Sample Insurica Guide : simplebooklet.com

WELCOME TO YOUR 2023 BENEFITS!We consider our employee benefits program to be one of our most important investments. Because we recognize the value our employees bring to our company, we are committed to providing you with a complete benefits program as part of yourtotal compensation. Your benefit needs are unique, and our program is designed to be comprehensive and flexible, so you areable choose the benefits that make the most sense for you and your family.This summary describes your employee benefits available to you. This guide is meant only to cover major points of eachbenefit anddoes not contain all the details of each plan or policy including limitations and exclusions. If there is ever a question about one of these plans or policies or if there is a conflict between the information in this summaryand the official carrier supplied plan or policy documents, the formal wordings in those documents will govern. These benefits may be changed at any time and do not represent a contractual obligation on the part of your employer.ELIGIBILITYEmployees• All full-time employees working at least (30) hours per week are eligible for group benefits.• All benefits are effective on the 1st of the month following date of employment.Eligible Dependents• Youreligibledependentsincludeyour legally married spouseandchildren(includingstepchildrenandadopted children) untilage(26) forallbenefits.• Coveragemay be availablefor amentally or physically disabled child who is age(26) or older.Please contact thecarrierorcallthe'Zs/EmployeeBenefits Helplineat1-800-424-8274formore information.WHEN CAN YOU ENROLL / MAKE CHANGESNew Hires / Newly Eligible for Benefits• When you are first hired or become eligible for benefits, you have (30) days to enroll for benefits.If you do not enroll within that time, you will not be eligible for benefits until the next Open Enrollment, unless youhave a Qualifying Life Event.Open Enrollment• During Open Enrollment you will have the opportunity to make changes to your benefit elections.• You must enroll online by the Open Enrollment deadline for your benefits to be effective June 1st.• Except for a Qualifying Life Event, you will NOTbe able to change your elections until the next year’s OpenEnrollment.Qualifying Life EventIf you have a Qualifying Life Event, you may be able to change your benefits before the next Open Enrollment. You must notify Human Resources within (3 0 ) days of the change.SomeexamplesofQualifying Life Events include:• Marriage / Divorce• Birth of a child, adoption or placement for adoption• Loss of other coverage• Court Order4

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New user registration (aetna.com)With Aetna Network Comfort Plan Option 1 Comfort Plan $7,900 DED Network In-Network Out of NetworkCalendar YearDeductibleIndividual/Family (Copays do not counttowards the Deductible)$7,900 / $15,800 $10,000 / $20,000Co-Insurance100% 50%Calendar Year Out-of-PocketMax Individual / Family(includes Deductible, Coinsurance, Copays)$7,900 / $15,800**In-Network Family Out of pocket is embeddedN/APhysicians Office Visit100% Covered 50% After DeductibleSpecialist Office Visit100% Covered 50% After DeductiblePreventative CareCovered at 100%, no Deductible 50% After DeductibleDiagnostic Lab & X-Ray(except for Complex Imaging)Office/Clinic: 100% CoveredHospital: No Charge after OOPM50% After DeductibleComplex Imaging(MRI, PET/CT Scans)Office/Clinic: 100% CoveredHospital: No Charge after OOPM50% After DeductibleOnline Care (Provided by MDLive)No Cost N/AOutpatient HospitalizationNo Charge after OOPM 50% After DeductibleInpatient HospitalizationNo Charge after OOPM 50% After DeductibleEmergency Room$250 Copay $250 CopayUrgent Care Facility100% Covered 50% After DeductibleRetail Prescription Drugs (30-day supply)• GenericBrand (Formulary/Preferred)*• Brand (Non-formulary/Non-preferred)*• SpecialtyN/AN/AN/A N/A Mail Order Prescription (90-day supply)• Generic• Brand (Formulary/Preferred)*• Brand (Non-formulary/Non-preferred)*• Specialty**(Mail Order Specialty Rx is filled at a 30 day supply ONLY)N/AN/AN/A N/A For coverage details, please refer to the SBC plan summary.**SPOUSAL SURCHARGE: If your spouse is offered coverage through their employer but chooses to enroll in the Commercial Siding &Maintenance medical planthere will be an additional charge of $200/month.**$0 copay$75 copay$100 copay$125 copay$0 copay$150 copay$200 copay$125 copay**

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New user registration (aetna.com)With Aetna Network H.S.A. Plan Option 2HSA $5,000 DED Network In-Network Out of NetworkCalendar Year Deductible Individual / Family(Copays do not counttowards the Deductible)$5,000 / $10,000**In-Network Family Deductible is embedded$10,000 / $20,000Co-Insurance100% 50%Calendar Year Out-of-Pocket Max Individual / Family(includes Deductible, Coinsurance, Copays)$5,000 / $10,000**In-Network Family Out of pocket is embeddedN/APhysicians Office Visit0% After Deductible 50% After DeductibleSpecialist Office Visit0% After Deductible 50% After DeductiblePreventative CareCovered at 100%, no Deductible 50% After DeductibleDiagnostic Lab & X-Ray(except for Complex imaging)0% After Deductible 50% After DeductibleComplex Imaging(MRI, PET/CT Scans)0% After Deductible 50% After DeductibleOnline Care (Provided by MDLive)General Medical: $50 CopayDermatologist: $59 CopayMental health visits range: $45-$250N/AOutpatient Hospitalization0% After Deductible 50% After DeductibleInpatient Hospitalization0% After Deductible 50% After DeductibleEmergency Room0% After Deductible 0% After DeductibleUrgent Care Facility0% After Deductible 50% After DeductibleRetail Prescription Drugs (30-day supply)• Generic• Brand (Formulary/Preferred)*• Brand (Non-formulary/Non-preferred)*• Specialty0% After Deductible0% After Deductible0% After Deductible0% After Deductible N/AN/AN/A N/A Mail Order Prescription (90-day supply)• Generic• Brand (Formulary/Preferred)*• Brand (Non-formulary/Non-preferred)*• Specialty0% After Deductible0% After Deductible0% After Deductible0% After DeductibleN/AN/AN/A N/AFor coverage details, please refer to the SBC plan summary.**SPOUSAL SURCHARGE: If your spouse is offered coverage through their employer but chooses to enroll in the Commercial Siding &Maintenance medical planthere will be an additional charge of $200/month.**

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New user registration (aetna.com) H.S.A. Option 3 With Aetna Network HSA $6,350 DED Network In-Network Out of NetworkCalendar Year Deductible Individual / Family(copays do not count toward deductible)$6,350 / $12,700**In-Network Family deductible is embedded $10,000 / $20,000Co-Insurance100% 50%Calendar Year Out-of-Pocket Max Individual / Family(includes deductible, coinsurance, copays)$6,350 / $12,700**In-Network Family Out of pocket is embeddedN/APhysicians Office Visit0% After Deductible 50% After DeductibleSpecialist Office Visit0% After Deductible 50% After DeductiblePreventative CareCovered at 100%, no deductible 50% After DeductibleDiagnostic Lab & X-ray(except for Complex imaging)0% After Deductible 50% After DeductibleComplex Imaging(MRI, PET/CT scans)0% After Deductible 50% After DeductibleOnline Care (Provided by MDLive)General Medical: $50 CopayDermatologist: $59 CopayMental health visits range: $45-$250N/AOutpatient Hospitalization0% After Deductible 50% After DeductibleInpatient Hospitalization0% After Deductible 50% After DeductibleEmergency Room0% After Deductible 0% After DeductibleUrgent Care Facility0% After Deductible 50% After DeductibleRetail Prescription Drugs (30-day supply)• Generic• Brand (Formulary/Preferred)*• Brand (Non-formulary/Non-preferred)*• Specialty0% After Deductible0% After Deductible0% After Deductible0% After Deductible N/AN/AN/AN/AMail Order Prescription (90-day supply)• Generic• Brand (Formulary/Preferred)*• Brand (Non-formulary/Non-preferred)*• Specialty0% After Deductible0% After Deductible0% After Deductible0% After DeductibleN/AN/AN/AN/AFor coverage details, please refer to the SBC plan summary.**SPOUSAL SURCHARGE: If your spouse is offered coverage through their employer but chooses to enroll in the Commercial Siding &Maintenance medical planthere will be an additional charge of $200/month.**

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Plan OptionsGra vie$PNGPSU001.(9Preventive Care100%/"%FEVDUJCMFPer PersonPer Family/"Out-of-Pocket Max/Year** Per PersonPer Family/P$PTU/P$PTUUrgent Care Visit /P$PTUOnline Care /P$PTUGeneric Rx* /P$PTUPreferred Brand Rx* Non-Preferred Brand Rx Specialty Rx Emergency Room Surgical Care /P$PTU"GUFS001.Inpatient Care /P$PTU"GUFS001.Out of Network"GUFS0VUPG/FUXPSL%FE*OEJWJEVBM'BNJMZ (FUNPOUITGPSUIFQSJDFPGDPQBZTBUSFUBJMPSNBJMPSEFS** Includes deductible. All plans are embedded except for the Silver 2000 HSA which means if you have family coverage, you will beginreceiving beneﬁts once you meet your individual deductible. No member on the plan can pay more than their individual deductible.Gra vie)4"%FE001.100%/P$PTU"GUFS%FE/P$PTU"GUFS%FE/P$PTU"GUFS%FE/P$PTU"GUFS%FE/P$PTU"GUFS%FE/P$PTU"GUFS%FE/P$PTU"GUFS%FE/P$PTU"GUFS%FE/P$PTU"GUFS%FE/P$PTU"GUFS%FE/P$PTU"GUFS%FEGra vie)4"%FE001.100%/P$PTU"GUFS%FE/P$PTU"GUFS%FE/P$PTU"GUFS%FE/P$PTU"GUFS%FE/P$PTU"GUFS%FE/P$PTU"GUFS%FE/P$PTU"GUFS%FE/P$PTU"GUFS%FE/P$PTU"GUFS%FE/P$PTU"GUFS%FE/P$PTU"GUFS%FEwww.gravie.com

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Medical Weekly DeductionsAETNA MEDICAL PLAN – HSA 6,350 DED AETNA MEDICAL PLAN – HSA 5,000 DEDCOBRACoverage for employees and their covered dependents terminates on the last day worked or the last day of the month in which the termination occurs, with no carry-over time or grace period. Employees leaving the Company will benotified in writing of their rights andoptions to continue medical, dental andvision insurance under COBRA. COBRA payments and procedures are handled between the ex-employee and the Plan Claims Administrator.29Years of ServiceEMPLOYEE ONLY EMPLOYEE + SPOUSE EMPLOYEE + CHILD(REN) EMPLOYEE + FAMILY0-3 $35.43 $163.00 $125.79 $269.304-8 $35.43 $141.74 $110.73 $230.329+ $29.53 $107.48 $84.75 $172.44Years of ServiceEMPLOYEE ONLY EMPLOYEE + SPOUSE EMPLOYEE + CHILD(REN) EMPLOYEE + FAMILY0-3 $39.41 $180.93 $139.71 $298.894-8 $39.41 $157.35 $123.00 $255.649+ $32.84 $119.33 $94.14 $191.41Years of ServiceEMPLOYEE ONLY EMPLOYEE + SPOUSE EMPLOYEE + CHILD(REN) EMPLOYEE + FAMILY0-3 $48.76 $224.12 $173.10 $370.594-8 $48.76 $194.89 $152.38 $316.959+ $40.63 $147.80 $116.62 $237.30Your premiums will be deducted on a pre-tax basis.AETNA MEDICAL PLAN – GRAVIE COMFORT 7,900 DEDEMPLOYEE ONLYEMPLOYEE + SPOUSE EMPLOYEE + CHILD(REN) EMPLOYEE + FAMILY$5.11 $10.23 $12.15 $18.89EMPLOYEE ONLYEMPLOYEE + SPOUSE EMPLOYEE + CHILD(REN) EMPLOYEE + FAMILY$1.40 $2.71 $2.50 $3.81Your premiums will be deducted on a pre-tax basis.DENTAL PLAN

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Health Savings Account5ELIGIBILITY & CONTRIBUTIONSA Health Savings Account is a tax-advantaged medical savings account available to individuals enrolled in a qualified High Deductible Health Plan (HDHP). Please note, this is a voluntary benefit. HSA Plans – HSA 3,000 and HSA 6,900 are qualified HDHP plans, which allows you to open an HSA account. If you elect one of these plan options, you can have funds deducted from your paycheck on a pre-tax basis to be deposited directly into your HSA account. The HSA funds may only be used to pay for qualified medical, dental, or vision expenses, otherwise federal tax liability and/or penalties will apply. Any unused funds will rollover and accumulate year to year if not spent. Since HSA accounts are owned by the individual, if you leave employment, you take the funds with you. If you later choose to enroll in a non-qualified HSA plan, you can no longer contribute to your HSA account, however, you can continue to access the funds to pay for qualified expenses. The IRS has set limits on the total amount that can be contributed into your HSA account. For 2023, the limits are as follows:MAXIMUM CONTRIBUTION LIMITS IN 2023Individual Account $3,850 / yearFamily Account $7,750 / yearOver age 55Optional $1,000 / year additional contributionHEALTHCARE EXPENSESFor ease of utilizing the Health Savings Account, you will receive a bank account and a debit card. You may simply use the debit card for any medical, dental and vision expense as your form of payment and the amount will be deducted from your balance. It is best to save all your expense receipts should you be asked to submit them in the future. Examples of eligible healthcare expenses include:• Doctor’s office visit and Prescription copays• Deductibles / Co-Insurance• Over the Counter Medication with a prescription• Eyeglasses / Eye Surgery / Contact Lenses• Braces and other dental services• Birth Control Pills• ChiropractorOnce your bank account has been set-up, you can visit, https://www.flores247.com/to view your account.COMPANY CONTRIBUTION (HSA 3000 ONLY)0-3 Years Up to $20.00/ Week4-8 Years Up to $27.00/ Week9+ Years Up to $35.00/ Week

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Wat ch our vi deoLearn how dental insurance canprotect your long-term health.DentalinsuranceTaking care of your teeth is about morethan just covering cavities and cleanings.It also means accounting for more expensivedental work, and your overall health.With dental insurance, routine preventive care can lead tobetter overall health. And you’ll be able to save money if anyextensive dental work is required.Who is it for?Everyone should have access to great dental coverage, which is why weoffer comprehensive plans that are available through employers as part ofyour benefit offerings.What does it cover?Dental insurance helps to protect your overall oral care. That includesservices like preventive cleanings, x-rays, restorative services like fillings,and other more serious forms of oral surgery if you ever need them.Why should I consider it?Poor oral health isn’t just aesthetic, it’s also been linked to conditionsincluding diabetes, heart disease, and strokes. So, while brushing andflossing every day can help keep your teeth clean, nothing should replaceregular visits to the dentist.You will receive these benefits if you meet the conditions listed in the policy.Staying healthyJoe visits his dentist for a routinedental cleaning, to take care of histeeth as well as his overall health.Oral health is about more than justteeth and gums. It’s also essentialfor a range of other health andwellbeing reasons:Cardiovascular disease: Someresearch suggests that heartdisease, clogged arteries, andinfectionsmaybelinkedtoinflammation and infectionsfrom oral bacteria.Osteoporosis: Weak and brittlebones may be linked to tooth loss.Diabetes: Research shows thatpeople with gum disease find itmore difficult to control theirblood sugar levels.Alzheimer’s disease: Tooth lossbefore the age of 35 may be a riskfactor for Alzheimer’s disease.All information contained here isfrom the Mayo Clinic, Oral Health:AWindowtoYourOverallHealth,www.mayoclinic.com. 2018.3

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Your dental coveragePPO plan, you'll have a ccess to one of the largest networks of dentists with two reimbursement levels that give you more controlover savings. You will always save money with any dentist in Guardian's network and when they belong to a tier in the Tier 1reimbur sement level you will maximize your savings. Reimbursement for covered services received from a non-contracted dentistwill be based on Guardian's fee schedule.Your Dental Plan PPOTier 1 Tier 2Your Network is Dent alGuard Preferred NetworkIn-Network Out-of-NetworkYour Weekly premium$5.11You and Spouse $10.23You and Child(ren) $12.15You, Spouse and Child(ren) $18.89Calendar year deductibleTier 1 Tier 2Individual $50 $50Family limit 3 per family (applies to all levels)Waived for Preventive PreventiveCharges covered for you (co-insurance)Tier 1 Tier 2Preventive Care 100% 100%Basic Care 80% 80%Major Care 50% 50%Orthodontia 50% 50%Annual M aximum Benefit$1500 (applies to all levels)Maximum RolloverYes (applies to all levels)Rollover Threshold $700Rollover Amount $350Rollover Account Limit $1250Lifetime Orthodontia Maximum$1000 (applies to all levels)Dependent Age Limits26 (applies to all levels)4

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A Sample of Services C overed by Your Plan:Your dental coveragePPOPlan pays (on average)Tier 1 Tier 2Preventive C are Cleaning (prophylaxis ) 100% 100%Frequency: Once Every 6 Months (applies to alllevels)Fluoride Treatments 100% 100%Limits: Under Age 14 (applies to all levels)Oral Exams 100% 100%X-rays 100% 100%Basic CareFillings‡ 80% 80%Perio Surgery 80% 80%Periodontal Maintenance 80% 80%Frequency: Once Every 6 Months (applies to alllevels)Root Canal 80% 80%Scaling & Root Planing (per quadrant) 80% 80%Simple Ext ract ions 80% 80%Major Care Anesthesia* 50% 50%Bridges and D entures 50% 50%Inlays, Onlays, Veneers** 50% 50%Repair & Maintenance ofCrowns, Bridges & D entures50% 50%Single Crowns 50% 50%Surgical Extractions 50% 50%Orthodontia Orthodontia 50% 50%Limits: Child(ren) (applies to all levels)Guardian’s Preferred Provider Organization co nsists of Dentists in the DentalGuard Preferred (“DGP”) network. These tiersrepresent s pecific benefit levels as desc ribed in Your Schedule of Benefits. Network access varies by geograph ic location and zip co de.Please v isit www.Guardianlif e.com to confirm you r Dentis t’s tiered participation.This is only a partial list of dental services. Your certificate of benefits will show exactly what is covered and excluded. **For PPO andor Indemnity members , Crowns, Inlays, Onlays and L abial Veneers are covered only when needed because of decay or injury or otherpathology when the tooth cannot be restored with amalgam or composite filing material. When Orthodontia coverage is for"Child(ren)" only, the orthodontic appliance must be placed prior to the age limit set by your plan; If full-time status is required byyour plan in order t o remain insured aft er a cert ain age; then orthodontic maintenance may c ontinue as long as full-time student statusis maintained. If Orthodontia coverage is for "Adults and Child(ren)" this limitation does not apply. *General Anesthesia – restrictionsapply. ‡For PPO and or Indemnity members, Fillings – restrictions may apply to composite fillings.5

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Your dental coverageManage Your Benefits:Go to www.Guardianlife.com to access secur e information aboutyour Guardian benefits including access to an image of your IDCard. Your on-line account will be set up within 30 days af ter yourplan effective date.Find A Dentist:Visit www.Guardianlife.comClick on “Find A Provider”; You will need to know your plan, whichcan b e found on the first page of your dental benefit summary.Need Assistance?Call the Guardian Helpline ( 888) 600-1600, weekdays,8:00 AM to 8:30 PM, EST. Refer to your member ID (socialsecurity number) and your plan number: 00051306Please call the Guardian Helpline if you need to useyour benefits within 30 days of plan effective date.Please note, self-serve options over the phone oronline at Guardian Anytime are not available until thecase is fully implemented, please wait to speak to alive agent when calling the Guardian Helpline.EXCLUSIONS AND LIMITATIONSn Important Information about Guardian’s DentalGuard Indemnity andDentalGuard Preferred Network PPO plans: This policy provides dentalinsurance only. Coverage is limited to those charges that are necessary toprevent, diagnose or treat dental disease, defect, or injury. Deductibles apply.The plan does not pay for: oral hygiene services (except as covered underpreventive services), orth odontia (un less expressly provided for), cosmetic orexperimental treatments ( unless they are expressly provided for), anytreatments to the extent benefits are payable by any other payor or for whichno charge is made, prosthetic devices unless certain conditions are met, andservices ancillary to surgical treatment. The plan limits benefits for diagnosticconsultations and for preventive, restorative, endodontic, periodontic, andprosthodontic services. The services, exclusions and limitations listed above donot constitute a contract and are a summary only. The Guardian plandocuments are the final arbiter of coverage. Contract # DG7-P et al.n PPO and or Indemnity Special Limitation: Teeth lo st or mis si ng befor e aco ver ed person becom es insured by this plan. A co ver ed person ma y have one ormo re congenitall y missing teeth or have lost one or more teeth before he becam einsured by this plan. W e won’t pay for a prosthetic devic e which replaces such teethunles s the dev i c e also repla c e s one or mor e natura l teeth los t or extra c t ed afte r theco vered perso n beca me insured by this pla n. R3-DG7DentalGuard Insurance is underwritten and issued by The Guardian Life Insurance Company of America, New York, NY. Products are not available in allstates. Policy limitations and exclusions apply. Optional riders and/or features may incur additional costs. Plan documents are the final arbiter ofcoverage. This policy provides DENTAL insurance only.Policy Form # GP-1-DG2000, et al, GP-1-DEN-166

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Plan annualmaximum**Threshold Maximumrollover amountMaximum rolloveraccount limit$1,500Maximum claimsreimbursèment$700Claims amount thatdetermines rollover eligibility$350Additional dollars added toa plan’s annual maximumfor future years$1,250The limit that cannotbe exceeded within themaximum rollover account* This example has been created for illustrative purposes only.** If a plan has a diģerent annual maximum for PPO beneĤts vs. non-PPO beneĤts, ($1500 PPO/$1000 non-PPO for example) the non-PPO maximumdetermines the Maximum Rollover plan. May not be available in all states.Guardian’s Dental Insurance is underwritten and issued by The Guardian Life Insurance Company of America, New York, NY. Products are not available in allstates. Policy limitations and exclusions apply. Optional riders and/or features may incur additional costs. Plan documents are the Ĥnal arbiter of coverage.Information provided in this communication is for informational purposes only. Dental Policy Form No. GP-1-DEN-16. GUARDIAN® is a registered service markof The Guardian Life Insurance Company of America ® ©Copyright 2019 The Guardian Life Insurance Company of America.Depending on a plan’s annual maximum, if claims made for acert ain year don’t reach a speciĤed threshold, then the setmaximum rollover amount can be rolled over.How maximum rollover works*Oral HealthRewardsProgramRegular visits to the dentist can help preventand detect the early signs of serious diseases.That’s why Guardian’s Maximum Rollover Oral Health RewardsProgram encourages and rewards members who visit thedentist, by rolling over par t of your unused annual maximuminto a Maximum Rollover Account (MRA). This can be used infuture years if your plan’s annual maximum is reached.Submit a claim (withoutexceeding the paid claimsthreshold of a beneĤt year),and Guardian will roll overa portion of your unusedannual dental maximum.Automatic rollover7

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Wat ch our vi deoHow vision insurance can helpyou see clearly as you get older.VisioninsuranceVision insurance helps protect thehealth of your eyes by providing coveragefor benefits that often aren’t coveredby regular medical insurance.Protecting your eyesight means allowing for routine visitsto the optometrist for eye exams, as well as coverage forglasses and contacts. Make sure your eyes remain in greatshape at any age – no matter how much time you spendstaring at digital screens.Who is it for?Even if you have perfect eyesight, it’s important to have regular eye examsto make sure you’re still seeing clearly. Most of us may eventually needvision correction, which is why we offer vision insurance to cover some ofthe costs.What does it cover?Vision insurance covers benefits not typically included in medical insuranceplans. It covers things like routine eye exams, allowances towards thepurchase of eyeglasses and contact lenses, as well as discounts oncorrective Lasik surgery.Why should I consider it?Regular eye exams can detect more than failing eyesight, they can also pickup diseases like glaucoma and diabetes. Vision problems are one of themost prevalent disabilities in the United States, making vision insuranceespecially useful for anyone who regularly needs to purchase eyeglasses orcontacts, or anyone who simply wants to help protect their eyesight andgeneral health.You will receive these benefits if you meet the conditions listed in the policy.20/20 coverageDavid notices that his vision isdeteriorating. He goes in for an eyeexam, and is diagnosed with myopia,which means he needs glasses.Average cost of vision exam: $171Average cost of frames andlenses: $350Total cost: $521With a Vision policy from Guardian,David pays just $10 for his eye exam.After $25 in copay, his lenses are fullycovered, and he pays $96 for hisframes.David’s total out-of-pocket expenseis $131, saving him $390.This example is for illustrativepurposes only. Your plan’s coveragemay vary. See your plan’s informationon the following pages for specificamounts and details.9

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Your vision coverageOption 1: Significant out-of-pocket savings available with your Full Feature plan by visiting one of VSP’s network locations,including one of the largest private practice provider networks, Visionworks and contracted Pearle Vision locations.Your Vision PlanFull FeatureYour Network is VSP Choice NetworkYour Weekly premium $ 1.40You and Spouse $ 2.71You and C hild(ren) $ 2.50You, Spouse and Child(ren) $ 3.81CopayExams Copay $ 10Materials Copay (waived for elective contact lenses) $25Sample of Covered Services You pay (after copay if applicable):In-network Out-of-networkEye Exams $0 Amount over $39Single Vision Lenses $0 Amount over $23Lined Bifocal Lenses $0 Amount over $37Lined Trifocal Lenses $0 Amount over $49Lenticular L enses $0 Amount over $64Frames 80% of amount over $130¹ Amount over $46Costco, Walmart and Sam's Club Frame AllowanceAmount over $70Contact Lenses (Elective) Amount over $130 Amount over $100Contact Lenses (Medically Necessary) $0 Amount over $210Contact Lenses (Evaluation and fitting) 15% off UCR No discountsCosmetic Extras Avg. 20-25% off retail price No discountsGlasses (Additional pair of frames and lenses) 20% off ret ail price** No discountsLaser Correction Surgery D isc ount Up to 15% off the us ual charge or 5%off promot ional priceNo discountsService FrequenciesExams Every calendar yearLenses (for glasses or contact lenses)‡‡ Every c alendar yearFrames Every two calendar years‡‡‡Network discounts (glasses and contact lens professional service) Limitless within 12 months of exam.Dependent Age Limits 26To Find a Provider: Regis ter at VSP.com to find a partic ipating provider.VSP•‡‡Benefit includes coverage for glasses or contact lenses, not both.•** For the discount to apply your purchase must be made within 12 months of the eye exam.10

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Your vision coverage•Charges for an initial purchase can be used toward the material allowance. Any unused balance remaining after the initial purchase cannot be banked for future use.The only exception would be if a member purchases contact lenses from an out of network provider, members can use the balance towards additional contactlenses within the same benefit period.•1Extra$20onselectbrands•Members can use their in network benefits on line at Eyeconic.com.•‡‡‡.The VSP system considers contact lenses to be the equivalent of a full pair of eyeglasses (lenses and frames) so while the member can obtain contact lenses one year andstandard eyeglass lenses the next year, the frames benefit would not be available until 24 months or two calendar years, depending on the plan design, afterthedatethememberobtained the contact lenses.•In Network Routine Retinal Screening Covered after no more than a $39 copay.EXCLUSIONS AND LIMITATIONSImportant Information: This policy provides vision care limited benefits healthinsurance only. It does not provide basic hospital, basic medical or majormedical insurance as defined by the New York State Insurance Department.Coverage is limited to those charges that are necessary for a routine visionexamination. Co-pays apply. The plan does not pay for: orthoptics or visiontraining and any associated supplemental testing; medical or surgical treatmentof the eye; and eye examination or corrective eyewear required by anemployer as a condition of employment; replacement of lenses and framesthat are furnished under this plan, which are lost or broken (except at normalintervals when services are otherwise available or a warranty exists). The planlimits benefits for blended lenses, oversized lenses, photochromic lenses,tinted lenses, progressive multifocal lenses, coated or laminated lenses, aframe that exceeds plan allowance, cosmetic lenses; U-V protected lenses andoptional cosmetic processes.The services, exclusions and limitations listed above do not constitute acontract and are a summary only. The Guardian plan documents are the finalarbiter of coverage. Contract #GP-1-VSN-96-VIS et al.Laser Correction Surgery:Discounts on average of 10-20% off usual and customary charge or 5% offpromotional price for vision laser Surgery. Members out-of-pocket costs arelimited to $1,800 per eye for LASIK or $1,500 per eye for PRK or $2300 pereye for Custom LASIK, Custom PRK, or Bladeless LASIK.Laser surgery is not an insured benefit. The surgery is available at a discountedfee. The covered person must pay the entire discounted fee. In addition, thelaser surgery discount may not be available in all states.Guardian’s Vision Insurance is underwritten and issued by The Guardian Life Insurance Company of America, New York, NY. Products are not available in allstates. Policy limitations and exclusions apply. Optional riders and/or features may incur additional costs. This policy provides vision care limited benefits healthinsurance only. It does NOT provide basic hospital, basic medical or major medical insurance as defined by the New York State Department of FinancialServices. Plan documents are the final arbiter of coverage.Policy Form # GP-1-GVSN-1711

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Wat ch our vi deoHow life insurance protectsfamilies and covers critical costs.LifeinsuranceIf something happens to you, lifeinsurance can help your familyreduce financial stress.Life insurance helps protect your family’s finances by providinga cash benefit if you pass away. This ensures that they’ll befinancially supported, and can cover important things frombills to funeral costs. With life policies, you can get affordablelife insurance protection for a set period of time.Who is it for?Everyone’s life insurance needs are different, depending on their familysituation. That’s why group life insurance through an employer is an easierand more affordable option than individual life insurance.What does it cover?Life insurance protects your loved ones by providing a benefit(which is usually tax-exempt) if you pass away.Why should I consider it?Life insurance is about more than just covering expenses. Dependingon your circumstances, it could take your family years to recover from theloss of your income.With a life insurance benefit, your family will have extra money to covermortgage and rent payments, legal or medical fees, childcare, tuition,and any outstanding debts.Guardian, its subsidiaries, agents, and employees do notprovidetax, legal,or accounting advice. Consult yourtax, legal,or accountingprofessionalregarding your individual situation.Prep ar ing and planningJorge’s neverconsidered purchasinglife insurance, but after being offered itthroughwork,hedecidesit’sasmartway to protect his family.Jorge has a mortgage, and becausehiswifeishelpingtotakecareofhermother, she only works part-time. Inaddition,his daughter is about tostart college.Jorge looks at how his family wouldbe affected by losing him.Average funeral cost: $9,000Average mortgage debt: $202,000Average cost of college: $17,000 -$44,000Average household credit card debt:$8,500With life insurance, Jorge canmake sure that part of thesecosts are covered if somethinghappens to him.This example is for illustrativepurposes only. Your plan’s coveragemay vary. See your plan’s informationon the following pages for specificamounts and details.You will receive these benefits if you meet the conditions listed in the policy.13

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Your life coverageVOLUNTARY TERM LIFEEmployee Benefit $10,000 increments to amaximum of $500,000. See Cos tIllustration page for details.Accidental Death and Dismemberment Employ ee, Spouse & Child(ren)coverage. Maximum 1 times lifeamount.Spouse Benefit $5,000 increments to a maximumof $250,000. See Cost Illustrationpage for details.‡Child Benefit Your dependent children agebirth† to 26 years.You may elect one of th efollowing benefit options: $10,000.Subject to state limits. See CostIllustration page for details.Guarantee Issue: The ‘guarantee’ means you are not requ ired to answer health questions t o qualify forcoverage up to and including t he s pec ified amount, when you sign up for cov erage during the initialenrollment period.We Guarantee Issue coverage upto:Employee Less than age 65$150,000, 65-69 $ 50,000, 70+$10,000.Spouse Less t han age 65 $25,000,65-69 $10,000.Dependent children $10,000.Premiums Increase on plan anniversary afteryou enter next f ive-year agegroupPortability: Allows you to t ake coverage with you if you terminate employment. Yes, with age and o therrestrictions14

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Voluntary Life Cost Illustration:To determine the most appropr iate level of coverage, as a rule of thumb, you should consider about 6 - 10 times your annual income,factoring in projected costs to help maintain your family’s current life style.Weekly premiums displayed.Policy Election Amount Policy Election Cost Per Age BracketEmployee< 30 30–34 35–39 40–44 45–49 50–54 55–59 60–6465–69†$10,000 $.14 $.20 $.25 $.40 $.68 $1.13 $ 1.78 $2.70 $3.61$20,000 $.28 $.39 $.51 $.79 $1.35 $2.25 $3.55 $5.41 $7.21$30,000 $.42 $.59 $.76 $1.18 $2.03 $ 3.38 $5.32 $ 8.11 $10.81$40,000 $.56 $.79 $ 1.02 $1.58 $ 2.71 $4.51 $ 7.10 $10.81 $14.42$50,000 $.70 $.98 $ 1.27 $1.97 $ 3.38 $5.63 $ 8.87 $13.51 $18.02$60,000 $.85 $1.18 $1.52 $2.37 $ 4.06 $6.76 $10.65 $16.21 $21.63$70,000 $.99 $1.37 $1.78 $2.76 $ 4.73 $7.88 $12.42 $18.92 $25.23$80,000 $1.13 $1.57 $ 2.03 $3.16 $ 5.41 $9.01 $14.20 $21.62 $28.84$90,000 $1.27 $1.77 $ 2.29 $3.55 $ 6.09 $10.14 $15.97 $24.32 $32.44$100,000 $1.41 $ 1.96 $2.54 $ 3.95 $6.76 $ 11.26 $17.75 $27.02 $36.05$110,000 $1.55 $ 2.16 $2.79 $ 4.34 $7.44 $ 12.39 $19.52 $29.73 $39.65$120,000 $1.69 $ 2.35 $3.05 $ 4.74 $8.11 $ 13.51 $21.30 $32.43 $43.26$130,000 $1.83 $ 2.55 $3.30 $ 5.13 $8.79 $ 14.64 $23.07 $35.13 $46.86$140,000 $1.97 $ 2.75 $3.55 $ 5.53 $9.47 $ 15.77 $24.85 $37.83 $50.47$150,000 $2.11 $ 2.94 $3.81 $ 5.92 $10.14 $ 16.89 $26.62 $40.54 $54.07$160,000 $2.25 $ 3.14 $4.06 $ 6.31 $10.82 $ 18.02 $28.39 $43.24 $57.67$170,000 $2.39 $ 3.34 $4.32 $ 6.71 $11.50 $ 19.15 $30.17 $45.94 $61.28$180,000 $2.53 $ 3.53 $4.57 $ 7.10 $12.17 $ 20.27 $31.94 $48.64 $64.88$190,000 $2.68 $ 3.73 $4.82 $ 7.50 $12.85 $ 21.40 $33.72 $51.34 $68.49$200,000 $2.82 $ 3.92 $5.08 $ 7.89 $13.52 $ 22.52 $35.49 $54.05 $72.09$210,000 $2.96 $ 4.12 $5.33 $ 8.29 $14.20 $ 23.65 $37.27 $56.75 $75.70$220,000 $3.10 $ 4.32 $5.59 $ 8.68 $14.88 $ 24.78 $39.04 $59.45 $79.30$230,000 $3.24 $ 4.51 $5.84 $ 9.08 $15.55 $ 25.90 $40.82 $62.15 $82.91$240,000 $3.38 $ 4.71 $6.09 $ 9.47 $16.23 $ 27.03 $42.59 $64.86 $86.51$250,000 $3.52 $ 4.90 $6.35 $ 9.87 $16.90 $ 28.15 $44.37 $67.56 $90.12$260,000 $3.66 $ 5.10 $6.60 $ 10.26 $17.58 $29.28 $46.14 $70.26 $93.72$270,000 $3.80 $ 5.30 $6.85 $ 10.66 $18.26 $30.41 $47.92 $72.96 $97.33$280,000 $3.94 $ 5.49 $7.11 $ 11.05 $18.93 $31.53 $49.69 $75.67 $100.93$290,000 $4.08 $ 5.69 $7.36 $ 11.44 $19.61 $32.66 $51.46 $78.37 $104.5316

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Voluntary Life Cost Illustration continued< 30 30–34 35–39 40–44 45–49 50–54 55–59 60–6465–69†$300,000 $4.22 $ 5.89 $7.62 $ 11.84 $20.29 $33.79 $53.24 $81.07 $108.14$310,000 $4.36 $ 6.08 $7.87 $ 12.23 $20.96 $34.91 $55.01 $83.77 $111.74$320,000 $4.51 $ 6.28 $8.12 $ 12.63 $21.64 $36.04 $56.79 $86.47 $115.35$330,000 $4.65 $ 6.47 $8.38 $ 13.02 $22.31 $37.16 $58.56 $89.18 $118.95$340,000 $4.79 $ 6.67 $8.63 $ 13.42 $22.99 $38.29 $60.34 $91.88 $122.56$350,000 $4.93 $ 6.87 $8.89 $ 13.81 $23.67 $39.42 $62.11 $94.58 $126.16$360,000 $5.07 $ 7.06 $9.14 $ 14.21 $24.34 $40.54 $63.89 $97.28 $129.77$370,000 $5.21 $ 7.26 $9.39 $ 14.60 $25.02 $41.67 $65.66 $99.99 $133.37$380,000 $5.35 $ 7.45 $9.65 $ 15.00 $25.69 $42.79 $67.44 $102.69 $136.98$390,000 $5.49 $ 7.65 $9.90 $ 15.39 $26.37 $43.92 $69.21 $105.39 $140.58$400,000 $5.63 $ 7.85 $10.15 $ 15.79 $27.05 $45.05 $70.99 $108.09 $144.19$410,000 $5.77 $ 8.04 $10.41 $ 16.18 $27.72 $46.17 $72.76 $110.80 $147.79$420,000 $5.91 $ 8.24 $10.66 $ 16.57 $28.40 $47.30 $74.53 $113.50 $151.39$430,000 $6.05 $ 8.44 $10.92 $ 16.97 $29.08 $48.43 $76.31 $116.20 $155.00$440,000 $6.19 $ 8.63 $11.17 $ 17.36 $29.75 $49.55 $78.08 $118.90 $158.60$450,000 $6.34 $ 8.83 $11.42 $ 17.76 $30.43 $50.68 $79.86 $121.60 $162.21$460,000 $6.48 $ 9.02 $11.68 $ 18.15 $31.10 $51.80 $81.63 $124.31 $165.81$470,000 $6.62 $ 9.22 $11.93 $ 18.55 $31.78 $52.93 $83.41 $127.01 $169.42$480,000 $6.76 $ 9.42 $12.19 $ 18.94 $32.46 $54.06 $85.18 $129.71 $173.02$490,000 $6.90 $ 9.61 $12.44 $ 19.34 $33.13 $55.18 $86.96 $132.41 $176.63$500,000 $7.04 $ 9.81 $12.69 $ 19.73 $33.81 $56.31 $88.73 $135.12 $180.23Policy Election AmountSpouse$5,000 $.07 $.10 $.13 $.20 $.34 $ .56 $.89 $1.35 $1.80$10,000 $.14 $ .20 $.25 $.40 $ .68 $1.13 $ 1.78 $2.70 $3.61$15,000 $.21 $ .29 $.38 $.59 $ 1.01 $1.69 $ 2.66 $4.05 $5.41$20,000 $.28 $ .39 $.51 $.79 $ 1.35 $2.25 $ 3.55 $5.41 $7.21$25,000 $.35 $ .49 $.64 $.99 $ 1.69 $2.82 $ 4.44 $6.76 $9.01$30,000 $.42 $ .59 $.76 $1.18 $2.03 $3.38 $ 5.32 $8.11 $10.81$35,000 $.49 $ .69 $.89 $1.38 $2.37 $3.94 $ 6.21 $9.46 $12.62$40,000 $.56 $ .79 $1.02 $ 1.58 $2.71 $ 4.51 $7.10 $ 10.81 $14.42$45,000 $.63 $ .88 $1.14 $ 1.78 $3.04 $ 5.07 $7.99 $ 12.16 $16.22$50,000 $.70 $ .98 $1.27 $ 1.97 $3.38 $ 5.63 $8.87 $ 13.51 $18.0217

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Voluntary Life Cost Illustration continued< 30 30–34 35–39 40–44 45–49 50–54 55–59 60–6465–69†$55,000 $.77 $ 1.08 $1.40 $ 2.17 $3.72 $ 6.19 $9.76 $ 14.86 $19.83$60,000 $.85 $ 1.18 $1.52 $ 2.37 $4.06 $ 6.76 $10.65 $ 16.21 $21.63$65,000 $.92 $ 1.28 $1.65 $ 2.57 $4.40 $ 7.32 $11.54 $ 17.57 $23.43$70,000 $.99 $ 1.37 $1.78 $ 2.76 $4.73 $ 7.88 $12.42 $ 18.92 $25.23$75,000 $1.06 $1.47 $1.90 $2.96 $5.07 $ 8.45 $13.31 $ 20.27 $27.04$80,000 $1.13 $1.57 $2.03 $3.16 $5.41 $ 9.01 $14.20 $ 21.62 $28.84$85,000 $1.20 $1.67 $2.16 $3.35 $5.75 $ 9.57 $15.08 $ 22.97 $30.64$90,000 $1.27 $1.77 $2.29 $3.55 $6.09 $ 10.14 $15.97 $24.32 $32.44$95,000 $1.34 $1.86 $2.41 $3.75 $6.42 $ 10.70 $16.86 $25.67 $34.24$100,000 $1.41 $1.96 $ 2.54 $3.95 $ 6.76 $11.26 $17.75 $27.02 $36.05$105,000 $1.48 $2.06 $ 2.67 $4.14 $ 7.10 $11.83 $18.63 $28.37 $37.85$110,000 $1.55 $2.16 $ 2.79 $4.34 $ 7.44 $12.39 $19.52 $29.73 $39.65$115,000 $1.62 $2.26 $ 2.92 $4.54 $ 7.78 $12.95 $20.41 $31.08 $41.45$120,000 $1.69 $2.35 $ 3.05 $4.74 $ 8.11 $13.51 $21.30 $32.43 $43.26$125,000 $1.76 $2.45 $ 3.17 $4.93 $ 8.45 $14.08 $22.18 $33.78 $45.06$130,000 $1.83 $2.55 $ 3.30 $5.13 $ 8.79 $14.64 $23.07 $35.13 $46.86$135,000 $1.90 $2.65 $ 3.43 $5.33 $ 9.13 $15.20 $23.96 $36.48 $48.66$140,000 $1.97 $2.75 $ 3.55 $5.53 $ 9.47 $15.77 $24.85 $37.83 $50.47$145,000 $2.04 $2.84 $ 3.68 $5.72 $ 9.80 $16.33 $25.73 $39.18 $52.27$150,000 $2.11 $2.94 $ 3.81 $5.92 $10.14 $16.89 $ 26.62 $40.54 $54.07$155,000 $2.18 $3.04 $ 3.94 $6.12 $10.48 $17.46 $ 27.51 $41.89 $55.87$160,000 $2.25 $3.14 $ 4.06 $6.31 $10.82 $18.02 $ 28.39 $43.24 $57.67$165,000 $2.32 $3.24 $ 4.19 $6.51 $11.16 $18.58 $ 29.28 $44.59 $59.48$170,000 $2.39 $3.34 $ 4.32 $6.71 $11.50 $19.15 $ 30.17 $45.94 $61.28$175,000 $2.46 $3.43 $ 4.44 $6.91 $11.83 $19.71 $ 31.06 $47.29 $63.08$180,000 $2.53 $3.53 $ 4.57 $7.10 $12.17 $20.27 $ 31.94 $48.64 $64.88$185,000 $2.60 $3.63 $ 4.70 $7.30 $12.51 $20.83 $ 32.83 $49.99 $66.69$190,000 $2.68 $3.73 $ 4.82 $7.50 $12.85 $21.40 $ 33.72 $51.34 $68.49$195,000 $2.75 $3.83 $ 4.95 $7.70 $13.19 $21.96 $ 34.61 $52.70 $70.29$200,000 $2.82 $3.92 $ 5.08 $7.89 $13.52 $22.52 $ 35.49 $54.05 $72.09$205,000 $2.89 $4.02 $ 5.20 $8.09 $13.86 $23.09 $ 36.38 $55.40 $73.90$210,000 $2.96 $4.12 $ 5.33 $8.29 $14.20 $23.65 $ 37.27 $56.75 $75.7018

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Voluntary Life Cost Illustration continued< 30 30–34 35–39 40–44 45–49 50–54 55–59 60–6465–69†$215,000 $3.03 $4.22 $ 5.46 $8.48 $14.54 $24.21 $ 38.15 $58.10 $77.50$220,000 $3.10 $4.32 $ 5.59 $8.68 $14.88 $24.78 $ 39.04 $59.45 $79.30$225,000 $3.17 $4.41 $ 5.71 $8.88 $15.21 $25.34 $ 39.93 $60.80 $81.10$230,000 $3.24 $4.51 $ 5.84 $9.08 $15.55 $25.90 $ 40.82 $62.15 $82.91$235,000 $3.31 $4.61 $ 5.97 $9.27 $15.89 $26.47 $ 41.70 $63.50 $84.71$240,000 $3.38 $4.71 $ 6.09 $9.47 $16.23 $27.03 $ 42.59 $64.86 $86.51$245,000 $3.45 $4.81 $ 6.22 $9.67 $16.57 $27.59 $ 43.48 $66.21 $88.31$250,000 $3.52 $4.90 $ 6.35 $9.87 $16.90 $28.15 $ 44.37 $67.56 $90.12Policy Election AmountChild(ren)$10,000 $0.51 $ 0.51 $0.51 $ 0.51 $0.51 $ 0.51 $0.51 $ 0.51 $0.51Refer to Guarantee Issue row on page above for Voluntary Life GI amounts.Premiums for Voluntary Life Increase in five-year incrementsInfant coverage is limited for the first two weeks of infant’s life.Spouse co verag e premium is based on Employee ag e.†Benefit reduct ions apply.The Guarantee Iss u e amount may be subject to reductions by percentage at t he ages shown in this s ummary .LIMITATIONS AND EXCLUSIONS:A SUMMARY OF PLAN LIMITATIONS AND EXCLUSIONS FOR LIFECOVERAGE:You must be working full-time on the effective date of your coverage; otherwise, yourcoverage becomes effective after you have completed a specific waiting period. Employeesmust be legally working in the United States in order to be eligible for coverage.Underwriting must approve coverage for employees on temporary assignment: (a)exceeding one year ; or (b) in an area under travel warning by the US Departm ent of State.Subject to state specific variations. Evidence of Insurability is required on all late enrollees.Thi s co v e r ag e will not be ef f ec t i v e until appr o v ed by a Guar di a n underw r it e r. This pro po sa lis hedged subject to satisfactory financial evaluation. Please refer to certificate of coverage forful l plan descr i pti o n.Depend ent lif e insura nce will not take effect if a dependent , other than a newbo r n, isconfined to the hospital or other health care facility or is unable to perform the normalactivities of someone of like age and sex.Accelerated Life Benefit is not paid to an employee under the following circumstances: onewho is required by law to use the benefit to pay creditors; is required by court order to paythe benefi t to anothe r perso n; is requi r ed by a go v er nm e nt ag enc y to use the paym e nt torec e i v e a go v e rnment benefi t ; or lo ses his or her gro up co v e ra g e bef o re an ac celer a te dbenef i t is pai d .We pay no benefits if the insured’s death is due to suicide within two years from theinsured’s original effective date. This two year limitation also applies to any increase inbenefit. This exclusion may vary according to state law. Late entrants and benefit increasesrequi r e under wr i t i ng approval.GP -1-R-EO P T-96Guarantee Issue/Conditional Issue amounts may vary based on age and case size. See yourPla n Administ r a to r for detai l s. Late entrant s and benef i t increas es requi r e under wr i t i ngappr o v a l .Guardian Group Life Insurance underwritten and issued by The Guardian Life Insurance Company of America, New York, NY. Products are notavailable in all states. Policy limitations and exclusions apply. Optional riders and/or features may incur additional costs. Plan documents arethe final arbiter of coverage.Policy Form # GP-1-LIFE-1519

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Accidental Death and Dismemberment Life Cost Illustration:AD&D coverage provides additional benefits following an accidental death or certain bodily injuries. Election amount will equal 1times the election amount for Voluntary life election.EmployeePolicy ElectionAmo untWeeklyPremiumsdisplayedSpousePolicy ElectionAmo untWeeklyPremiumsdisplayedChild(ren)Policy ElectionAmo untWeeklyPremiumsdisplayed$10,000 $0.11 $5,000 $0.06 $10,000 $0.11$20,000 $0.22 $10,000 $0.11$30,000 $0.33 $15,000 $0.17$40,000 $0.44 $20,000 $0.22$50,000 $0.55 $25,000 $0.28$60,000 $0.67 $30,000 $0.33$70,000 $0.78 $35,000 $0.39$80,000 $0.89 $40,000 $0.44$90,000 $1.00 $45,000 $0.50$100,000 $1.11 $50,000 $0.55$110,000 $1.22 $55,000 $0.61$120,000 $1.33 $60,000 $0.67$130,000 $1.44 $65,000 $0.72$140,000 $1.55 $70,000 $0.78$150,000 $1.66 $75,000 $0.83$160,000 $1.77 $80,000 $0.89$170,000 $1.88 $85,000 $0.94$180,000 $1.99 $90,000 $1.00$190,000 $2.11 $95,000 $1.05$200,000 $2.22 $100,000 $1.11$210,000 $2.33 $105,000 $1.16$220,000 $2.44 $110,000 $1.22$230,000 $2.55 $115,000 $1.27$240,000 $2.66 $120,000 $1.33$250,000 $2.77 $125,000 $1.39$260,000 $2.88 $130,000 $1.44$270,000 $2.99 $135,000 $1.50$280,000 $3.10 $140,000 $1.55$290,000 $3.21 $145,000 $1.61$300,000 $3.32 $150,000 $1.66$310,000 $3.43 $155,000 $1.72$320,000 $3.55 $160,000 $1.77$330,000 $3.66 $165,000 $1.83$340,000 $3.77 $170,000 $1.88$350,000 $3.88 $175,000 $1.94$360,000 $3.99 $180,000 $1.99$370,000 $4.10 $185,000 $2.05$380,000 $4.21 $190,000 $2.11$390,000 $4.32 $195,000 $2.16$400,000 $4.43 $200,000 $2.22$410,000 $4.54 $205,000 $2.27$420,000 $4.65 $210,000 $2.33$430,000 $4.76 $215,000 $2.38$440,000 $4.87 $220,000 $2.44$450,000 $4.99 $225,000 $2.49$460,000 $5.10 $230,000 $2.5520

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EmployeePolicy ElectionAmo untWeeklyPremiumsdisplayedSpousePolicy ElectionAmo untWeeklyPremiumsdisplayedChild(ren)Policy ElectionAmo untWeeklyPremiumsdisplayed$470,000 $5.21 $235,000 $2.60$480,000 $5.32 $240,000 $2.66$490,000 $5.43 $245,000 $2.71$500,000 $5.54 $250,000 $2.77Infant coverage is limited for the first two weeks of infant’s life.Benefit reductions apply.LIMITATIONS AND EXCLUSIONS:A SUMMARY OF PLAN LIMITATION AND EXCLUSIONSFOR AD&DYoumustbeworkingfull-timeontheeffectivedateofyourcoverage;otherwise,your coverage becomes effective after you have completed a specific waiting period.Employees must be legally working in the United States in order to be eligible forcoverage. Underwriting must approve coverage for employees on temporaryassignment: (a) exceeding one year; or (b) in an area under travel warning by theUS Department of State. Subject to state specific variations. This proposal ishedged subject to satisfactory financial evaluation. Please refer to policy booklet forfull plan description.Dependent life insurance will not take effect if a dependent, other than a newborn,is confined to the hospital or other health care facility or is unable to perform thenormal activities of someone of like age and sex.We pay no benefits for any loss caused: by willful self-injury; sickness, disease ormedical treatment; by participating in a civil disorder or committing a felony;Traveling on any type of aircraft while having duties on that aircraft; by declaredor undeclared act of war or armed aggression; while a member of any armedforce (May vary by state); while driving a motor vehicle without a current, validdriver’s license; by legal intoxication; or by voluntarily using anon-prescription controlled substance. Contract #GP-1-R-ADCL1-00 et al.We won't pay more than 100% of the Insurance amount for all losses due tothe same acci dent, except as stated.The loss must occur within a specified period of time of the accident. Pleasesee contract for specific definition; definition of loss may vary depending on thebenefit payable.Guardian Group AD&D Insurance is underwritten and issued by The Guardian Life Insurance Company of America, New York, NY. Products are notavailable in all states. Policy limitations and exclusions apply. Optional riders and/or features may incur additional costs. Plan documents are thefinalarbiter of coverage.Policy Form # GP-1-ADD-15.21

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How it can helpThis ser vice is only available if you purchase qualif ying lines of coverage.See your plan administrator for more details.WillPrep Ser vices are provided by Uprise Health, and its contractors. The Guardian LifeInsurance Company of America (Guardian) does not provide any part of Will Prep Ser vices.Guardian is not responsible or liable for care or advice given by any provider or resourceunder the program. This information is for illustrative purposes only. It is not a contract.Only the Administration Agreement can provide the ac tual terms, services, limitationsand exclusions. Guardian and Uprise Health reserve the right to discontinue the WillPrepServices at any time without notice. Legal ser vices will not be provided in connection withor preparation for any ac tion against Guardian, Uprise Health, or your employer.Prepare your willwith the assistanceor support ofan attorneyAccess simpledocuments includingwills and power ofattorney l et tersSpeak withconsu lt ants todiscuss est a teplanningHow to accessTo access Wi llPrep Services,you’ll need a few personal details.Visitwillprep . uprisehealth.c omUsernameWillPr epPasswordGLIC09For more information or suppor t ,you can reach out by phoning18774336789.WillPrepProtect t he ones you love with a rangeof dedicated services designed to helpyou provide for your family.WillPrep Ser vices includes a range of dif ferent resources thatmake it easier for you to prepare a will.These range from a library of online planning documents toaccessing experienced professionals that can help you withthe more complicated details.22

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Wat ch our vi deoHow short term disability insurancecan supplement your income.You will receive these benefits if you meet the conditions listed in the policy.DisabilityinsurancePartial incomereplacementMike injures his back in a bicycleaccident and can’t work for 13 weeks.Unpaid time off work: 13 weeksElimination period: 1weekAfter a 1-week elimination periodfollowing his accident, Mike’sGuardian Short Term Disabilitypolicy kicks in and replaces $400 ofhis weekly income for the remaining12 weeks of his rehabilitation.This gives him a total of $4,800 tocover his expenses while he’s unableto work.This example is for illustrativepurposes only. Your plan’s coveragemay vary. See your plan’s informationon the following pages for specificamounts and details.Short term disabilityDisability insurance covers a part of yourincome, so you can pay your bills if you’reinjured or sick and can’t work.Disability may be more common than you might realize, andpeople can be unable to work for all sorts of different reasons.There are times when many disabilities can be caused bylllness, including common conditions like heart disease andarthritis. However, many disabilities aren't covered byworkers' compensation.Who is it for?If you rely on your income to pay for everyday expenses, thenyou should probably consider disability insurance. It helps ensure thatyou’ll receive a partial income if you’re injured or too sick to work.What does it cover?Many disability insurance plans pay out a portion or percentageof your income if you’re diagnosed with a serious illness orexperience an injury that prevents you from doing your job.Why should I consider it?Accidents happen, and you can’t always anticipate if or when you’llbecome sick or injured. That’s why it’s important to have a disabilitypolicy that helps you pay your bills in the event of being unable tocollect your normal paycheck.23

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Wat ch our vi deoHow long term disability insurancecan supplement your income.You will receive these benefits if you meet the conditions listed in the policy.DisabilityinsurancePartial incomereplacementJim suffers a heart attack that leaveshim unable to work for two years.Unpaid time off work: 24 monthsElimination period: 6 monthsAfter a 6 month elimination period,Jim’s Guardian Long Term Disabilitypolicy kicks in and replaces $2,000 ofhis monthly income for the remaining18 mont h s of his disability or illness.This gives him a total of $36,000 tocover his expenses while he’s unableto work.This example is for illustrativepurposes only. Your plan’s coveragemay vary. See your plan’s informationon the following pages for specificamounts and details.Long term disabilityDisability insurance covers a part of yourincome, so you can pay your bills if you’reinjured or sick and can’t work.Disability may be more common than you might realize, andpeople can be unable to work for all sorts of different reasons.There are times when many disabilities can be caused bylllness, including common conditions like heart disease andarthritis. However, many disabilities aren't covered byworkers' compensation.Who is it for?If you rely on your income to pay for everyday expenses, thenyou should probably consider disability insurance. It helps ensure thatyou’ll receive a partial income if you’re injured or too sick to work.What does it cover?Many disability insurance plans pay out a portion or percentageof your income if you’re diagnosed with a serious illness orexperience an injury that prevents you from doing your job.Why should I consider it?Accidents happen, and you can’t always anticipate if or when you’llbecome sick or injured. That’s why it’s important to have a disabilitypolicy that helps you pay your bills in the event of being unable tocollect your normal paycheck.24

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Your disability coverageShort-Term Disability Long-Term Disability.Coverag e amount60% of salary to maximum$1200/week60% of salary to maximum$6000/monthMaximum payment period: Maximum length of time you canreceive disability benefits.24 weeksLesserof5yearsortoage70Accident benefits beg in: Thelengthoftimeyoumustbedisabled before benefits begin.Day 15 Day 181Illness benefits begin: The length of time you must be disabledbefore benefits begin.Day 15 Day 181Evidence of Insurability: A health statement requiring you toanswer a few medical history questions.Health St atement may be required Health Statement may be requiredGuarantee Issue: The ‘guaran tee’ means you are not required toanswer health questions to qualify for c ov erage up to and includingthe specified amount, when applicant s igns up for cov erage duringthe initial enrollment p eriod.We Guarantee Is s ue $1200 incoverageWe Guarantee Issue $6000 incoverageMinimum work hours/week: Minimum number of hours youmust regularly work each week to be eligible for coverage.Planholder Determines Planholder DeterminesPre-existing conditions: A pre-existing condition includes anycondition/symptom for which you, in the specified time periodprior to coverage in this plan, consulted with a physician, receivedtreat ment, or took prescribed drugs.3 months look back; 12 monthsafter 2 week limitation3 months look back; 12 monthsafter exclusionPremium waived if disabled: Premium will not need to be paidwhen you are receiving benef its.Yes YesSurvivor benefit: Additional benefit payable to your family if youdie while disabled.No 3 monthsUNDERSTANDING YOUR BENEFITS—DISABILITY (Some information may vary by state)l Disability (long-term): For f irst two years of disability, you will receive benefit payments while you are unable to work inyour own occupation. After two years, you will continue to receive benefits if you cannot work in any occupation based ontraining, exper ience and education.l Earnings definition: Your covered salary excludes bonuses and commissions.l Special limitations: Provides a 24-month benef it limit for specific conditions including mental health and substance abuse.Other conditions such as chronic fatigue are also included in this limitation. Refer to contract for details.l Work incentive: Plan benefit will not be reduced for a specified amount of months so that you have part- time earnings whileyou r emain disabled, unless the combined benefit and earnings exceed 100% of your pr evious earnings.25

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Disability C ost Illustration:To determine the most appropriate level of coverage, you should consider your current basic monthly expenses.Short-Term Disability Plan Cost Illustration:Policy amounts shown based on sample salar y amounts only.< 25 25–29 30–34 35–39 40–44 45–49 50–54 55–59 60+Your premium r ate$0.550 $0.550 $0.550 $0.550 $0.550 $0.550 $0.550 $0.550 $0.550Election Cost Per Age Bracket< 25 25–29 30–34 35–39 40–44 45–49 50–54 55–59 60+$20,000 Annual Salary$23 1 Weekly Benefit $2.93 $2.93 $2.93 $2.93 $2.93 $2.93 $2.93 $2.93 $2.93$30,000 Annual Salary$34 6 Weekly Benefit $4.39 $4.39 $4.39 $4.39 $4.39 $4.39 $4.39 $4.39 $4.39$40,000 Annual Salary$46 2 Weekly Benefit $5.86 $5.86 $5.86 $5.86 $5.86 $5.86 $5.86 $5.86 $5.86$50,000 Annual Salary$57 7 Weekly Benefit $7.32 $7.32 $7.32 $7.32 $7.32 $7.32 $7.32 $7.32 $7.32$60,000 Annual Salary$69 2 Weekly Benefit $8.78 $8.78 $8.78 $8.78 $8.78 $8.78 $8.78 $8.78 $8.78$70,000 Annual Salary$80 8 Weekly Benefit $10 .26 $10 .26 $10 .26 $10 .26 $10 .26 $10 .26 $10 .26 $10 .26 $10 .26$80,000 Annual Salary$92 3 Weekly Benefit $11 .72 $11 .72 $11 .72 $11 .72 $11 .72 $11 .72 $11 .72 $11 .72 $11 .72$90,000 Annual Salary$1,038 Weekly Benefit $13 .18 $13 .18 $13 .18 $13 .18 $13 .18 $13 .18 $13 .18 $13 .18 $13 .18$100,000 Annual Salary$1,154 Weekly Benefit $14 .65 $14 .65 $14 .65 $14 .65 $14 .65 $14 .65 $14 .65 $14 .65 $14 .65$110,000 Annual Salary$1,200 Weekly Benefit $15 .23 $15 .23 $15 .23 $15 .23 $15 .23 $15 .23 $15 .23 $15 .23 $15 .23Long-Term Disability Plan Cost Illustration:Policy amounts shown based on sample salar y amounts only.< 25 25–29 30–34 35–39 40–44 45–49 50–54 55–59 60+Your premium r ate$0.640 $0.640 $0.640 $ 0.640 $0.640 $0.640 $0.640 $0.640 $0.640Election Cost Per Age Bracket< 25 25–29 30–34 35–39 40–44 45–49 50–54 55–59 60+$20,000 Annual Salary$1,000 Monthly Benefit $2.46 $2.46 $ 2.46 $2.46 $2.46 $ 2.46 $2.46 $2.46 $2.46$30,000 Annual Salary$1,500 Monthly Benefit $3.69 $3.69 $ 3.69 $3.69 $3.69 $ 3.69 $3.69 $3.69 $3.6926

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<2525–29 30–34 35–39 40–44 45–49 50–54 55–59 60+$40,000 Annual Salary$2,000 Monthly Benefit $4.92 $4.92 $ 4.92 $4.92 $4.92 $ 4.92 $4.92 $4.92 $4.92$50,000 Annual Salary$2,500 Monthly Benefit $6.15 $6.15 $ 6.15 $6.15 $6.15 $ 6.15 $6.15 $6.15 $6.15$60,000 Annual Salary$3,000 Monthly Benefit $7.39 $7.39 $ 7.39 $7.39 $7.39 $ 7.39 $7.39 $7.39 $7.39$70,000 Annual Salary$3,500 Monthly Benefit $8.62 $8.62 $ 8.62 $8.62 $8.62 $ 8.62 $8.62 $8.62 $8.62$80,000 Annual Salary$4,000 Monthly Benefit $9.85 $9.85 $ 9.85 $9.85 $9.85 $ 9.85 $9.85 $9.85 $9.85$90,000 Annual Salary$4,500 Monthly Benefit $11.08 $11.08 $11.08 $11.08 $11.08 $11.08 $11.08 $11.08 $ 11.08$100,000 Annual Salary$5,000 Monthly Benefit $12.31 $12.31 $12.31 $12.31 $12.31 $12.31 $12.31 $12.31 $ 12.31$110,000 Annual Salary$5,500 Monthly Benefit $13.54 $13.54 $13.54 $13.54 $13.54 $13.54 $13.54 $13.54 $ 13.54$120,000 Annual Salary$6,000 Monthly Benefit $14.77 $14.77 $14.77 $14.77 $14.77 $14.77 $14.77 $14.77 $ 14.77A SUMMARY OF DISABILITY PLAN LIMITATIONSAND EXCLUSIONSn Evidence of Insurability may be required on all late enrollees. This coveragewill not be effective until approved by a Guardian underwriter. Thisproposal is hedged subject to satisfactory financial evaluation. Please refer tocertificate of coverage for full plan description.n Youmustbeworkingfull-timeontheeffectivedateofyourcoverage;otherwise, your coverage becomes effective after you have completed aspecific waiting period.n Employees must be legally working in the United States in order to beeligible for coverage. Underwriting must approve coverage for employees ontemporary assignment: (a) exceeding one year; or (b) in an area under travelwarning by the US Department of State. Subject to state specific variations.n For Long-Term Disability coverage, we pay no benefits for a disability causedor contributed to by a pre-existing condition unless the disability starts afteryou have been insured under this plan for a specified period of time. Welimit the duration of payments for long term disabilities caused by mental oremotional conditions, or alcohol or drug abuse.n For Short-Term Disability coverage, benefits for a disability caused orcontributed to by a pre-existing condition are limited, unless the disabilitystarts after you have been insured under this plan for a specified period oftime. We do not pay short term disability benefits for any job-related oron-the-job injury, or conditions for which Workers' Compensation benefitsare payable.n We do not pay benefits for charges relating to a covered person: taking partin any war or act of war (including service in the armed forces) committing afelony or taking part in any riot or other civil disorder or intentionallyinjuring themselves or attempting suicide while sane or insane. We do notpay benefits for charges relating to legal intoxication, including but notlimited to the operation of a motor vehicle, and for the voluntary use of anypoison, chemical, prescription or non-prescription drug or controlledsubstance unless it has been prescribed by a doctor and is used asprescribed. We limit the duration of payments for long term disabilitiescaused by mental or emotional conditions, or alcohol or drug abuse. We donot pay benefits during any period in which a covered person is confined toa correctional facility, an employee is not under the care of a doctor, anemployee is receiving treatment outside of the US or Canada, and theemployee’s loss of earnings is not solely due to disability.n This policy provides disability income insurance only. It does not provide"basic hospital", "basic medical", or "medical" insurance as defined by theNew York State Insurance Department.n If this plan is transferred from another insurance carrier, the time an insuredis covered under that plan will count toward satisfying Guardian'spre-existing condition limitation period. State variations may apply.n When applicable, this coverage will integrate with NJ TDB, NY DBL, CASDI, RI TDI, Hawaii TDI and Puerto Rico DBA, DC PFML and WA PFML.27

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Insurance Terms and DefinitionsPPO ( PREFERRED PROVIDER ORGANIZATION )A PPO is a type of insurance network. In this type of network, you may choose to to obtain care in or out of your network. If youchoose to visit a "Preferred", or "In-Network", provider, your out of pocket expense will be significantly less than if you visit a provideroutside your network. The reason for this is the In network provider agrees to accept set, contracted rates as payment in full for theirservices in return for being part of the insurance carrier's Preferred Provider network.HMO ( HEALTH MAINTENANCE ORGANIZATION )An HMO is a type of insurance network. In this type of network, you must stay in your network to obtain care under your plan. Thereare no benefits paid out for services obtained outside the network. In some instances, HMO's may require that you have a referralfrom your primary care physician to obtain services from a specialist.DEDUCTIBLEThe amount you pay before the insurance carrier starts sharing the expense of your medical care. Major medical expenses apply tothe deductible like inpatient/outpatient surgeries, MRI's, CT Scans, etc…EMBEDDED DEDUCTIBLEThis only applies to employees who have dependents enrolled on their plans. In an Embedded deductible, no member of the familyunit can satisfy more than the single deductible during the deductible period. Even though the family is subject to the familydeductible as a whole, no one person can satisfy more than the single deductible.DEDUCTIBLE PERIODThis is the 12 month time period in which all medical expenses that would apply to your deductible accumulate. Your deductible willreset after this period ends. This time period is important to note, because it does not always align with your plan yearDEDUCTIBLE CREDITIf your Deductible Period and Plan Year are not the same with your new health insurance carrier, the new carrier will give you "credit"for the portion of the deductible you've satisfied with the old health insurance carrier during the most recent Deductible period. Inorder to obtain this credit, please supply your Plan Administrator with your most recent Explanation of Benefits ( EOB ) from the oldcarrier.CO-INSURANCEAfter you've reached your deductible for the year, the insurance carrier will split the balance of the major medical expense with you.They pay a percentage and you pay a percentage of your medical expense until you've reached your Out of Pocket MaximumOUT OF POCKET MAXIMUMThis is the maximum amount you will pay for covered medical expenses during your deductible period

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CO-PAYSThis is a set Dollar amount you pay when you receive medical care from a PCP, Specialist, Urgent Care, Emergency Room, orPharmacy. It's called a CO-pay, because you pay the set dollar amount and your insurance carrier pays the rest of the actualcharge from the doctor/facility. Co-pays DO NOT apply to the deductibleNEGOTIATED RATE ( CONTRACTED RATE )When a Provider (doctor, facility, pharmacy or hospital ) contracts with an insurance carrier, they are considered In-Network. Part ofthe contract states that the provider will accept a lower payment ( lower than what they normally charge ) from the insurancecarrier as payment in full. This lower payment is the Negotiated Rate.EXPLANATION OF BENEFITSCommonly referred to as an "EOB". The EOB is a very useful document as it explains how the insurance carrier processed your claim.It shows the billed charges from the provider, the network discount applied, and what the resulting Negotiated Rate is. ( ProviderCharge - Network Discount = Negotiated Rate ) It also shows whether the service was applied to your deductible or paid as a co-pay. It is not a bill, but merely an explanation of how the insurance carrier paid your claim.HEALTH SAVINGS ACCOUNT ( H S A )This is an Employee Owned savings account that allows you to pay for Qualified Medical Expenses ( IRS Publication 502 ) throughtax free contributions. The maximum contributions for 2023 are $3,850 for single coverage and $7,750 for family coverage. Membersages 55-64 can contribute an additional $1,000. If you are age 65 or older, you are no longer eligible to contribute to the H S A. Thisis a true savings account plan, so you can rollover all unused funds from year to year. With an H S A, money has to be in theaccount for you to be able to use it.

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Important Items to RememberNEW HIRE WAITING PERIODNew employees are eligible for company insurance benefits: The day after 30 days of continuous full time employmentTERMINATION OF BENEFITSWhen your employment with the company is terminated, your benefits will stop: At the end of that monthELIGIBLE EMPLOYEESTo be eligible for company benefits, you must be a full time employee working an average of 30 hours per week during the yearDEPENDENT CHILDRENChildren under the age of 26 are eligible to be covered under the benefits. They will be taken off of the plan at the end of the monthin which they turn 26OPEN ENROLLMENTYou can make changes to your plans ( enroll in coverage, waive coverage, add/drop dependents, etc.. ) during this time periodeach year. Open enrollment occurs 30 days prior to your plan renewal. All changes made during this time period will take effect onthe renewal dateMAKING PLAN CHANGES DURING THE YEARIf you've had a major life event ( getting married, having a child, getting divorced, losing coverage, becoming eligible for Medicare,etc… ) during the year, you're able to make coverage changes to your plan even though it's outside of the Open Enrollment window.Please turn in all paperwork within 30 days of your Qualifying Event to ensure it will be processed timely and any claims incurred willbe paid. PLEASE NOTE: If adding a newborn baby to your plan, the baby's social security number will not be available right away.Please submit the paperwork without it, and provide it once's it's availableCOBRAPLEASE NOTE: In the event your employment is terminated with the company, you will receive a packet in the mail giving you theopportunity to continue your Medical, Dental and Vision benefits for up to 18 months. This is called COBRA coverage. Your employerDOES NOT contribute to this coverage as they may when you are employed with them. You will be responsible for 102% of the actualcost of the insurance if you wish to continue with it.STAY IN NETWORKTo obtain the best benefits, it's important to stay in the insurance carrier's network. Always check online or verify over the phone thata doctor or hospital is in network BEFORE your visit. Also, when having a procedure done in a hospital/facility, ask the hospital staff tomake sure EVERY doctor/nurse/radiologist/anesthesiologist/etc... is in your networkEXPLANATION OF BENEFITSCommonly referred to as an "EOB". The EOB is a very useful document as it explains how the insurance carrier processed your claim.

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Premium Assistance Under Medicaid and theChildren’s Health Insurance Program (CHIP)If you or your children are eligible for Medicaid or CHIP and you’re eligible for health coverage from your employer, your state may have a premium assistanceprogram that can help pay for coverage, using funds from their Medicaid or CHIP programs. If you or your children aren’t eligible for Medicaid or CHIP, youwon’t be eligible for these premium assistance programs but you may be able to buy individual insurance coverage through the Health Insurance Marketplace. Formore information, visit www.healthcare.gov.If you or your dependents are already enrolled in Medicaid or CHIP and you live in a State listed below, contact your State Medicaid or CHIP office to find out ifpremium assistance is available.If you or your dependents are NOT currently enrolled in Medicaid or CHIP, and you think you or any of your dependents might be eligible for either of theseprograms, contact your State Medicaid or CHIP office or dial 1-877-KIDS NOW or www.insurekidsnow.gov to find out how to apply. If you qualify, ask yourstate if it has a program that might help you pay the premiums for an employer-sponsored plan.If you or your dependents are eligible for premium assistance under Medicaid or CHIP, as well as eligible under your employer plan, your employer must allow youto enroll in your employer plan if you aren’t already enrolled. This is called a “special enrollment” opportunity, and you must request coverage within 60 days ofbeing determined eligible for premium assistance. If you have questions about enrolling in your employer plan, contact the Department of Labor atwww.askebsa.dol.gov or call 1-866-444-EBSA (3272).If you live in one of the following states, you may be eligible for assistance paying your employer health plan premiums. The following list of states is current as of January 31, 2023. Contact your State for more information on eligibility – ALABAMA – Medicaid ALASKA – MedicaidWebsite: http://myalhipp.com/ Phone: 1-855-692-5447 The AK Health Insurance Premium Payment Program Website: http://myakhipp.com/ Phone: 1-866-251-4861 Email: CustomerService@MyAKHIPP.com Medicaid Eligibility: https://health.alaska.gov/dpa/Pages/default.aspxARKANSAS – Medicaid CALIFORNIA – MedicaidWebsite: http://myarhipp.com/ Phone: 1-855-MyARHIPP (855-692-7447) Website: Health Insurance Premium Payment (HIPP) Program http://dhcs.ca.gov/hipp Phone: 916-445-8322 Fax: 916-440-5676 Email: hipp@dhcs.ca.govCOLORADO – Health First Colorado (Colorado’s Medicaid Program) & ChildHealth Plan Plus (CHP+)FLORIDA – MedicaidHealth First Colorado Website: https://www.healthfirstcolorado.com/ HealthFirst Colorado Member Contact Center: 1-800-221-3943/ State Relay 711CHP+: https://hcpf.colorado.gov/child-health-plan-plus CHP+ CustomerService: 1-800-359-1991/ State Relay 711 Health Insurance Buy-In Program(HIBI): https://www.mycohibi.com/HIBI Customer Service: 1-855-692-6442Website: https://www.flmedicaidtplrecovery.com/flmedicaidtplrecovery.com/hipp/index.htmlPhone: 1-877-357-3268GEORGIA – Medicaid INDIANA – MedicaidGA HIPP Website: https://medicaid.georgia.gov/health-insurance-premium-payment-program-hipp Phone: 678-564-1162, Press 1 GA CHIPRA Website: https://medicaid.georgia.gov/programs/third-party-liability/childrens-health-insurance-program-reauthorization-act-2009-chipra Phone: (678) 564-1162,Press 2Healthy Indiana Plan for low-income adults 19-64 Website: http://www.in.gov/fssa/hip/ Phone: 1-877-438-4479 All other Medicaid Website: https://www.in.gov/medicaid/ Phone 1-800-457-4584IOWA – Medicaid and CHIP (Hawki) KANSAS – MedicaidMedicaid Website: https://dhs.iowa.gov/ime/membersMedicaid Phone: 1-800-338-8366 Hawki Website: http://dhs.iowa.gov/HawkiHawki Phone: 1-800-257-8563 HIPP Website: https://dhs.iowa.gov/ime/members/medicaid-a-to-z/hipp HIPP Phone: 1-888-346-9562Website: https://www.kancare.ks.gov/ Phone: 1-800-792-4884 HIPP Phone: 1-800-766-9012KENTUCKY – MedicaidLOUISIANA – MedicaidKentucky Integrated Health Insurance Premium Payment Program (KI-HIPP)Website: https://chfs.ky.gov/agencies/dms/member/Pages/kihipp.aspx Phone: 1-855-459-6328 Email: KIHIPP.PROGRAM@ky.gov KCHIP Website:https://kidshealth.ky.gov/Pages/index.aspx Phone: 1-877-524-4718 KentuckyMedicaid Website: https://chfs.ky.govWebsite: www.medicaid.la.gov or www.ldh.la.gov/lahipp Phone: 1-888-342-6207 (Medicaid hotline) or 1-855-618-5488 (LaHIPP)MAINE – Medicaid MASSACHUSETTS – Medicaid and CHIPEnrollment Website: https://www.mymaineconnection.gov/benefits/s/?language=en_US Phone: 1-800-442-6003 TTY: Maine relay 711 Private Health Insurance Premium Webpage:https://www.maine.gov/dhhs/ofi/applications-forms Phone: 1-800-977-6740TTY: Maine relay 711Website: https://www.mass.gov/masshealth/pa Phone: 1-800-862-4840 TTY:(617) 886-8102MINNESOTA – Medicaid MISSOURI – MedicaidWebsite: https://mn.gov/dhs/people-we-serve/children-and-families/health-care/health-care-programs/programs-and-services/other-insurance.jsp Phone: 1-800-657-3739Website: http://www.dss.mo.gov/mhd/participants/pages/hipp.htm Phone: 573-751-2005MONTANA – Medicaid NEBRASKA – Medicaid

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Website: http://dphhs.mt.gov/MontanaHealthcarePrograms/HIPP Phone: 1-800-694-3084 Email: HHSHIPPProgram@mt.govWebsite: http://www.ACCESSNebraska.ne.gov Phone: 1-855-632-7633 Lincoln:402-473-7000 Omaha: 402-595-1178NEVADA – Medicaid NEW HAMPSHIRE – MedicaidMedicaid Website: http://dhcfp.nv.gov Medicaid Phone: 1-800-992-0900 Website: https://www.dhhs.nh.gov/programs-services/medicaid/health-insurance-premium-program Phone: 603-271-5218 Toll free number for the HIPP program:1-800-852-3345, ext. 5218NEW JERSEY – Medicaid and CHIP NEW YORK – MedicaidMedicaid Website: http://www.state.nj.us/humanservices/dmahs/clients/medicaid/ Medicaid Phone: 609-631-2392 CHIP Website: http://www.njfamilycare.org/index.html CHIP Phone: 1-800-701-0710Website: https://www.health.ny.gov/health_care/medicaid/ Phone: 1-800-541-2831NORTH CAROLINA – Medicaid NORTH DAKOTA – MedicaidWebsite: https://medicaid.ncdhhs.gov/ Phone: 919-855-4100 Website: http://www.nd.gov/dhs/services/medicalserv/medicaid/ Phone: 1-844-854-4825OKLAHOMA – Medicaid and CHIP OREGON – MedicaidWebsite: http://www.insureoklahoma.org Phone: 1-888-365-3742 Website: http://healthcare.oregon.gov/Pages/index.aspxhttp://www.oregonhealthcare.gov/index-es.html Phone: 1-800-699-9075PENNSYLVANIA – Medicaid and CHIP RHODE ISLAND – Medicaid and CHIPWebsite: https://www.dhs.pa.gov/Services/Assistance/Pages/HIPP-Program.aspxPhone: 1-800-692-7462 CHIP Website: Children's Health Insurance Program (CHIP) (pa.gov) CHIP Phone: 1-800-986-KIDS (5437)Website: http://www.eohhs.ri.gov/ Phone: 1-855-697-4347, or 401-462-0311(Direct RIte Share Line)SOUTH CAROLINA – Medicaid SOUTH DAKOTA - MedicaidWebsite: https://www.scdhhs.gov Phone: 1-888-549-0820 Website: http://dss.sd.gov Phone: 1-888-828-0059TEXAS – Medicaid UTAH – Medicaid and CHIPWebsite: http://gethipptexas.com/ Phone: 1-800-440-0493 Medicaid Website: https://medicaid.utah.gov/ CHIP Website: http://health.utah.gov/chip Phone: 1-877-543-7669VERMONT– Medicaid VIRGINIA – Medicaid and CHIPWebsite: Health Insurance Premium Payment (HIPP) Program | Department of Vermont Health Access Phone: 1-800-250-8427Website: https://www.coverva.org/en/famis-selecthttps://www.coverva.org/en/hipp Medicaid/CHIP Phone: 1-800-432-5924WASHINGTON – Medicaid WEST VIRGINIA – Medicaid and CHIPWebsite: https://www.hca.wa.gov/ Phone: 1-800-562-3022 Website: href="https://dhhr.wv.gov/bms/" https://dhhr.wv.gov/bms/ http://mywvhipp.com/ Medicaid Phone:304-558-1700 CHIP Toll-free phone: 1-855-MyWVHIPP (1-855-699-8447)WISCONSIN – Medicaid and CHIP WYOMING – MedicaidWebsite: https://www.dhs.wisconsin.gov/badgercareplus/p-10095.htm Phone: 1-800-362-3002Website: https://health.wyo.gov/healthcarefin/medicaid/programs-and-eligibility/Phone: 1-800-251-1269To see if any other states have added a premium assistance program since January 31, 2023, or for more information on special enrollment rights, contact either:U.S. Department of Labor U.S. Department of Health and Human ServicesEmployee Benefits Security Administration Centers for Medicare & Medicaid Serviceshttps://www.dol.gov/agencies/ebsahttps://www.cms.hhs.gov1-866-444-EBSA (3272) 1-877-267-2323, Menu Option 4, Ext. 61565Paperwork Reduction Act StatementAccording to the Paperwork Reduction Act of 1995 (Pub. L. 104-13) (PRA), no persons are required to respond to a collection of information unless such collectiondisplays a valid Office of Management and Budget (OMB) control number. The Department notes that a Federal agency cannot conduct or sponsor a collection ofinformation unless it is approved by OMB under the PRA, and displays a currently valid OMB control number, and the public is not required to respond to acollection of information unless it displays a currently valid OMB control number. See 44 U.S.C. 3507. Also, notwithstanding any other provisions of law, noperson shall be subject to penalty for failing to comply with a collection of information if the collection of information does not display a currently valid OMBcontrol number. See 44 U.S.C. 3512.The public reporting burden for this collection of information is estimated to average approximately seven minutes per respondent. Interested parties areencouraged to send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, tothe U.S. Department of Labor, Employee Benefits Security Administration, Office of Policy and Research, Attention: PRA Clearance Officer, 200 ConstitutionAvenue, N.W., Room N-5718, Washington, DC 20210 or email ebsa.opr@dol.gov and reference the OMB Control Number 1210-0137.

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Special Enrollment NoticeIf you are declining enrollment for yourself or your dependents (including your spouse) because of other health insurance or group health plan coverage, you may be able to enroll yourself and your dependents in this plan if you or your dependents lose eligibility for that other coverage (or if the employer stops contributing toward your or your dependents’ other coverage). However, you must request enrollment within after your or your dependents’ other coverage ends (or after the employer stops contributing toward the other coverage).In addition, if you have a new dependent as a result of marriage, birth, adoption, or placement for adoption, you may be able to enroll yourself and your dependents. However, you must request enrollment within after the marriage, birth, adoption, or placement for adoption.To request special enrollment or obtain more information, contact XPatient Protection Model DisclosureFor plans and issuers that require or allow for the designation of primary care providers by participants or beneficiaries, insert:generally REQUIRES the designation of a primary care provider. You have the right to designate any primary care provider who participates in our network and who is available to accept you or your family members. For information on how to select a primary care provider, and for a list of the participating primary care providers, contact XFor plans and issuers that require or allow for the designation of a primary care provider for a child, add:For children, you may designate a pediatrician as the primary care provider. For plans and issuers that provide coverage for obstetric or gynecological care and require the designation by a participant or beneficiary of a primary care provider, add:You do not need prior authorization from or from any other person (including a primary care provider) in order to obtain access to obstetrical or gynecological care from a health care professional in our network who specializes in obstetrics or gynecology. The health care professional, however, may be required to comply with certain procedures, including obtaining prior authorization for certain services, following a pre-approved treatment plan, or procedures for making referrals. For a list of participating health care professionals who specialize in obstetrics or gynecology, contact XNewborn's Act DisclosureGroup health plans and health insurance issuers generally may not, under Federal law, restrict benefits for any hospital length of stay in connection with childbirth for the mother or newborn child to less than 48 hours following a vaginal delivery, or less than 96 hours following a cesarean section. However, Federal law generally does not prohibit the mother’s or newborn’s attending provider, after consulting with the mother, from discharging the mother or her newborn earlier than 48 hours (or 96 hours as applicable). In any case, plans and issuers may not, under Federal law, require that a provider obtain authorization from the plan or the insurance issuer for prescribing a length of stay not in excess of 48 hours (or 96 hours).WHCRA Enrollment NoticeIf you have had or are going to have a mastectomy, you may be entitled to certain benefits under the Women’s Health and Cancer Rights Act of 1998 (WHCRA). For individuals receiving mastectomy-related benefits, coverage will be provided in a manner determined in consultation with the attending physician and the patient, for:All stages of reconstruction of the breast on which the mastectomy was performed;Surgery and reconstruction of the other breast to produce a Symmetrical appearanceProsthesesTreatment of physical complications of the mastectomy, including lymphedema.These benefits will be provided subject to the same deductibles and coinsurance applicable to other medical and surgical benefits provided under this plan.Therefore, the following deductibles and coinsurance apply: .If you would like more information on WHCRA benefits, call your plan administrator 800-229-4276WHCRA Annual NoticeDo you know that your plan, as required by the Women’s Health and Cancer Rights Act of 1998, provides benefits for mastectomy-related services including allstages of reconstruction and surgery to achieve symmetry between the breasts, prostheses, and complications resulting from a mastectomy, including lymphedema?Call your plan administrator at 800-229-4276 for more information.

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General Notice of COBRA Continuation Coverage Rights(For use by single-employer group health plans)** Continuation Coverage Rights Under COBRA**IntroductionYou’re getting this notice because you recently gained coverage under a group health plan (the Plan). This notice has important information about your right toCOBRA continuation coverage, which is a temporary extension of coverage under the Plan. This notice explains COBRA continuation coverage, when it may become available to you and your family, and what you need to do to protect your right to get it. When you become eligible for COBRA, you may alsobecome eligible for other coverage options that may cost less than COBRA continuation coverage.The right to COBRA continuation coverage was created by a federal law, the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA). COBRAcontinuation coverage can become available to you and other members of your family when group health coverage would otherwise end. For more informationabout your rights and obligations under the Plan and under federal law, you should review the Plan’s Summary Plan Description or contact the Plan Administrator.You may have other options available to you when you lose group health coverage. For example, you may be eligible to buy an individual plan through theHealth Insurance Marketplace. By enrolling in coverage through the Marketplace, you may qualify for lower costs on your monthly premiums and lower out-of-pocket costs. Additionally, you may qualify for a 30-day special enrollment period for another group health plan for which you are eligible (such as a spouse’splan), even if that plan generally doesn’t accept late enrolleesWhat is COBRA continuation coverage?COBRA continuation coverage is a continuation of Plan coverage when it would otherwise end because of a life event. This is also called a “qualifying event.”Specific qualifying events are listed later in this notice. After a qualifying event, COBRA continuation coverage must be offered to each person who is a “qualifiedbeneficiary.” You, your spouse, and your dependent children could become qualified beneficiaries if coverage under the Plan is lost because of the qualifying event.Under the Plan, qualified beneficiaries who elect COBRA continuation coverage MUST PAY for COBRA continuation coverage.If you’re an employee, you’ll become a qualified beneficiary if you lose your coverage under the Plan because of the following qualifying events:Your hours of employment are reduced, orYour employment ends for any reason other than your gross misconduct.If you’re the spouse of an employee, you’ll become a qualified beneficiary if you lose your coverage under the Plan because of the following qualifying events:Your spouse diesYour spouse’s hours of employment are reduced;Your spouse’s employment ends for any reason other than his or her gross misconduct;Your spouse becomes entitled to Medicare benefits (under Part A, Part B, or both); orYou become divorced or legally separated from your spouse.Your dependent children will become qualified beneficiaries if they lose coverage under the Plan because of the following qualifying events:The parent-employee dies;The parent-employee’s hours of employment are reduced;The parent-employee’s employment ends for any reason other than his or her gross misconduct;The parent-employee becomes entitled to Medicare benefits (Part A, Part B, or both);The parents become divorced or legally separated; orThe child stops being eligible for coverage under the Plan as a “dependent child.”RETIREE COVERAGE ONLY:Sometimes, filing a proceeding in bankruptcy under title 11 of the United States Code can be a qualifying event. If a proceeding in bankruptcy is filed with respectto COMMERICAL SIDING & MAINTENANCE , and that bankruptcy results in the loss of coverage of any retired employee covered under the Plan, the retiredemployee will become a qualified beneficiary. The retired employee’s spouse, surviving spouse, and dependent children will also become qualified beneficiaries ifbankruptcy results in the loss of their coverage under the Plan.When is COBRA continuation coverage available?The Plan will offer COBRA continuation coverage to qualified beneficiaries only after the Plan Administrator has been notified that a qualifying event hasoccurred. The employer must notify the Plan Administrator of the following qualifying events:The end of employment or reduction of hours of employment;Death of the employee;Retiree coverage only: Commencement of a proceeding in bankruptcy with respect to the employer;; orThe employee’s becoming entitled to Medicare benefits (under Part A, Part B, or both).

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For all other qualifying events (divorce or legal separation of the employee and spouse or a dependent child’s losing eligibility for coverage as a dependent child), you must notify the Plan Administrator within after the qualifying event occurs. You must provide this notice to: XHow is COBRA continuation coverage provided?Once the Plan Administrator receives notice that a qualifying event has occurred, COBRA continuation coverage will be offered to each of the qualifiedbeneficiaries. Each qualified beneficiary will have an independent right to elect COBRA continuation coverage. Covered employees may elect COBRAcontinuation coverage on behalf of their spouses, and parents may elect COBRA continuation coverage on behalf of their children.COBRA continuation coverage is a temporary continuation of coverage that generally lasts for 18 months due to employment termination or reduction of hours ofwork. Certain qualifying events, or a second qualifying event during the initial period of coverage, may permit a beneficiary to receive a maximum of 36 months ofcoverage.There are also ways in which this 18-month period of COBRA continuation coverage can be extended:Disability extension of 18-month period of COBRA continuation coverageIf you or anyone in your family covered under the Plan is determined by Social Security to be disabled and you notify the Plan Administrator in a timely fashion,you and your entire family may be entitled to get up to an additional 11 months of COBRA continuation coverage, for a maximum of 29 months. The disabilitywould have to have started at some time before the 60th day of COBRA continuation coverage and must last at least until the end of the 18-month period ofCOBRA continuation coverage.Second qualifying event extension of 18-month period of continuation coverageIf your family experiences another qualifying event during the 18 months of COBRA continuation coverage, the spouse and dependent children in your family canget up to 18 additional months of COBRA continuation coverage, for a maximum of 36 months, if the Plan is properly notified about the second qualifying event.This extension may be available to the spouse and any dependent children getting COBRA continuation coverage if the employee or former employee dies;becomes entitled to Medicare benefits (under Part A, Part B, or both); gets divorced or legally separated; or if the dependent child stops being eligible under thePlan as a dependent child. This extension is only available if the second qualifying event would have caused the spouse or dependent child to lose coverage underthe Plan had the first qualifying event not occurred.Are there other coverage options besides COBRA Continuation Coverage?Yes. Instead of enrolling in COBRA continuation coverage, there may be other coverage options for you and your family through the Health InsuranceMarketplace, Medicaid, or other group health plan coverage options (such as a spouse’s plan) through what is called a “special enrollment period.” Some of theseoptions may cost less than COBRA continuation coverage. You can learn more about many of these options at www.healthcare.gov.Can I enroll in Medicare instead of COBRA continuation coverage after my group health plan coverageends?In general, if you don’t enroll in Medicare Part A or B when you are first eligible because you are still employed, after the Medicare initial enrollment period, youhave an 8-month special enrollment period* to sign up for Medicare Part A or B, beginning on the earlier ofThe month after your employment ends; orThe month after group health plan coverage based on current employment ends.If you don’t enroll in Medicare and elect COBRA continuation coverage instead, you may have to pay a Part B late enrollment penalty and you may have a gap in coverage if you decide you want Part B later. If you elect COBRA continuation coverage and later enroll in Medicare Part A or B before the COBRA continuation coverage ends, the Plan may terminate your continuation coverage. However, if Medicare Part A or B is effective on or before the date of the COBRA election, COBRA coverage may not be discontinued on account of Medicare entitlement, even if you enroll in the other part of Medicare after the date of the election of COBRA coverage.If you are enrolled in both COBRA continuation coverage and Medicare, Medicare will generally pay first (primary payer) and COBRA continuation coverage will pay second. Certain plans may pay as if secondary to Medicare, even if you are not enrolled in Medicare.For more information visit https://www.medicare.gov/medicare-and-you.*https://www.medicare.gov/sign-up-change-plans/joining-a-health-or-drug-plan/special-circumstances-special-enrollment-periodsIf you have questionsQuestions concerning your Plan or your COBRA continuation coverage rights should be addressed to the contact or contacts identified below. For more information about your rights under the Employee Retirement Income Security Act (ERISA), including COBRA, the Patient Protection and Affordable Care Act, and other laws affecting group health plans, contact the nearest Regional or District Office of the U.S. Department of Labor’s Employee Benefits Security Administration (EBSA) in your area or visit www.dol.gov/ebsa. (Addresses and phone numbers of Regional and District EBSA Offices are available through EBSA’s website.) For more information about the Marketplace, visit www.HealthCare.gov.Keep your Plan informed of address changesTo protect your family’s rights, let the Plan Administrator know about any changes in the addresses of family members.You should also keep a copy, for your records, of any notices you send to the PPlan AdministratorX

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New Health Insurance Marketplace Coverage Options and Your Health CoveragePART A: General InformationWhen key parts of the health care law take effect in 2014, there will be a new way to buy health insurance: the Health Insurance Marketplace. To assist you as youevaluate options for you and your family, this notice provides some basic information about the new Marketplace and employment-based health coverage offeredby your employer.What is the Health Insurance Marketplace?The Marketplace is designed to help you find health insurance that meets your needs and fits your budget. The Marketplace offers "one-stop shopping" to find andcompare private health insurance options. You may also be eligible for a new kind of tax credit that lowers your monthly premium right away. Open enrollment forhealth insurance coverage through the Marketplace begins in October 2013 for coverage starting as early as January 1, 2014.Can I Save Money on my Health Insurance Premiums in the Marketplace?You may qualify to save money and lower your monthly premium, but only if your employer does not offer coverage, or offers coverage that doesn't meet certainstandards. The savings on your premium that you're eligible for depends on your household income.Does Employer Health Coverage Affect Eligibility for Premium Savings through the Marketplace?Yes. If you have an offer of health coverage from your employer that meets certain standards, you will not be eligible for a tax credit through the Marketplace andmay wish to enroll in your employer's health plan. However, you may be eligible for a tax credit that lowers your monthly premium, or a reduction in certain cost-sharing if your employer does not offer coverage to you at all or does not offer coverage that meets certain standards. If the cost of a plan from your employer thatwould cover you (and not any other members of your family) is more than 9.5% of your household income for the year, or if the coverage your employer providesdoes not meet the "minimum value" standard set by the Affordable Care Act, you may be eligible for a tax creditNote: If you purchase a health plan through the Marketplace instead of accepting health coverage offered by your employer, then you may lose the employercontribution (if any) to the employer-offered coverage. Also, this employer contribution -as well as your employee contribution to employer-offered coverage- isoften excluded from income for Federal and State income tax purposes. Your payments for coverage through the Marketplace are made on an after-tax basis.How Can I Get More Information?For more information about your coverage offered by your employer, please check your summary plan description or contact your employer via the informationprovided belowThe Marketplace can help you evaluate your coverage options, including your eligibility for coverage through the Marketplace and its cost. Please visitHealthCare.gov for more information, including an online application for health insurance coverage and contact information for a Health Insurance Marketplace inyour area.PART B: Information About Health Coverage Offered by Your EmployerThis section contains information about any health coverage offered by your employer. If you decide to complete an application for coverage in the Marketplace,you will be asked to provide this information. This information is numbered to correspond to the Marketplace application.Here is some basic information about health coverage offered by this employer• As your employer, we offer a health plan to: All Employees, Eligible employees are: Some Employees, Eligible employees are:

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• With respect to dependents: We do offer coverage, Eligible dependents are: We do not offer coverage. If checked, this coverage meets the minimum value standard, and the cost of this coverage to you is intended to be affordable, based on employeewages.** Even if your employer intends your coverage to be affordable, you may still be eligible for a premium discount through the Marketplace.The Marketplace will use your household income, along with other factors, to determine whether you may be eligible for a premium discount.If, for example, your wages vary from week to week (perhaps you are an hourly employee or you work on a commission basis), if you arenewly employed mid-year, or if you have other income losses, you may still qualify for a premium discount.If you decide to shop for coverage in the Marketplace, HealthCare.gov will guide you through the process. Here's the employer information you'll enter when youvisit HealthCare.gov to find out if you can get a tax credit to lower your monthly premiums.The information below corresponds to the Marketplace Employer Coverage Tool. Completing this section is optional for employers, but will help ensure employeesunderstand their coverage choices.13. Is the employee currently eligible for coverage offered by this employer, or will the employee be eligible in the next 3 months?Yes (Continue)13a. If the employee is not eligible today, including as a result of a waiting or probationary period, when is the employee eligible for coverage?___________ (mm/dd/yyyy) (Continue)No (STOP and return this form to employee)14. Does the employer offer a health plan that meets the minimum value standard*?Yes (Go to question 15) No (STOP and return form to employee)15. For the lowest-cost plan that meets the minimum value standard* offered only to the employee (don't include family plans): If the employer has wellnessprograms, provide the premium that the employee would pay if he/ she received the maximum discount for any tobacco cessation programs, and didn't receive anyother discounts based on wellness programs.a. How much would the employee have to pay in premiums for this plan? $_________b. How often ? Weekly Every 2 weeks Twice a week Monthly Quarterly Yearly If the plan year will end soon and you know that the health plans offered will change, go to question 16. If you don't know, STOP and return form to employee.16. What change will the employer make for the new plan year? _______________ Employer won't offer health coverage Employer will start offering health coverage to employees or change the premium for the lowest-cost plan available only to the employee that meets theminimum value standard.* (Premium should reflect the discount for wellness programs. See question 15.)a. How much would the employee have to pay in premiums for this plan? $_________b. How often ? Weekly Every 2 weeks Twice a week Monthly Quarterly Yearly

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NOTICE REGARDING WELLNESS PROGRAMis a voluntary wellness program available to all employees. The program is administered according to federal rules permitting employer-sponsored wellness programs that seek to improve employee health or prevent disease, including the Americans with Disabilities Act of 1990, the Genetic Information Nondiscrimination Act of 2008, and the Health Insurance Portability and Accountability Act, as applicable, among others. If you choose to participate in the wellness program you will be asked to complete a voluntary health risk assessment or "HRA" that asks a series of questions about your health-related activities and behaviors and whether you have or had certain medical conditions (e.g., cancer, diabetes, or heart disease). You will also be asked to complete a biometric screening, which will include a blood test for . You are not required to complete the HRA or to participate in the blood test or other medical examinations.However, employees who choose to participate in the wellness program will receive an incentive of . Although you are not required to complete the HRA or participate in the biometric screening, only employees who do so will receive [the incentive].Additional incentives of may be available for employees who participate in certain health-related activities : or achieve certain health outcomes : . If you are unable to participate in any of the health-related activities or achieve any of the health outcomes required to earn an incentive, you may be entitled to a reasonable accommodation or an alternative standard. You may request a reasonable accommodation or an alternative standard by contacting XThe information from your HRA and the results from your biometric screening will be used to provide you with information to help you understand your current health and potential risks, and may also be used to offer you services through the wellness program, such as . You also are encouraged to share your results or concerns with your own doctor.Protections from Disclosure of Medical InformationWe are required by law to maintain the privacy and security of your personally identifiable health information. Although the wellness program and X may use aggregate information it collects to design a program based on identified health risks in the workplace, [name of wellness program] will never disclose any of your personal information either publicly or to the employer, except as necessary to respond to a request from you for a reasonable accommodation needed to participate in the wellness program, or as expressly permitted by law. Medical information that personally identifies you that is provided in connection with the wellness program will not be provided to your supervisors or managers and may never be used to make decisions regarding your employment.Your health information will not be sold, exchanged, transferred, or otherwise disclosed except to the extent permitted by law to carry out specific activities related to the wellness program, and you will not be asked or required to waive the confidentiality of your health information as a condition of participating in the wellness program or receiving an incentive. Anyone who receives your information for purposes of providing you services as part of the wellness program will abide by the same confidentiality requirements. The only individual(s) who will receive your personally identifiable health information (is are) in order to provide you with services under the wellness program.In addition, all medical information obtained through the wellness program will be maintained separate from your personnel records, information stored electronically will be encrypted, and no information you provide as part of the wellness program will be used in making any employment decision. . Appropriate precautions will be taken to avoid any data breach, and in the event a data breach occurs involving information you provide in connection with the wellness program, we will notify you immediately.You may not be discriminated against in employment because of the medical information you provide as part of participating in the wellness program, nor may you be subjected to retaliation if you choose not to participate.X

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Important Notice from X About Your Prescription Drug Coverage and MedicarePlease read this notice carefully and keep it where you can find it. This notice has information about your current prescription drug coverage with X and about your options under Medicare’s prescription drug coverage. This information can help you decide whether or not you want to join a Medicare drug plan. If you are considering joining, you should compare your current coverage, including which drugs are covered at what cost, with the coverage and costs of the plans offering Medicare prescription drug coverage in your area. Information about where you can get help to make decisions about your prescription drug coverage is at the end of this notice.There are two important things you need to know about your current coverage and Medicare’s prescription drug coverage:1. Medicare prescription drug coverage became available in 2006 to everyone with Medicare. You can get this coverage if you join a Medicare Prescription Drug Plan or join a Medicare Advantage Plan (like an HMO or PPO) that offers prescription drug coverage. All Medicare drug plans provide at least a standard level of coverage set by Medicare. Some plans may also offer more coverage for a higher monthly premium.2. X has determined that the prescription drug coverage offered by the is, on average for all plan participants, expected to pay out as much as standard Medicare prescription drug coverage pays and is therefore considered Creditable Coverage. Because your existing coverage is Creditable Coverage, you can keep this coverage and not pay a higher premium (a penalty) if you later decide to join a Medicare drugplan.When Can You Join A Medicare Drug Plan?You can join a Medicare drug plan when you first become eligible for Medicare and each year from October 15th to December 7th. However, if you lose your current creditable prescription drug coverage, through no fault of your own, you will also be eligible for a two (2) month Special Enrollment Period (SEP) to join a Medicare drug plan.What Happens To Your Current Coverage If You Decide to Join A Medicare Drug Plan?If you decide to join a Medicare drug plan, your current X coverage WILL be affected. . If you do decide to join a Medicare drug plan and drop your current X coverage, be aware that you and your dependents WILL be able to get this coverage back.When Will You Pay A Higher Premium (Penalty) To Join A Medicare Drug Plan?You should also know that if you drop or lose your current coverage with X and don’t join a Medicare drug plan within 63 continuous days after your current coverage ends, you may pay a higher premium (a penalty) to join a Medicare drug plan later. If you go 63 continuous days or longer without creditable prescription drug coverage, your monthly premium may go up by at least 1% of the Medicare base beneficiary premium per month for every month that you did not have that coverage. For example, if you go nineteen months without creditable coverage, your premium may consistently be at least 19% higher than the Medicare base beneficiary premium. You may have to pay this higher premium (a penalty) as long as you have Medicare prescription drug coverage. In addition, you may have to wait until the following October to join.For More Information About This Notice Or Your Current Prescription Drug Coverage…Contact the person listed below for further information. NOTE: You’ll get this notice each year. You will also get it before the next period you can join a Medicare drug plan, and if this coverage through X changes. You also may request a copy of this notice at any time.For More Information About Your Options Under Medicare Prescription Drug Coverage…More detailed information about Medicare plans that offer prescription drug coverage is in the “Medicare & You” handbook. You’ll get a copy of the handbook in the mail every year from Medicare. You may also be contacted directly by Medicare drugplans. For more information about Medicare prescription drug coverage:Visit www.medicare.govCall your State Health Insurance Assistance Program (see the inside back cover of your copy of the “Medicare & You” handbook for their telephonenumber) for personalized helpCall 1-800-MEDICARE (1-800-633-4227). TTY users should call1-877-486-2048.If you have limited income and resources, extra help paying for Medicare prescription drug coverage is available. For information about this extra help, visit Social Security on the web at www.socialsecurity.gov, or call them at 1-800-772-1213 (TTY 1-800-325-0778). Remember: Keep this Creditable Coverage notice. If you decide to join one of the Medicare drug plans, you may be required to provide a copy of this notice when you join to show whether or not you have maintained creditable coverage and, therefore, whether or not you are required to pay a higher premium (a penalty).

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EMPLOYEE RIGHTSPAID SICK LEAVE AND EXPANDED FAMILY AND MEDICAL LEAVE UNDER THE FAMILIES FIRSTCORONAVIRUS RESPONSE ACTThe Families First Coronavirus Response Act (FFCRA or Act) requires certain employers to provide their employees with paid sick leave and expanded familyand medical leave for specified reasons related to COVID-19. These provisions will apply from April 1, 2020 through December 31, 2020.PAID LEAVE ENTITLEMENTSGenerally, employers covered under the Act must provide employees:Up to two weeks (80 hours, or a part-time employee’s two-week equivalent) of paid sick leave based on the higher of their regular rate of pay, or the applicablestate or Federal minimum wage, paid at:100% for qualifying reasons #1-3 below, up to $511 daily and $5,110 total;2/3 for qualifying reasons #4 and 6 below, up to $200 daily and $2,000 total; andUp to 12 weeks of paid sick leave and expanded family and medical leave paid at 2/3 for qualifying reason #5 below for up to $200 daily and $12,000 total.A part-time employee is eligible for leave for the number of hours that the employee is normally scheduled to work over that period.ELIGIBLE EMPLOYEESIn general, employees of private sector employers with fewer than 500 employees, and certain public sector employers, are eligible for up to two weeks of fully orpartially paid sick leave for COVID-19 related reasons (see below). Employees who have been employed for at least 30 days prior to their leave request may beeligible for up to an additional 10 weeks of partially paid expanded family and medical leave for reason #5 below.QUALIFYING REASONS FOR LEAVE RELATED TO COVID-19An employee is entitled to take leave related to COVID-19 if the employee is unable to work, including unable to telework, because the employee:1.is subject to a Federal, State, or local quarantine or isolation order related to COVID-19;2. has been advised by a health care provider toself-quarantine related to COVID-19;3.is experiencing COVID-19 symptoms and is seeking a medical diagnosis;4. is caring for his or her child whose school or place of care is closed (or child care provider is unavailable) due to COVID-19 related reasons; or5.is caring for an individual subject to an order described in (1) or self-quarantine as described in (2);6.is experiencing any other substantially-similar condition specified by the U.S. Department of Health and Human Services.ENFORCEMENTThe U.S. Department of Labor’s Wage and Hour Division (WHD) has the authority to investigate and enforce compliance with the FFCRA. Employers may notdischarge, discipline, or otherwise discriminate against any employee who lawfully takes paid sick leave or expanded family and medical leave under the FFCRA,files a complaint, or institutes a proceeding under or related to this Act. Employers in violation of the provisions of the FFCRA will be subject to penalties andenforcement by WHD.For additional information or to file a complaint: 1-866-487-9243TTY: 1-877-889-5627dol.gov/agencies/whd

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Sample Insurica Guide

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