a fare paying passenger;• jumping, parachuting, or falling from any aircraft or hot air balloon, including those which are not motor-driven;• travel or flight in any aircraft or hot air balloon, including those which are not motor-driven, if it is being used for testing or experimental purposes, used by or for any military authority, or used for travel beyond the earth’s atmosphere;#practicing for or participating in any semi-professional or professional competitive athletic contests for which any type of compensation or remuneration is received;• riding or driving an air, land or water vehicle in a race, speed or endurance contest; and• engaging in hang-gliding, bungee jumping, sail gliding, parasailing, parakiting, or BASE jumping.The Accidental Death and Dismemberment Benefits are also subject to the following Exclusions. We will not pay benefits for a claim that is caused by, contributed to by, or resulting from any of the following:• being intoxicated; and• voluntary use of or treatment for voluntary use of any prescription or non-prescription drug, intoxicant, poison, fume, or other chemical substance unless taken as prescribed or directed by the Insured’s PhysicianAdditionally, no benefits will be paid for a Covered Loss that occurs prior to the Coverage Effective Date.Termination of employee coverageIf you choose to cancel your coverage your coverage ends on the first of the month following the date you provide notification to your employer. Otherwise, your coverage ends on the earliest of the:• the date this policy is canceled by Unum or your employer;• the date you are no longer in an eligible group;• the date your eligible group is no longer covered;• the date of your death;• the last day of the period any required premium contributions are made;• the last day you are in active employment. However, as long as premium is paid as required, coverage will continue• in accordance with the Continuation of your Coverage during Absences provision; or• if you elect to continue coverage for you, your Spouse, and Children under Portability of Accident Insurance. We will provide coverage for a Payable Claim that occurs while you are covered under this certificateAccident InsuranceTHIS IS A LIMITED BENEFITS POLICYThis 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 benefits payable. For complete details of coverage and availability, please refer to certificate form GAC16-1 et al. and GAC16-2, GAC16-2-IL, GAC16-3-NH, GAC16-2-OH, and GAC16-2-UT. Policy Form GAP16-1 et al. in all states, GAP16-3-NH in New Hampshire or contact your Unum representative.Unum complies with state civil union and domestic partner laws when applicable.Underwritten by: Unum Insurance Company, Portland, Maine© 2022 Unum Group. All rights reserved. Unum is a registered trademark and marketing brand of Unum Group and its insuring subsidiaries.
EN-372230 FOR EMPLOYEES (10-22) Unum | Hospital Insurance Pegaso Energy ServicesWho can get coverage?You:If you’re actively at work.Your spouse:Can get coverage as long as you have purchased coverage for yourself.Your children:Dependent children newborn until their 26th birthday, regardless of marital or student statusEmployee must purchase coverage for themselves in order to purchase spouse or child coverage. Employees must be legally authorized to work in the United States and actively working at a U.S. location to receive coverage. Please refer to the certificate for complete definitions about these covered conditions. Coverage may vary by state. See exclusions and limitations.This plan has a childbirth limitation. See disclosures for more information.If enrolling, and eligible for Medicare (age 65+; or disabled) the Guide to Health Insurance for People with Medicare is available at www.medicare.gov/sites/default/files/2022-03/02110-medigap-guide-health-insurance.pdfHow does it work?Hospital Insurance helps covered employees and their families cope with the financial impacts of a hospitalization. You can receive benefits when you’re admitted to the hospital for a covered accident, illness or childbirth.Why is this coverage so valuable? • The money is paid directly to you — not to a hospital or care provider. The money can also help you pay the out-of-pocket expenses your medical plan may not cover, such as co-insurance, co-pays and deductibles. • You get affordable rates when you buy this coverage at work. • The cost is conveniently deducted from your paycheck. • The benefits in this plan are compatible with a Health Savings Account (HSA). • You may take the coverage with you if you leave the company or retire, without having to answer new health questions. You’ll be billed directly.Since our founding in 1848, Unum has been a leader in the employee benefits business. Innovation, integrity and an unwavering commitment to our customers has helped us become a global leader in financial protection benefits.Hospital InsuranceHospital Insurance can pay benefits that help you with the costs of a covered hospital visit.How much does it cost?Your monthly premiumYou$9.23You and your spouse$29.62You and your children$15.32Family$35.71
EN-372230 FOR EMPLOYEES (10-22)Unum | Hospital Insurance HospitalHospital AdmissionPayable for a maximum of 1 day per year$1,000ICU AdmissionPayable for a maximum of 1 day per year$1,000Hospital Daily StayPayable per day up to 365 days $100ICU Daily Stay Payable per day up to 30 days $100Short StayPayable for a maximum of 1 day per year$100Exclusions and LimitationsHospital insurance filed policy name is Group Hospital Indemnity Insurance PolicyActive employmentYou are considered in active employment if, on the day you apply for coverage, you are being paid regularly for the required minimum 20 hours per week and you are performing the material and substantial duties of your regular occupation. Insurance coverage will be delayed if you are not in active employment because of an injury, sickness, temporary layoff, or leave of absence on the date that insurance would otherwise become effective. New employees have a 30 day waiting period to be eligible for coverage. Please contact your plan administrator to confirm your eligibility date.Childbirth LimitationWe will pay benefits due to Childbirth for any Insured within the first nine months after the Insured’s Coverage Effective Date.Childbirth or Complications of Pregnancy will be covered to the same extent as any other Covered Sickness.Exclusions and limitationsWe will not pay benefits for a claim that is caused by, contributed to by, or resulting from any of the following:• participation in a felony ;• being engaged in an illegal occupation;• injuring oneself intentionally or attempting or committing suicide, whether sane or not;• participation in a riot, or insurrection. This does not include civil commotion or disorder, Injury as an innocent bystander, or Injury for self-defense;• participating in war or any act of war, whether declared or undeclared;• combat while serving in the armed forces of any nation or authority, including the National Guard, or similar government organizations while coverage is suspended and no premiums are collected;• being legally intoxicated;• a Covered Loss that occurs while an Insured is legally incarcerated in a penal or correctional institution;• elective procedures, cosmetic surgery, or reconstructive surgery unless it is a result of organ donation, trauma, infection, gender identity disorders, or other diseases;• treatment for dental care or dental procedures, unless treatment is the result of a Covered Accident; • any Admission of a newborn Child immediately following Childbirth unless the newborn is Injured or Sick;• voluntary use of illegal drugs; and • Mental or Nervous Disorders. This exclusion does not include dementia if it is a result of:• stroke, Alzheimer’s disease, trauma, viral infection; or• other conditions which are not usually treated by a mental health provider or other qualified provider using psychotherapy, psychotropic drugs, or other similar methods of treatment.Additionally, no benefits will be paid for a Covered Loss that occurs prior to the Coverage Effective Date.End of employee coverageIf you choose to cancel your coverage under this certificate, your coverage will end on the first of the month following the date you provide notification to your Employer.Otherwise, your coverage under this certificate ends on the earliest of:• the date the Policy is cancelled by us or your Employer;• the date you are no longer in an Eligible Group;• the date your Eligible Group is no longer covered;• the date of your death;• the last day of the period any required premium contributions are made; or• the last day you are in Active Employment.However, as long as premium is paid as required, coverage will continue in accordance with the Continuation of your Coverage During Absences provision or if you elect to continue coverage for you under Portability of Hospital Indemnity Insurance.We will provide coverage for a Payable Claim that occurs while you are covered under this certificate.THIS INSURANCE PROVIDES LIMITED BENEFITSThis coverage is a supplement to health insurance. It is not a substitute for comprehensive health insurance and does not qualify as minimum essential health coverage as defined in federal law. Some states may require individuals to have comprehensive medical coverage before purchasing hospital insurance.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 benefits payable. For complete definitions of coverage and availability, please refer to Certificate Form GHIC16-1 and policy form GHIP16-1 or contact your Unum representative.Unum complies with all state civil union and domestic partner laws when applicable.Underwritten by: Unum Insurance Company, Portland, Maine© 2022 Unum Group. All rights reserved. Unum is a registered trademark and marketing brand of Unum Group and its insuring subsidiaries.