2015 PBT ISD Benefit Guide

Pecos-Barstow-Toyah Independent School District

Employee BeneďŹ t Guide EFFECTIVE 0 /01/201 - 0 /31/201

www.mybenefitshub.com/pecos-barstow-toyahisd

Table of Contents 1

Contact Information

19

Superior Vision

2

Online Benefit Enrollment

20-28

UNUM Long Term Disability

3

Benefit Updates

29-35

Loyal American Cancer

4-7

Benefit Summary

36-40

Allstate Heart & Stroke

8

MDLIVE Telehealth

41-44

The Hartford Life & AD&D

9-10

APL Medlink Medical Supplement

45-48

Trustmark Universal Life

11-15

APL Accident Plan

49-52

NBS Flexible Spending Accounts

16-18

CIGNA Dental

Benefit Contact Information Refer to this list when you need to contact one of your benefit providers. For general information please contact your Benefits Department, Financial Benefit Services or log on to www.mybenefitshub.com/pecos-barstow-toyahisd

Benefit Pecos-Barstow-Toyah ISD Benefit Website

Vendor

Phone Number

Financial Benefit Services (800) 583-6908

Website www.mybenefitshub.com/pecos-barstowtoyahisd

MDLIVE

(888) 365-1663

www.consultmdlive.com

American Public Life

(800) 256-8606

www.ampublic.com

Dental

CIGNA

(800) 244-6224

www.cigna.com

Vision

Superior Vision

(800) 507-3800

www.superiorvision.com

UNUM

(800) 583-6908

www.mybenefitshub.com/pecos-barstowtoyahisd

Loyal American

(800) 366-8354

www.mybenefitshub.com/pecos-barstowtoyahisd

American Public Life

(800) 256-8606

www.ampublic.com

Allstate

(800) 348-4489

www.mybenefitshub.com/pecos-barstowtoyahisd

The Hartford

(800) 583-6908

www.mybenefitshub.com/pecos-barstowtoyahisd

Trustmark

(866) 914-5202

www.trustmarkinsurance.com

National Benefit Services

(800) 274-0503

www.nbsbenefits.com

National Benefit Services

(800) 274-0503

www.nbsbenefits.com

Telehealth Medical Supplement - Medlink

Disability Cancer Accident Heart & Stroke Voluntary Group Life and AD&D Universal Life with Long Term Care Flexible Spending Accounts COBRA (dental, vision, medical FSA) Retirement 403b & 457

Page 1

Online Benefit Enrollment For benefit information and to enroll go to: www.mybenefitshub.com/pecos-barstow-toyahisd

1 1

2 2

Click the Login button to begin your Online Enrollment

*If you have trouble logging in, Click on the “Login Help Video” for assistance.

3 Passwords

Passwords All passwords have been RESET to the default described below:

Username:

4

The first Six (6) characters of your last name, followed by the first letter of your first name, followed by the last four (4) digits of your Social Security Number.

Default Password:

Last Name* (lowercase, excluding punctuation) followed by the last four (4) digits of your Social Security Number.

Example:

George Washington 000-00-1234

Username: washing1234 Password: washington1234

Example:

John Smith 000-00-4321

Username: smithj4321 Password: smith4321 Page 2

Enrollment Instructions Cl Click on “Enrollment Instructions” for more information about how to enroll .

2/01/2015 - 1/31/2016

Annual Benefit Enrollment www.mybenefitshub.com/pecos-barstow-toyahisd PBT ISD Annual Medical Enrollment Open 8/01/2015 - 8/31/2015

What’s New for September 2015: Benefit elections will become effective 9/1/2015 (elections requiring evidence of insurability, such as life Insurance, may have a later effective date, if approved). After annual enrollment closes, benefit changes can only be made if you experience a qualifying event (and changes must be made within 30 days of event).

Flex Spending: New hires enrolling in a HealthCare or Dependent Care FSA, please remember the flex plan year ends 1/31/2016 with 75 day grace period. Please choose your 5 month contributions wisely. Funds are “use it or lose it”. New participants will receive medical flex card in late Sept. Funds are available thru web or paper claim mid Sept.

Online Benefit Access: www.mybenefitshub.com/pecosbarstow-toyahisd You have access to benefit information 24/7 on the employee benefit website provided. You can review and print the consolidated enrollment form or benefit guide, download claim forms and plan summaries, link to carrier websites and provider searches.

Employees who currently participate in a Healthcare FSA (flexible spending account), please KEEP your card. You will be able to login thru the THEBenefits HUB or use the smart phone app to view your balances and card swipes.

Due to new federal ACA Regulations, every employee (including active contributing members and employees working 10 hours/week) is required to log in and complete the enrollment process, even if declining benefits. Health Insurance elections will not roll over. If you do not log in and enroll, you will not have this benefit in the 2015/16 plan year.

For complete TRS medical information, visit the TRS website at www.trsactivecareaetna.com or call 800.222.9205 or www.trsactivecareaetna.com 800.884.4901

Vision: Generic Superior Vision card available on your Benefit Website. Network Providers- Superior National.

Telehealth: MDLIVE is the new telehealth carrier effective 2/1/2015 . This is the same employer-paid benefit for all eligible employees. Telephone consultation for diagnosis & treatment for common conditions. Plan covers employee, spouse and all unmarried dependents under the age of 26 years. No Cards are mailed, but they are available on the Benefit Website in the Welcome Kit for your convenience.

Don’t Forget!

Login and complete your benefit enrollment from 08/01/2015 - 08/31/2015 Enrollment assistance is available by calling Financial Benefit Services at (866) 914-5202 between 10am – 7 pm (Spanish speaking representatives will be available) Update your profile information: home address, phone numbers, email, beneficiaries REQUIRED: Provide correct dependent social security numbers

Pecos-Barstow-Toyah ISD Employee Benefits HUB:

www.mybenefitshub.com/pecos-barstow-toyahisd

Benefit Summary

www.mybenefitshub.com/pecos-barstow-toyahsisd

Telehealth - MDLIVE

This Employer Paid plan provides you and your family with around-the-clock access to U.S-based, licensed physicians for telephone consultations. It’s easy to connect with a doctor in real-time for treatment or diagnosis of common non-emergency conditions.

MEDlink Insurance - American Public Life (APL)

This supplemental coverage helps offset out-of-pocket costs you experience due to deductible & coinsurance for an in-patient hospital stay. The available plan options are based on enrollment in your employer’s medical plan & includes $1,500 or $2,500 inpatient hospital benefit option This plan also pays a $200 outpatient benefit and a $25.00 Physician Outpatient Benefit. You are not eligible for MEDlink if any of the following apply: employees (or dependents) who aren’t covered under your employer’s medical plan, anyone covered by TRS-Care (retiree plan), Medicare, Medicaid, or Medical Savings Accounts, employees who have an HSA that is being actively funded, non-residents of the US, employees not actively at work on the plan effective date.

Dental Insurance - CIGNA

This is a PPO dental plan with the freedom to chose any dentist. In-network benefits are 100% for preventive, 80% for Basic, 50% for Major services and 50% Orthodontia with a Lifetime maximum of $1,000 for dependent children to age 19. Out-of-Network charges are paid based on usual, reasonable and customary fees. There is a $50 deductible for Basic and Major services per person, to a maximum of $150. Calendar year plan maximums per insured are: Year 1 -$1,250; Year 2 - $1,350; Year 3 -$1,450 and Year 4 -$1550.

Vision Insurance - Superior Vision

Members pay a copay for in-network benefits. Out-of-network vision services are reimbursed up to a certain dollar amount for covered expenses. The in-network exam co-pay is $10.00, the materials copay is $25.00 and the contact lenses fitting exam copay is $25.00.

Exams, lenses & frames (within plan allowance) are covered in-network with a co-pay, once every 12 months.

Long-Term Disability Insurance - UNUM

This insurance is designed to provide a monthly income to an individual who is disabled due to an accident or illness. There are different plans available with benefits becoming available from the 1st day of disability to as late as the 180th day. Benefits can be payable to age 65 if disability occurs prior to age 65. All new or increases in coverage are subject to pre-existing condition exclusions.

Cancer Insurance - Loyal American

Cancer insurance is designed to be a supplement & pays for many costs not covered by your medical insurance. There are 3 plan options available, with Guaranteed Issue and no medical questions. Some plan benefit are: cancer screening tests, first occurrence, chemotherapy/radiation and surgical benefits. All new or increases in coverage are subject to pre-existing condition exclusions.

Accident Insurance -American Public Life (APL)

This Plan pays a benefit amount for covered accidental injuries. This plan has an ambulance, hospital and physician expense benefit for covered accidents. Coverage is issuable for ages 18-64 and is portable, you can choose to keep your benefit even if you leave the district or retire until age 70.

Voluntary Group Term Life & AD&D Insurance - The Hartford

This portable plan is an affordable way to purchase additional life insurance. Employees must enroll in order to enroll dependents.

Employees can enroll for up to a max of 5 times salary not to exceed $500,000 and $250,000 on their spouse and $10,000 on each eligible dependent child under age 26. New coverage in excess of 10k for employee and 5k for spouse is subject to underwriting and Evidence of Insurability form is required. New employees can enroll for up to $150,000 on themselves, $50,000 on their spouse and $10,000 on their children on a Guarantee Issue Basis (No Health Questions Asked) as long as the election is made within 31 days of hire date. For new or increases in coverage to take effect, employees must be actively at work and spouse/child cannot be disabled.

Universal Life with Long Term Care Insurance - Trustmark

Plan offers Permanent Life Insurance designed to match your needs throughout your lifetime. It pays higher death benefit during working years when expenses are high and you need maximum protection. Then, at age 70 when financial needs are lower, the death benefit reduces. However, the Living Benefit for Long Term Care (LTC) never reduces. That means you will have maximum protection during your retirement when you are more than likely to need it. Your LTC Benefit helps supplement the cost of home healthcare, assisted living, adult day care and nursing home care. (Speak to an Enroller for an application, paper application required.)

Heart & Stroke Insurance - Allstate

Plan pays you benefits that can be used for non-medical expenses that health insurance might not cover. No benefits are payable during the first year of coverage for a pre-existing condition. Plan is portable, you can choose to keep your benefit if you leave the district.

Paper application required.

Healthcare & Dependent Care Flexible Spending Account by National Benefit Services

Tax-sheltered flexible spending accounts allow an individual to set aside dollars to pay for future healthcare & dependent care expenses. Eligible expenses must be incurred within the plan year 2/1/2015—1/31/2016 & 75 day grace period. Contributions are useit-or- lose-it. The healthcare reimbursement maximum is $2,400/plan year. The dependent care reimbursement maximum is $5,000 married or $2,500 for married individuals filing separately. Remember to keep all your receipts!

Current Healthcare FSA Participants: Do not discard your NBS Flex Card. Your new Flex funds will be loaded on your current NBS Flex Card. Please allow up to 14 days following February 1, 2015 for your funds to be available.

This is only an outline of benefits. If the terms of this benefit summary differ from your policy, the policy will govern.

Page 4

Annual Enrollment During your annual enrollment period, you have the opportunity to review, change or continue benefit elections each year. Changes are not permitted during the plan year (outside of annual enrollment) unless a Section 125 qualifying event occurs.



Changes, additions or drops may be made only during the annual enrollment period without a qualifying event.



Employees must review their personal information and verify that dependents they wish to provide coverage for are included in the dependent profile. Additionally, you must notify your employer of any discrepancy in personal and/or benefit information.



Employees must confirm on each benefit screen (dental, vision, etc.) that each dependent to be covered is selected in order to be included in the coverage for that particular benefit.

New Hire Enrollment All new hire enrollment elections must be completed in the online enrollment system within the first 31 days of benefit eligibility employment. Failure to complete elections during this timeframe will result in the forfeiture of coverage.

Q&A Who do I contact with Questions?

For supplemental benefit questions, you can contact your Benefits/HR department or you can call Financial Benefit Services at 866-914-5202 for assistance.

Where can I find forms?

For benefit summaries and claim forms, go to the Pecos-Barstow-Toyah ISD benefit website: www.mybenefitshub.com/pecos-barstow-toyahisd Click on the benefit plan you need information on (i.e., Dental) and you can find the forms you need under the Benefits and Forms section.

How can I find a Network Provider?

For benefit summaries and claim forms, go to the PBT ISD benefit website: www.mybenefitshub.com/pecos-barstowtoyahisd Click on the benefit plan you need information on (i.e., Dental) and you can find provider search links under the Quick Links section.

When will I receive ID cards?

If the insurance carrier provides ID cards, you can expect to receive those 3-4 weeks after your effective date. For most dental and vision plans, you can login to the carrier website and print a temporary ID card or simply give your provider the insurance company’s phone number and they can call and verify your coverage if you do not have an ID card at that time.

If you do not receive your ID card, you can call the carrier’s customer service number to request another card.

Page 5

Employee Eligibility Requirements Supplemental Benefits: Eligible employees must work 20 or more regularly scheduled hours each work week.

Eligible employees must be actively at work on the plan effective date for new benefits to be effective, meaning you are physically capable of performing the functions of your job on the first day of work concurrent with the plan effective date. For example, if your 2015 benefits become effective on February 1, 2015, you must be actively-at-work on February 1, 2015 to be eligible for your new benefits.

Dependent Eligibility Requirements Dependent Eligibility: You can cover eligible dependent children under a benefit that offers dependent coverage, provided you participate in the same benefit, through the maximum age listed below. Dependents cannot be double covered by married spouses within the PBT ISD or as employees and dependents.

!

Plan

Carrier

Child Maximum Age

Dental

Cigna

Through 25

Vision

Superior Vision

Through 25

Cancer

Loyal American

Through 24

Accident

American Public Life

Through 25

Heart & Stroke

Allstate

Through 25

Telehealth

MDLIVE

Through 25

Voluntary Life & AD&D

The Hartford

Through 24, IRS dependent

Medical Gap Plan

American Public Life

Through 25

Healthcare FSA & HSA

National Benefit Services

IRS Tax Dependent

Dependent Flex

National Benefit Services

12 or younger or qualified individual unable to care for themselves & claimed as a dependent on your taxes

If your dependent is disabled, coverage can continue past the maximum age under certain plans. If you have a disabled dependent who is reaching an ineligible age, you may need to provide documentation confirming your dependent’s disability. Contact your HR/Benefit Administrator for more information .

This is a general overview of your plan benefits. Additional details on covered expenses, limitations and exclusions are included in the summary plan description located on the PBT ISD Benefits Website: www.mybenefitshub.com/pecos-barstow-toyahisd

Page 6

Section 125 Cafeteria Plan Guidelines A Cafeteria plan enables you to save money by using pre-tax dollars to pay for eligible group insurance premiums sponsored and offered by your employer. Enrollment is automatic unless you decline this benefit. Elections made during annual enrollment will become effective on the plan effective date and will remain in effect during the entire plan year.

Changes in benefit elections can occur only if you experience qualifying event. You must present proof of a qualifying event to your Benefit Office within 30 days of your qualifying event and meet with your Benefit/HR Office to complete and sign the necessary paperwork in order to make a benefit election change. Benefit changes must be consistent with the qualifying event .

Changes In Status (CIS): Qualifying Events Marital Status

A change in marital status includes marriage, death of a spouse, divorce or annulment (legal separation is not recognized in all states).

A change in number of dependents includes the following: birth, adoption and placement for Change in Number of Tax adoption. You can add existing dependents not previously enrolled whenever a dependent gains Dependents eligibility as a result of a valid change in status event.

Change in Status of Employment Affecting Coverage Eligibility

Change in employment status of the employee, or a spouse or dependent of the employee, that affects the individual's eligibility under an employer's plan includes commencement or termination of employment.

An event that causes an employee's dependent to satisfy or cease to satisfy coverage Gain/Loss of Dependents' requirements under an employer's plan may include change in age, student, marital, Eligibility Status employment or tax dependent status.

Judgment/Decree/Order

If a judgment, decree, or order from a divorce, annulment or change in legal custody requires that you provide accident or health coverage for your dependent child ( including a foster child who is your dependent), you may change your election to provide coverage for the dependent child. If the order requires that another individual (including your spouse and former spouse) covers the dependent child and provides coverage under that individual's plan, you may change your election to revoke coverage only for that dependent child and only if the other individual actually provides the coverage.

Eligibility for Government Gain or loss of Medicare/Medicaid coverage may trigger a permitted election change.

Programs

Page 7

24/7/365 on-demand access to affordable, quality healthcare.

Anytime, Anywhere.

MDLIVE offers 24/7/365 on-demand access to a national network of board-certified doctors and pediatricians that can diagnose, recommend treatment, and prescribe medication. Get the care you need, when you need it.

What can be treated?

When should I use MDLIVE? If you’re considering the ER or urgent care for a non-emergency medical issue Your primary care physician is not available At home, traveling, or at work 24/7/365, even holidays!

Pediatric Care related to: Cold & Flu Constipation Ear Infection Fever Nausea & Vomiting Pink Eye And More!

Allergies Asthma Bronchitis Cold and Flu Ear Infections Joint Aches and Pain Respiratory Infection Sinus Problems And More!

Who are our providers?

Are children eligible?

Our providers practice primary care, pediatrics, family and emergency medicine, and have incorporated MDLIVE into their practice to provide convenient access to quality care.

Yes. MDLIVE has local pediatricians on-call 24/7/365.

However, a parent or guardian must be present during registration and any consultations involving minors.

Call us at (888) 365-1663 or visit us at consultmdlive.com Disclaimers: MDLIVE does not replace the primary care physician. MDLIVE operates subject to state regulation and may not be available in certain states. MDLIVE does not guarantee that a prescription will be written. MDLIVE does not prescribe DEA controlled substances, non-therapeutic drugs and certain other drugs which may be harmful because of their potential for abuse. MDLIVE physicians reserve the right to deny care for potential misuse of services. For complete terms of use visit www.mdlive.com/pages/terms.html 010113

Page 8

MEDlink® Limited Benefit Medical Expense Supplemental Insurance Pecos Barstow Toyah ISD Group #14986 / #15841 THE POLICY UNDER WHICH THIS CERTIFICATE IS ISSUED IS NOT A POLICY OF WORKERS’ COMPENSATION INSURANCE. THE EMPLOYER DOES NOT BECOME A SUBSCRIBER TO THE WORKERS’ COMPENSATION SYSTEM BY PURCHASING THE POLICY AND IF THE EMPLOYER IS A NON-SUBSCRIBER, THE EMPLOYEE LOSES THOSE BENEFITS WHICH WOULD OTHERWISE ACCRUE UNDER THE WORKERS’ COMPENSATION LAWS. THE EMPLOYER MUST COMPLY WITH THE WORKERS’ COMPENSATION LAW AS IT PERTAINS TO NON-SUBSCRIBERS AND THE REQUIRED NOTIFICATIONS THAT MUST BE FILED AND POSTED.

Summary of Benefits Benefit Description

Option 1 $1,500 per confinement

$2,500 per confinement up to $200 per treatment

$25 per treatment; $125 max per family per Calendar Year

$25 per treatment; $125 max per family per Calendar Year

Outpatient Benefit Physician Outpatient Treatment Benefit

Option 2

up to $200 per treatment

In-Hospital Benefit - Maximum In-Hospital Benefit

Option 1 Total Monthly Premiums by Plan*

Option 2 Total Monthly Premiums by Plan*

Issue Ages 17-54

Issue Ages 55-59

Issue Ages 60-69

Issue Ages 17-54

Issue Ages 55-59

Issue Ages 60-69

Employee

$21.50

$32.00

$49.00

Employee

$28.00

$44.50

$68.50

Employee & Spouse

$39.50

$59.00

$88.00

Employee & Spouse

$51.50

$81.50

$122.50

1 Parent Family

$36.50

$47.00

$64.00

1 Parent Family

$45.50

$62.00

$86.00

2 Parent Family

$54.50

$74.00

$103.00

2 Parent Family

$69.00

$99.00

$140.00

Option 2 Total 9-Pay Premiums by Plan*

Option 1 Total 9-Pay Premiums by Plan*

Issue Ages 17-54

Issue Ages 55-59

Issue Ages 60-69

Employee

$37.33

$59.33

$91.33

$117.33

Employee & Spouse

$68.67

$108.67

$163.33

$85.33

1 Parent Family

$60.67

$82.67

$114.67

$137.33

2 Parent Family

$92.00

$132.00

$186.67

Issue Ages 17-54

Issue Ages 55-59

Issue Ages 60-69

Employee

$28.67

$42.67

$65.33

Employee & Spouse

$52.67

$78.67

1 Parent Family

$48.67

$62.67

2 Parent Family

$72.67

$98.67

*Total premium includes the Plan selected and any applicable rider premium. Premiums are subject to increase with notice.

The premium and amount of benefits vary dependent upon the Plan selected at time of application.

Limitations Eligibility

This policy will be issued to those persons who meet American Public Life Insurance Company’s insurability requirements. Evidence of insurability acceptable to us may be required. If our underwriting rules are met, you are on active service, you are covered under your Employer’s Medical Plan and premium has been paid, your insurance will take effect on the requested Effective Date or the Effective Date assigned by us upon approval of your written application, whichever is later.

Covered Charges mean those charges that are incurred by a Covered Person because of an Accident or Sickness; are for necessary treatment, services and medical supplies and recommended by a Physician; are not more than any dollar limit set forth in the Schedule; are incurred while insured under the Policy, subject to any Extension of Benefits; and are not excluded under the Policy.

A Hospital is not any institution used as a place for rehabilitation; a place for rest, or for the aged; a nursing or convalescent home; a long term nursing unit or geriatrics ward; or an extended care facility for the care of convalescent, rehabilitative or ambulatory patients.

In-Hospital Benefit

Benefits payable are limited to any out-of-pocket deductible amount; any out-of-pocket co-payment or coinsurance amounts the Covered Person actually incurs after your Employer’s Medical Plan has paid; any out-of-pocket amount the Covered Person actually incurs for surgery performed by a Physician after the your Employer’s Medical Plan has paid; and the Maximum

APSB-22330(TX) MGM/FBS Pecos Barstow Toyah ISD

In-Hospital Benefit shown in the Policy Schedule. The Covered Person must be an Inpatient and covered by your Employer’s Medical Plan when the Covered Charges are incurred.

Outpatient Benefits

Treatment is for the same or related conditions, unless separated by a period of 90 consecutive days. After 90 consecutive days, a new Outpatient Benefit will be payable. The Covered Person must be covered by your Employer’s Medical Plan when the Covered Charges are incurred.

Physician Outpatient Treatment Benefit

Benefit maximum of $125 per family per Calendar Year. The Covered Person must be covered by your Employer’s Medical Plan when the Covered Charges are incurred. The Covered Person must not be an Inpatient when the Covered Charges are incurred.

Premiums

The premium rates may be changed by Us. If the rates are changed, We will give You at least 31 days advance written notice. If a change in benefits increases Our liability, premium rates may be changed on the date Our liability is increased.

This plan may be continued in accordance with the Consolidated Omnibus Reconciliation Act of 1986.

Page 9

Exclusions

We will pay no benefits for any expenses incurred during any period the Covered Person does not have coverage under your Employer’s Medical Plan, except as provided in the Absence of your Employer’s Medical Plan provision or which result from: (a) suicide or any attempt, thereof, while sane or insane; (b) any intentionally self-inflicted injury or Sickness; (c) rest care or rehabilitative care and treatment; (d) routine newborn care, including routine nursery charges; (e) voluntary abortion except, with respect to You or Your covered Dependent spouse:

(1) where Your or Your Dependent spouse’s life would be

endangered if the fetus were carried to term; or

(2) where medical complications have arisen from abortion; (f) pregnancy of a Dependent child; (g) participation in a riot, civil commotion, civil disobedience, or unlawful assembly. This does not include a loss which occurs while acting in a lawful manner within the scope of authority; (h) commission of a felony; (i) participation in a contest of speed in power driven vehicles, parachuting, or hang gliding; (j) air travel, except:

(1) as a fare-paying passenger on a commercial airline on a

regularly scheduled route; or

(2) as a passenger for transportation only and not as a pilot or

crew member; (k) intoxication; (Whether or not a person is intoxicated is determined and defined by the laws and jurisdiction of the geographical area in which the loss occurred.) (l) alcoholism or drug use, unless such drugs were taken on the advice of a Physician and taken as prescribed; (m) sex changes; (n) experimental treatment, drugs, or surgery; (o) an act of war, whether declared or undeclared, or while performing police duty as a member of any military or naval organization; (This exclusion includes Accident sustained or Sickness contracted while in the service of any military, naval, or air force of any country engaged in war. We will refund the pro rata unearned premium for any such period the Covered Person is not covered.) (p) Accident or Sickness arising out of and in the course of any occupation for compensation, wage or profit; (This does not apply to those sole proprietors or partners not covered by Workers’ Compensation.) (q) mental illness or functional or organic nervous disorders, regardless of the cause;

(r)

(s) (t) (u)

dental or vision services, including treatment, surgery, extractions, or x-rays, unless: (1) resulting from an Accident occurring while the Covered

Person’s coverage is in force and if performed within 12

months of the date of such Accident; or (2) due to congenital disease or anomaly of a covered

newborn child. routine examinations, such as health exams, periodic check-ups, or routine physicals; any expense for which benefits are not payable under the Covered Person’s your Employer’s Medical Plan; or air or ground ambulance.

Termination of Coverage

Your Insurance coverage will end on the earliest of these dates: the date You no longer qualify as an Insured; the end of the last period for which premium has been paid; the date the Policy is discontinued; the date You retire; if You work for an employer employing less than 20 employees on a typical work day in the preceding Calendar Year, the date You attain age 70; the date You cease to be on Active Service; the date Your coverage under your Employer’s Medical Plan ends; or the date You cease employment with the employer through whom You originally became insured under the Policy.

Insurance coverage on a Dependent will end on the earliest of these dates: the date Your coverage terminates; the end of the last period for which premium has been paid; the date the Dependent no longer meets the definition of Dependent; the date the Dependent’s coverage under your Employer’s Medical Plan ends; or the date the Policy is modified so as to exclude Dependent coverage.

We may end the coverage of any Covered Person who submits a fraudulent claim.

We may end the coverage of a Subscribing Unit if fewer persons are insured than the Policyholder’s application requires.

Underwritten by:

2305 Lakeland Drive | Flowood, MS | 39232 ampublic.com | 800.256.8606 This is a brief description of the coverage. For actual benefits, limitations, exclusions and other provisions, please refer to the policy and riders. This coverage does not replace Workers’ Compensation Insurance. This product is inappropriate for people who are eligible for Medicaid coverage. | This policy is considered an employee welfare benefit plan established and/ or maintained by an association or employer intended to be covered by ERISA, and will be administered and enforced under ERISA. Group policies issued to governmental entities and municipalities may be exempt from ERISA guidelines. Policy Form MEDlink® Series | Texas | Limited Benefit Medical Expense Supplemental Insurance | (10/14) | Pecos Barstow Toyah ISD

APSB-22330(TX) MGM/FBS Pecos Barstow Toyah ISD

Page 10

American Public Life Insurance Company EZ2DOBIZWITHTM

Supplemental

Accident Insurance

Because Life is full of surprises

Form FormA-3B A-3BRevised Revised(10/06) (10/06)

Page 11

Gen/D.C./ID/NC/TN/WV Gen/D.C./ID/NC/TN/WV

ACCIDENTS HAPPEN IT’S A SIMPLE FACT OF LIFE BUT THEY DON’T HAVE TO CATCH YOU UNPREPARED With added security coverage, you can rest assured that you’re protected if a covered accident happens to threaten your financial security, or the security of your family. So give yourself and your family the protection and peace of mind you need. Wouldn’t this be the perfect time to add this valuable protection?

IT’S A LEVEL OF PROTECTION OTHER COVERAGE PLANS SIMPLY CAN’T MATCH • Added Security Coverage pays regardless of any other medical coverage • It protects you 24 hours a day on or off the job • Issue ages, 18-64 • It’s guaranteed renewable up to age 70 • Family members receive full benefits • Benefits are paid directly to you • There is no limit on the number of accidents covered

Page 12

Pecos-Barstow-Toyah Independent School District A3 - Accident Expense Policy Benefits

1 Unit

Accidental Injury Benefit - We will pay the actual charges per accident (not to exceed maximum benefits for units selected) for physician’s treatment, surgery, x-rays, reduction of fractures and dislocations or other emergency treatment expenses. In no case will the benefit exceed actual charges. There is a $50 deductible for emergency room expenses, per occurrence, regardless of the number of units.

$500

Ambulance Benefit - We will pay the actual charges (not to

2 Units

3 Units

4 Units

$1,000

$1,500

$2,000

$1,250

$2,500

$3,750

$5,000

$75

$150

$225

$300

$100

$100

$100

$100

$150

$150

$150

$150

$5,000

$10,000

exceed maximum benefits for units selected) for emergency transportation for covered treatment (ground or air).

Hospital Confinement - We will pay the daily hospital benefit, based upon the number of units selected, when a covered insured is confined to a hospital due to accident or injury. This benefit begins the first day of confinement and pays up to 30 days per any one injury.

Hospital Admission Benefit - We will pay for the benefit shown, based upon the number of units selected, upon admission to a hospital due to a covered accident.

Accident Only Intensive Care Benefit: We will pay the daily benefit shown, based on the number of units selected, for intensive care confinement as a result of accidental bodily injury, subject to a maximum benefit period of 30 days. This benefit pays $150 daily per unit. A maximum of four units may be purchased.

Accidental Death Benefit* - We will pay the benefit shown for accidental death which results within 90 days of injury, based upon the number of units selected.

$15,000

$20,000

Dismemberment* - We will pay the following benefit, based upon the number of units selected, for dismemberment which results within 90 days of injury (dismemberment benefits are subject to a $5,000 per unit cumulative maximum).

Single Finger or toe Multiple fingers or toes Single Hand, Arm, Foot or Leg Multiple Hands, Arms, Feet or Legs

$250 $500 $2,500 $5,000

$500 $1,000 $5,000 $10,000

$750 $1,500 $7,500 $15,000

$1,000 $2,000 $10,000 $20,000

Loss of Sight Benefit - We will pay the benefit, based upon the number of units selected, shown for the loss of sight due to accidental injury.

Loss of sight in one eye Loss of sight in both eyes

$2,500 $5,000

$5,000 $10,000

$7,500 $15,000

$10,000 $20,000

$11.70 $20.70 $22.70 $31.70

$18.00 $31.10 $36.40 $49.50

$22.40 $40.20 $46.70 $64.50

$25.40 $46.20 $53.50 $74.30

Premiums: Individual Individual and Spouse Individual and Children Family (2 Parents and children)

Page 13

DEFINITIONS INJURY or ACCIDENTAL INJURY or ACCIDENTAL BODILY INJURY means physical damage to an Insured Person, sustained on or after the Effective Date, and while this Policy is in force, which is the direct cause of the loss, independent of disease, bodily infirmity or any other cause. All injuries sustained in any one accident and all complications arising therefrom and recurrence and complication shall be deemed to be a single “Injury.”

DISABILITY means Your inability, as a result of covered Accidental Injury, to perform the substantial and material duties of Your occupation and You are not gainfully employed.

EXCLUSIONS AND LIMITATION Benefits otherwise provided by this policy will not be payable for services or expenses or any such loss resulting from or in connection with: 1. sickness, illness or bodily infirmity; except as covered by the Sickness Disability Rider; 2. suicide, attempted suicide or intentional self-inflicted injury, whether sane or insane; 3. dental care or treatment due to accidental injury to natural teeth; 4. war or any act of war (whether declared or undeclared) or participating in a riot or felony; 5. alcoholism or drug addiction; 6. travel or flight in or descent from any aircraft or device which can fly above the earth’s surface in any capacity other than as a fare-paying passenger on a regularly scheduled airline; 7. injury originating prior to the effective date of the policy; 8. injury occurring while intoxicated (intoxication means that which is determined and defined by the laws and jurisdiction of the geographical area in which the loss or cause of loss is incurred); 9. voluntary inhalation of gas or fumes or taking of poison or asphyxiation; 10. voluntary ingestion or injection of any drug, narcotic or sedative, unless administered on the advice and taken in such doses as prescribed by a physician; 11. injury sustained or sickness which manifests itself while on full-time duty in the armed forces. Upon notice, the company will refund the proportion of unearned premium while in such forces; 12. injury incurred while engaged in an illegal occupation; 13. injury incurred while attempting to commit a felony or an assault; 14. mental or emotional disorders; 15. injury to a covered person while practicing for or being a part of organized or competitive rodeo, sky diving, hang gliding parachuting or scuba diving; 16. driving in any race or speed test or while testing an automobile or any vehicle on any racetrack or speedway; 17. charges incurred outside the U.S. if an insured traveled to the location for the purpose of receiving medical services, drugs or supplies; 18. hernia, carpal tunnel syndrome or any complication therefrom; 19. any bacterial infection (except pyogenic infections which shall occur with and through an accidental cut or wound).

If you are entitled to benefits under this policy, as a result of sprained or lame back, or any intervertebral disk conditions, such benefits shall be payable for a maximum period of time, not exceeding in the aggregate three (3) months for any injury.

These exclusions and limitations are not applicable for all states. Please refer to your policy or outline for applicable exclusions and limitations.

Page 14

This coverage should be viewed as a supplement to other health insurance. This is not the insurance contract, and only the actual policy provisions will apply. It is therefore important that you read your policy carefully. All products are not available in all states.

In West Virginia: 18, and 19 above are changed and read as follows: 18. hernia, within six (6) months after the Effective Date; 19. carpal tunnel syndrome or any complication therefrom; 20. any bacterial infection (except pyogenic infections which shall occur with and through an accidental cut or wound).

In Idaho: Exclusions and Limitations 1. sickness, illness or bodily infirmity; 2. suicide, attempted suicide or intentional self-inflicted Injury, whether sane or insane; 3. dental care or treatment due to accidental Injury to natural teeth; 4. war or any act of war (whether declared or undeclared) or participating in a riot or felony; 5. alcoholism or drug addiction; 6. participation in any form of flight aviation other than as a fare-paying passenger in a licensed, passenger-carrying aircraft; 7. a Pre-existing Condition incurred within 12 months following the effective date of coverage; 8. Injury occurring while intoxicated or under the influence of any narcotic, unless administered on the advice and taken in such doses as prescribed by a Physician; 9. Injury sustained or sickness which first manifests itself while on full-time duty in the armed forces. Upon notice, We will refund the proportion of unearned premium while in such forces.

10. Injury incurred while engaging in an illegal occupation; 11. Injury incurred while attempting to commit a felony; 12. mental or emotional disorders; 13. Injury to a covered person while participating as a professional as a part of organized or competitive rodeo, sky diving, hang gliding, parachuting or scuba diving; 14. driving as a professional in any race or speed test or while testing an automobile or any vehicle on any racetrack or speedway; 15. charges incurred outside the U.S., if an Insured traveled to the location for the purpose of receiving medical services, drugs or supplies;

American Public Life Insurance Company

®

A member of the American Fidelity Group® American Public Life Insurance Company • P.O. Box 925 • Jackson, Mississippi 39205 800-256-8606 • 800-256-6736 (Sales Department) • www.ampublic.com

This brochure does not constitute the full contract and is intended to provide basic information about American Public Life Insurance Company’s Form A-3B Supplemental Accident product. For specific details, please consult an actual policy and its provisions.

Page 15

Cigna Dental Benefit Summary Pecos-Barstow-Toyah ISD Account #3335679

EE Only EE + Spouse EE + Child(ren) Family Coverage

$ $ $ $

25.69 54.54 57.33 83.91

Receiving regular dental care can not only catch minor problems before they become major and expensive to treat - it may even help improve your overall health. Gum disease is increasingly being linked to complications for pre-term birth, heart disease, stroke, diabetes, osteoporosis and other health issues. That’s why this dental plan includes Cigna Dental WellnessPlusSM features. When you or your family members receive any preventive care in one plan year, the annual dollar maximum will increase in the following plan year. When you or your family members remain enrolled in the plan and continue to receive preventive care, the annual dollar maximum will increase in the following plan year, until it reaches the level specified below. Please refer to your plan materials for additional information on this plan feature.

Benefits Network Calendar Year Maximum (Class I, II and III expenses) Annual Deductible Individual Family Reimbursement Levels**

Class I - Preventive & Diagnostic Care

Cigna Dental PPO In-Network Total Cigna DPPO

Out-of-Network

Year 1: $1,250

Year 2: $1,350#

Year 1: $1,250

Year 2: $1,350#

Year 3: $1,450+

Year 4 and beyond: $1,550^

Year 3: $1,450+

Year 4 and beyond: $1,550^

$50 per person $150 per family

$50 per person $150 per family

Based on Reduced Contracted Fees

90th percentile of Reasonable and Customary Allowances

Plan Pays

You Pay

Plan Pays

You Pay

100%

No Charge

100%

No Charge

80%*

20%*

80%*

20%*

50%*

50%*

50%*

50%*

50%*

50%* $1,000 Dependent children to age 19

50%*

Oral Exams Routine Cleanings Bitewing X-rays Full Mouth X-rays Panoramic X-ray Fluoride Application Sealants Space Maintainers

Class II - Basic Restorative Care Fillings Emergency Care to Relieve Pain Surgical Extractions of Impacted Teeth Brush Biopsies Oral Surgery - all except simple extractions Anesthetics Oral Surgery – Simple Extractions

Class III - Major Restorative Care Crowns Root Canal Therapy/Endodontics Osseous Surgery Periodontal Scaling and Root Planing Histopathologic Exams Denture Repairs Denture Relines, Rebases and Adjustments Repairs to Bridges, Crowns and Inlays Dentures Bridges Inlays/Onlays Prosthesis Over Implant

Class IV - Orthodontia Lifetime Maximum

50%* $1,000 Dependent children to age 19

Page 16

Important Notes Missing Tooth Limitation – The amount payable is 50% of the amount otherwise payable until insured for 24 months; thereafter, considered a Class III expense. Pretreatment review is available on a voluntary basis when extensive dental work in excess of $200 is proposed. * Subject to annual deductible Dental Oral Health Integration Program (OHIP)- All dental customers= Clinical research shows an association between oral health and overall health. The Cigna Dental Oral Health Integration Program (OHIP)® is designed to provide enhanced dental coverage for customers with certain eligible medical conditions. Eligible conditions for the program include cardiovascular disease, cerebrovascular disease (stroke), diabetes, maternity, chronic kidney disease, organ transplants, and head and neck cancer radiation. The program provides: • 100% coverage for certain dental procedures • guidance on behavioral issues related to oral health • discounts on prescription and non-prescription dental products For more information and to see the complete list of eligible conditions, go to www.mycigna.com or call customer service 24/7 at 1.800.CIGNA24. **For services provided by a Cigna Dental PPO network dentist, Cigna Dental will reimburse the dentist according to a Contracted Fee Schedule. For services provided by an out-of-network dentist, Cigna Dental will reimburse according to Reasonable and Customary Allowances but the dentist may balance bill up to their usual fees. #Increase contingent upon receiving Preventive Services in Plan Year 1 +Increase contingent upon receiving Preventive Services in Plan Years 1 and 2 ^Increase contingent upon receiving Preventive Services in Plan Years 1, 2 and 3

Cigna Dental PPO Exclusions and Limitations Procedure Exclusions and Limitations Late Entrants Limit Exams Prophylaxis (Cleanings) Fluoride Histopathologic Exams X-Rays (routine) X-Rays (non-routine) Model Minor Perio (non-surgical) Perio Surgery Crowns and Inlays Bridges Dentures and Partials Relines, Rebases Adjustments Repairs - Bridges Repairs - Dentures Sealants Space Maintainers Prosthesis Over Implant Alternate Benefit

50% coverage on Class III and IV for 24 months Two per Calendar year Two per Calendar year 1 per Calendar year for people under 19 Various limits per Calendar year depending on specific test Bitewings: 2 per Calendar year Full mouth: 1 every 36 consecutive months., Panorex: 1 every 36 consecutive months Payable only when in conjunction with Ortho workup Various limitations depending on the service Various limitations depending on the service Replacement every 5 years Replacement every 5 years Replacement every 5 years Covered if more than 6 months after installation Covered if more than 6 months after installation Reviewed if more than once Reviewed if more than once Limited to posterior teeth. One treatment per tooth every three years up to age 14 Limited to non-Orthodontic treatment 1 per 60 consecutive months if unserviceable and cannot be repaired. Benefits are based on the amount payable for nonprecious metals. No porcelain or white/tooth colored material on molar crowns or bridges When more than one covered Dental Service could provide suitable treatment based on common dental standards, Cigna HealthCare will determine the covered Dental Service on which payment will be based and the expenses that will be included as Covered Expenses

Benefit Exclusions: · Services performed primarily for cosmetic reasons · Replacement of a lost or stolen appliance · Replacement of a bridge or denture within five years following the date of its original installation · Replacement of a bridge or denture which can be made useable according to accepted dental standards · Procedures, appliances or restorations, other than full dentures, whose main purpose is to change vertical dimension, diagnose or treat conditions of TMJ, stabilize · · · · · · · · · · · · · · · · · · · ·

periodontally involved teeth, or restore occlusion Veneers of porcelain or acrylic materials on crowns or pontics on or replacing the upper and lower first, second and third molars Bite registrations; precision or semi-precision attachments; splinting A surgical implant of any type Instruction for plaque control, oral hygiene and diet Dental services that do not meet common dental standards Services that are deemed to be medical services Services and supplies received from a hospital Charges which the person is not legally required to pay Charges made by a hospital which performs services for the U.S. Government if the charges are directly related to a condition connected to a military service Experimental or investigational procedures and treatments Any injury resulting from, or in the course of, any employment for wage or profit Any sickness covered under any workers’ compensation or similar law Charges in excess of the reasonable and customary allowances To the extent that payment is unlawful where the person resides when the expenses are incurred; Procedures performed by a Dentist who is a member of the covered person’s family (covered person’s family is limited to a spouse, siblings, parents, children, grandparents, and the spouse’s siblings and parents); For charges which would not have been made if the person had no insurance; For charges for unnecessary care, treatment or surgery; To the extent that you or any of your Dependents is in any way paid or entitled to payment for those expenses by or through a public program, other than Medicaid; To the extent that benefits are paid or payable for those expenses under the mandatory part of any auto insurance policy written to comply with a “no-fault” insurance law or an uninsured motorist insurance law. Cigna HealthCare will take into account any adjustment option chosen under such part by you or any one of your Dependents.

In addition, these benefits will be reduced so that the total payment will not be more than 100% of the charge made for the Dental Service if benefits are provided for that service under this plan and any medical expense plan or prepaid treatment program sponsored or made available by your Employer.

Page 17

This benefit summary highlights some of the benefits available under the proposed plan. A complete description regarding the terms of coverage, exclusions and limitations, including legislated benefits, will be provided in your insurance certificate or plan description. Benefits are insured and/or administered by Connecticut General Life Insurance Company.

"Cigna HealthCare" refers to various operating subsidiaries of Cigna Corporation. Products and services are provided by these subsidiaries and not by Cigna Corporation. These subsidiaries include Connecticut General Life Insurance Company, Cigna Health and Life Insurance Company, and HMO or service company subsidiaries of Cigna Health Corporation and Cigna Dental Health, Inc. DPPO insurance coverage is set forth on the following policy form numbers: AR: HP-POL77; CA: HP-POL57; CO: HP-POL78; CT: HP-POL58; DE: HP-POL79; FL: HP-POL60; ID: HP-POL82; IL: HP-POL62; KS: HP-POL84; LA: HP-POL86: MA: HP-POL 63; MI: HP-POL88; MO: HP- POL65; MS: HP-POL90; NC: HPPOL96; NE: HP-POL92; NH: HP-POL94; NM: HP-POL95; NV: HP-POL93; NY: HP-POL67; OH: HP-POL98; OK: HP-POL99; OR: HP-POL68; PA: HP-POL100; RI: HP-POL101; SC: HP-POL102; SD: HP-POL103; TN: HP-POL69; TX: HP-POL70; UT: HP-POL104; VA: HP-POL72; VT: HP-POL71; WA: POL-07/08; WI: HP-POL107; WV: HP-POL106; and WY: HP-POL108.

“Cigna,” the “Tree of Life” logo and “Cigna Dental Care” are registered service marks of Cigna Intellectual Property, Inc., licensed for use by Cigna Corporation and its operating subsidiaries. All products and services are provided by or through such operating subsidiaries and not by Cigna Corporation. Such operating subsidiaries include Connecticut General Life Insurance Company (CGLIC), Cigna Health and Life Insurance Company (CHLIC), Cigna HealthCare of Connecticut, Inc., and Cigna Dental Health, Inc. and its subsidiaries. Cigna Dental PPO plans are underwritten or administered by CGLIC or CHLIC, with network management services provided by Cigna Dental Health, Inc. and certain of its subsidiaries. In Arizona and Louisiana, the insured Dental PPO plan offered by CGLIC is known as the “CG Dental PPO”. In Texas, the insured dental product offered by CGLIC and CHLIC is referred to as the Cigna Dental Choice Plan, and this plan utilizes the national Cigna Dental PPO network. Cigna Dental Care (DHMO) plans are underwritten or administered by Cigna Dental Health Plan of Arizona, Inc., Cigna Dental Health of California, Inc., Cigna Dental Health of Colorado, Inc., Cigna Dental Health of Delaware, Inc., Cigna Dental Health of Florida, Inc., a Prepaid Limited Health Services Organization licensed under Chapter 636, Florida Statutes, Cigna Dental Health of Kansas, Inc. (Kansas and Nebraska), Cigna Dental Health of Kentucky, Inc. (Kentucky and Illinois), Cigna Dental Health of Maryland, Inc., Cigna Dental Health of Missouri, Inc., Cigna Dental Health of New Jersey, Inc., Cigna Dental Health of North Carolina, Inc., Cigna Dental Health of Ohio, Inc., Cigna Dental Health of Pennsylvania, Inc., Cigna Dental Health of Texas, Inc., and Cigna Dental Health of Virginia, Inc. In other states, Cigna Dental Care plans are underwritten by CGLIC, CHLIC, or Cigna HealthCare of Connecticut, Inc. and administered by Cigna Dental Health, Inc. BSD45193

© 2014 Cigna

Page 18

Vision Plan Benefits for Pecos-Barstow-Toyah Independent School District Co-Pays

Services/Frequency

Monthly Premiums

Exam

$10

Emp. only

Materials1

$25

Emp. + 1 dependent

Contact Lens Fitting

$25

Emp. + family

Exam

12 months

$14.84

Frame

12 months

$21.80

Contact Lens Fitting

12 months

Lenses

12 months

Contact Lenses

12 months

$7.64

(standard & specialty)

(Based on date of service)

Benefits

In-Network

Exam (Ophthalmologist) Exam (Optometrist) Frames Contact Lens Fitting (standard2) Contact Lens Fitting (specialty2) Lenses (standard) per pair Single Vision Bifocal Trifocal Progressive Contact Lenses3

Out-of-Network

Covered in full Covered in full $100 retail allowance Covered in full $50 retail allowance

Up to Up to Up to Not Not

Covered in full Covered in full Covered in full Covered at lined trifocal level $100 retail allowance

$42 retail $37 retail $48 retail covered covered

Up to $32 retail Up to $46 retail Up to $61 retail Up to $61 retail Up to $100 retail

Co-pays apply to in-network benefits; co-pays for out-of-network visits are deducted from reimbursements.

1 Materials co-pay applies to lenses and frames only, not contact lenses.

Visit FAQs on www.superiorvision.com for definitions of standard and specialty CLF. 3 Contact lenses are in lieu of eyeglass lenses and frames benefit

2

Discount Features Look for providers in the Provider Directory who accept discounts; please verify their discounts prior to service.

Discounts on Covered Materials Frames: Lens options: Progressives:

20% off amount over allowance 20% off retail 20% off amount over retail lined trifocal lens, including lens options 4

The following options have out-of-pocket maximums on standard (not premium, brand, or progressive) plastic lenses.

Maximum Member Out-of-Pocket Single Vision Bifocal & Trifocal Scratch coat $13 $13 Ultraviolet coat $15 $15 Tints, solid or gradients $25 $25 Anti-reflective coat $50 $50 Polycarbonate $40 20% off retail High index 1.6 $55 20% off retail Photochromics $80 20% off retail

www.superiorvision.com Customer Service 800-507-3800 Refractive Surgery Superior Vision has a nationwide network of refractive surgeons and leading LASIK networks who offer members a discount. These discounts range from 5%-50%, and are the best possible discounts available to Superior Vision.

All allowances are retail; member is responsible for any amount over the allowance, minus available discounts.

Discounts are subject to change without notice.

Discounts on Non-Covered Exam and Materials Exams, frames, and prescription lenses: Lens options, contacts, other prescription materials: Disposable contact lenses: 4

Disclaimer: All final determinations of benefits, administrative duties, and definitions are governed by the Certificate of Insurance for your vision plan.

Please check with your Human Resources department if you have any questions.

30% off retail 20% off retail 10% off retail

Discounts and maximums may vary by lens type. Please check with your provider.

Superior Vision Services, Inc. P.O. Box 967 Rancho Cordova, CA 95741 800-507-3800 www.superiorvision.com The Superior Vision Plan is underwritten by National Guardian Life Insurance Company. National Guardian Life Insurance Company is not affiliated with The Guardian Life Insurance Company of America, AKA The Guardian or Guardian Life NVIGRP 5-07 1211-BSv1/TX

Page 19

Educator Select Income Protection Plan Insurance Highlights

ď€

Pecos-Barstow-Toyah Independent School District Policy # 217516 Please read carefully the following description of your Unum Educator Select Income Protection Plan insurance.

Your Plan Eligibility

You are eligible for disability coverage if you are an active employee in the United States working a minimum of 20 hours per week. The date you are eligible for coverage is the later of: the plan effective date; or the day after you complete the waiting period.

Guarantee Issue

Current Employees: Coverage is available to you without answering any medical questions or providing evidence of insurability. You may enroll on or before the enrollment deadline. After the initial enrollment period, you can apply only during an annual enrollment period.

New Hires: Coverage is available to you without answering any medical questions or providing evidence of insurability. You may apply for coverage within 60 days after your eligibility date. If you do not apply within 60 days after your eligibility date, you can apply only during an annual enrollment period.

Benefits are subject to the pre-existing condition exclusion referenced later in this document.

Please see your Plan Administrator for your eligibility date.

Benefit Amount

You may purchase a monthly benefit in $100 units, starting at a minimum of $200, up to 66 2/3% of your monthly earnings rounded to the nearest $100, but not to exceed a monthly maximum benefit of $8,000. Please see your Plan Administrator for the definition of monthly earnings.

The total benefit payable to you on a monthly basis (including all benefits provided under this plan) will not exceed 100% of your monthly earnings unless the excess amount is payable as a Cost of Living Adjustment.

However, if you are participating in Unum’s Rehabilitation and Return to Work Assistance program, the total benefit payable to you on a monthly basis (including all benefits provided under this plan) will not exceed 110% of your monthly earnings (unless the excess amount is payable as a Cost of Living Adjustment).

Elimination Period

EB-975

The Elimination Period is the length of time of continuous disability, due to sickness or injury, which must be satisfied before you are eligible to receive Page 20

benefits.

You may choose an Elimination Period (injury/sickness) of 14/14, 30/30, 60/60, 90/90 or 180/180 days.

If, because of your disability, you are hospital confined as an inpatient, benefits begin on the first day of inpatient confinement. Inpatient means that you are confined to a hospital room due to your sickness or injury for 23 or more consecutive hours. (Applies to Elimination Periods of 30 days or less.)

Benefit Duration

Your duration of benefits is based on your age when the disability occurs.

Plan: ADEA II: Your duration of benefits is based on the following table: Age at Disability Less than age 60 Age 60 through 64 Age 65 through 69 Age 70 and over

Federal Income Taxation

Maximum Duration of Benefits To age 65, but not less than 5 years 5 years To age 70, but not less than 1 year 1 year

The taxability of benefits depends on how premium was taxed during the plan year in which you become disabled. If you paid 100% of the premium for the plan year with post-tax dollars, your benefits will not be taxed. If premium for the plan year is paid with pre-tax dollars, your benefits will be taxed. If premium for the plan year is paid partially with post-tax dollars and partially with pre-tax dollars, or if you and your Employer share in the cost, then a portion of your benefits will be taxed.

Additional Benefits Work/Life Balance Employee Assistance 1 Program

Work-life balance is a comprehensive resource providing access to professional assistance for a wide range of personal and work-related issues. The service is available to you and your family members twentyfour hours a day, 365 days a year, and provides resources to help employees find solutions to everyday issues such as financing a car or selecting child care, as well as more serious problems such as alcohol or drug addiction, divorce, or relationship problems.

Services include: toll-free phone access to master’s-level consultants, up to three face-to-face sessions to help with more serious issues; and online resources. There is no additional charge for utilizing the program.

Participation is confidential and strictly voluntary, and employees do not have to have filed a disability claim or be receiving benefits to use the program.

However, if you become disabled and are receiving benefits, Unum's On Claim Support can provide additional resources including: coaching on how to communicate effectively with medical personnel, conducting consumer research for medical equipment and supplies, assessing emotional needs and locating counseling resources.

Return to Work/

Unum supports efforts that enable a disabled employee to remain on the job or return to work as soon as possible. If you are disabled but working part Page 21

Work Incentive Benefit

time with monthly disability earnings of 20% or more of your indexed monthly earnings, during the first 12 months, the monthly benefit will not be reduced by any earnings until the gross disability payment plus your disability earnings, exceeds 100% of your indexed monthly earnings. The monthly benefit will then be reduced by that amount.

Rehabilitation and Return to Work Assistance

Unum has a vocational Rehabilitation and Return to Work Assistance program available to assist you in returning to work. We will make the final determination of your eligibility for participation in the program, and will provide you with a written Rehabilitation and Return to Work Assistance plan developed specifically for you. This program may include, but is not limited to the following benefits:  coordination with your Employer to assist your return to work;  adaptive equipment or job accommodations to allow you to work;  vocational evaluation to determine how your disability may impact your employment options;  job placement services;  resume preparation;  job seeking skills training; or  education and retraining expenses for a new occupation.

If you are participating in a Rehabilitation and Return to Work Assistance program, we will also pay an additional disability benefit of 10% of your gross disability payment to a maximum of $1,000 per month. In addition, we will make monthly payments to you for 3 months following the date your disability ends, if we determine you are no longer disabled while:  you are participating in a Rehabilitation and Return to Work Assistance program; and  you are not able to find employment.

(This benefit is not allowed in New Jersey.)

Worksite Modification

If a worksite modification will enable you to remain at work or return to work, a designated Unum professional will assist in identifying what’s needed. A written agreement must be signed by you, your employer and Unum, and we will reimburse your employer for the greater of $1,000 or the equivalent of two months of your disability benefit.

Medical Treatment Benefit

A Medical Treatment Benefit will be paid when you receive treatment by a doctor as a result of a sickness or injury, provided no other benefits are payable under the plan as a result of the condition for which the treatment was rendered.

The Medical Treatment Benefit will be the doctor's actual charge for services rendered, up to a maximum benefit of $50 for sickness or $100 for injury. In addition, the charges must be for medically necessary care and treatment and in keeping with the extent of the sickness or injury.

No benefit will be paid unless you are personally seen and treated by a doctor and the treatment is not for routine medical examinations or dental Page 22

work.

Note: No more than one Medical Treatment Benefit will be paid for the same or related condition(s) unless the treatment dates are separated by at least 14 consecutive days. In addition, no more than one benefit will be paid for treatment during any 24 hour period and the benefit will not be paid more than 4 times per calendar year.

Waiver of Premium

After you have received disability payments under the plan for 90 consecutive days, from that point forward you will not be required to pay premiums as long as you are receiving disability benefits.

Survivor Benefit

Unum will pay your eligible survivor a lump sum benefit equal to 3 months of your gross disability payment.

This benefit will be paid if, on the date of your death, your disability had continued for 180 or more consecutive days, and you were receiving or were entitled to receive payments under the plan. If you have no eligible survivors, payment will be made to your estate, unless there is none. In that case, no payment will be made. However, we will first apply the survivor benefit to any overpayment which may exist on your claim.

You may receive your survivor benefit prior to your death if you are receiving monthly payments and your physician certifies in writing that you have been diagnosed as terminally ill and your life expectancy has been reduced to less than 12 months. This benefit is only payable once and if you elect to receive this benefit, no survivor benefit will be payable to your eligible survivor upon your death. (Note this “Accelerated Survivor Benefit” is not available in Connecticut.)

Dependent Care Expense Benefit

If you are disabled and participating in Unum’s Rehabilitation and Return to Work Assistance program, Unum will pay a Dependent Care Expense Benefit when you are disabled and you provide satisfactory proof that you:  are incurring expenses to provide care for a child under the age of 15;  and/or start incurring expenses to provide care for a child age 15 or older or a family member who needs personal care assistance.

The payment will be $350 per month per dependent, to a maximum of $1,000 per month for all dependent care expenses combined.

Worldwide Emergency Travel 2 Assistance Services

Whether your travel is for business or pleasure, our worldwide emergency travel assistance program is there to help you when an unexpected emergency occurs. With one phone call anytime of the day or night, you, your spouse and dependent children can get 3 immediate assistance anywhere in the world . Emergency travel assistance is available to you when you travel to any foreign country, including neighboring Canada or Mexico. It is also available anywhere in the United States for those traveling more Page 23

than 100 miles from home. Your spouse and dependent children do not have to be traveling with you to be eligible. However, spouses traveling on business for their employer are not covered by this program.

Other Important Provisions Pre-existing Condition Exclusion

Benefits will not be paid for disabilities caused by, contributed to by, or resulting from a pre-existing condition. You have a pre-existing condition if: 

Continuity of Coverage

If you are actively at work at the time you convert to Unum’s plan and become disabled due to a pre-existing condition, benefits may be payable if you were:  in active employment and insured under the plan on its effective date; and  insured by the prior plan at the time of change.

To receive a payment, you must satisfy the pre-existing condition under the Unum policy or the prior carrier’s policy. If you satisfy Unum’s pre-existing condition provision, payments will be determined by the Unum policy.

If you only satisfy the pre-existing condition provision for the prior carrier’s policy, the claim will be administered according to the Unum policy.

However,  



Definition of Disability

you received medical treatment, consultation, care or services including diagnostic measures, or took prescribed drugs or medicines in the 3 months just prior to your effective date of coverage; and the disability begins in the first 12 months after your effective date of coverage.

the payments will be the lesser of the benefit payable under the terms of the prior plan or the benefit under the Unum plan; the elimination period will be the shorter of the elimination period under the prior plan or the elimination period under the Unum plan; and benefits will end on the earlier of the end of the maximum period of payment under the Unum plan or the date benefits would have ended under the prior plan.

You are disabled when Unum determines that: 

you are limited from performing the material and substantial duties of your regular occupation due to your sickness or injury;



you have a 20% or more loss in indexed monthly earnings due to the same sickness or injury; and



during the elimination period you are unable to perform any of the material and substantial duties of your regular occupation.

After benefits have been paid for 24 months, you are disabled when Unum determines that due to the same sickness or injury, you are unable to perform the duties of any gainful occupation for which you are reasonably fitted by education, training or experience.

Page 24

You must be under the regular care of a physician in order to be considered disabled.

Gainful Occupation

Gainful occupation means an occupation that is or can be expected to provide you with an income within 12 months of your return to work, that exceeds 80% of your indexed monthly earnings if you are working or 60% of your indexed monthly earnings if you are not working.

Benefit Integration

Your disability benefit will be reduced by deductible sources of income and any earnings you have while disabled. Your gross disability payment will be reduced immediately by such items as disability income or other amounts you receive or are entitled to receive from workers compensation or similar occupational benefit laws, sabbatical or assault leave plans and the amount of earnings you receive from an extended sick leave plan as described in Louisiana Revised Statutes or any other act or law with similar intent.

After you have received monthly disability payments for 6 months, your gross disability payment will be reduced by such items as additional deductible sources of income you receive or are entitled to receive under: state compulsory benefit laws; automobile liability insurance; legal judgments and settlements; certain retirement plans; salary continuation or sick leave plans; other group or association disability programs or insurance; and amounts you or your family receive or are entitled to receive from Social Security or similar governmental programs.

Regardless of deductible sources of income, an employee who qualifies for disability benefits is guaranteed to receive a minimum benefit amount of the greater of $100 or 10% of the gross disability payment.

Mental Illness/Self-Reported Symptoms

The lifetime cumulative maximum benefit period for all disabilities due to mental illness and disabilities based primarily on self-reported symptoms is 24 months. Only 24 months of benefits will be paid for any combination of such disabilities even if the disabilities are not continuous and/or are not related. Payments would continue beyond 24 months only if you are confined to a hospital or institution as a result of the disability.

Instances When Benefits Would Not Be Paid

Benefits will not be paid for disabilities caused by, contributed to by, or resulting from:  intentionally self-inflicted injuries;  active participation in a riot;  commission of a crime for which you have been convicted;  loss of professional license, occupational license or certification;  pre-existing conditions (see definition).

Unum will not cover a disability due to war, declared or undeclared, or any act of war.

Unum will not pay a benefit for any period of disability during which you are incarcerated.

Termination of Coverage

Your coverage under the policy ends on the earliest of the following:  The date the policy or plan is cancelled;

Page 25

   

The date you no longer are in an eligible group; The date your eligible group is no longer covered; The last day of the period for which you made any required contributions; The later of the last day you are in active employment except as provided under the covered layoff or leave of absence provision; or if applicable, the last day of your contract with your Employer but not beyond the end of your Employer’s current school contract year.

Unum will provide coverage for a payable claim which occurs while you are covered under the policy or plan.

Next Steps How to Apply/ Effective Date of Coverage

Current employees: To apply for coverage, complete your enrollment form by the enrollment deadline. Your effective date of coverage is 02/01.

New Hires: To apply for coverage, complete your enrollment form within 60 days of your eligibility date. Please see your Plan Administrator for your effective date.

If you do not enroll during the initial enrollment period, you may apply only during an annual enrollment.

Delayed Effective Date of Coverage

If you are absent from work due to injury, sickness, temporary layoff or leave of absence, your coverage will not take effect until you return to active employment. Please contact your Plan Administrator after you return to active employment for when your coverage will begin.

Questions

If you should have any questions about your coverage or how to enroll, please contact your Plan Administrator.

This plan highlight is a summary provided to help you understand your insurance coverage from Unum.

Some provisions may vary or not be available in all states. Please refer to your certificate booklet for your complete plan description. If the terms of this plan highlight summary or your certificate differ from your policy, the policy will govern. For complete details of coverage, please refer to policy form number C.FP-1, et al.

1,2

Work-life balance employee assistance program and On-Claim Support services are provided by Ceridian Corporation. Worldwide emergency travel assistance services are provided by Assist America, Inc. Services are available with selected Unum insurance offerings. Exclusions, limitations and prior notice requirements may apply, and service features, terms and eligibility criteria are subject to change. The services are not valid after termination of coverage and may be withdrawn at any time. Please contact your Unum representative for full details.

3 All Worldwide emergency travel assistance must be arranged by Assist America, which pays for all services it provides. Medical expenses such as prescriptions or physician, lab or medical facility fees are paid by the employee or the employee’s health insurance.

Underwritten by: Unum Life Insurance Company of America 2211 Congress Street, Portland, Maine 04122, www.unum.com ©2007 Unum Group. All rights reserved. Unum is a registered trademark and marketing brand of Unum Group and its insuring subsidiaries.

Page 26

PECOS-BARSTOW-TOYAH INDEPENDENT SCHOOL DISTRICT Costs below are based on a Monthly payroll deduction (Employer billing mode is based on 12 Payments per year) Product: Educator Select Income Protection Plan

Plan A ADEA II Duration of Benefits

Injury (Days) Sickness (Days) Annual Earnings

Monthly Earnings

Maximum Monthly Benefit

3600 5400 7200 9000 10800 12600 14400 16200 18000 19800 21600 23400 25200 27000 28800 30600 32400 34200 36000 37800 39600 41400 43200 45000 46800 48600 50400 52200 54000 55800 57600 59400 61200 63000 64800 66600 68400 70200 72000 73800 75600 77400 79200 81000 82800 84600 86400 88200 90000 91800 93600

300 450 600 750 900 1050 1200 1350 1500 1650 1800 1950 2100 2250 2400 2550 2700 2850 3000 3150 3300 3450 3600 3750 3900 4050 4200 4350 4500 4650 4800 4950 5100 5250 5400 5550 5700 5850 6000 6150 6300 6450 6600 6750 6900 7050 7200 7350 7500 7650 7800

200 300 400 500 600 700 800 900 1000 1100 1200 1300 1400 1500 1600 1700 1800 1900 2000 2100 2200 2300 2400 2500 2600 2700 2800 2900 3000 3100 3200 3300 3400 3500 3600 3700 3800 3900 4000 4100 4200 4300 4400 4500 4600 4700 4800 4900 5000 5100 5200

14* 14*

30* 30*

Elimination Period (Days) 60 60

90 90

180 180

5.78 8.67 11.56 14.45 17.34 20.23 23.12 26.01 28.90 31.79 34.68 37.57 40.46 43.35 46.24 49.13 52.02 54.91 57.80 60.69 63.58 66.47 69.36 72.25 75.14 78.03 80.92 83.81 86.70 89.59 92.48 95.37 98.26 101.15 104.04 106.93 109.82 112.71 115.60 118.49 121.38 124.27 127.16 130.05 132.94 135.83 138.72 141.61 144.50 147.39 150.28

4.98 7.47 9.96 12.45 14.94 17.43 19.92 22.41 24.90 27.39 29.88 32.37 34.86 37.35 39.84 42.33 44.82 47.31 49.80 52.29 54.78 57.27 59.76 62.25 64.74 67.23 69.72 72.21 74.70 77.19 79.68 82.17 84.66 87.15 89.64 92.13 94.62 97.11 99.60 102.09 104.58 107.07 109.56 112.05 114.54 117.03 119.52 122.01 124.50 126.99 129.48

4.00 6.00 8.00 10.00 12.00 14.00 16.00 18.00 20.00 22.00 24.00 26.00 28.00 30.00 32.00 34.00 36.00 38.00 40.00 42.00 44.00 46.00 48.00 50.00 52.00 54.00 56.00 58.00 60.00 62.00 64.00 66.00 68.00 70.00 72.00 74.00 76.00 78.00 80.00 82.00 84.00 86.00 88.00 90.00 92.00 94.00 96.00 98.00 100.00 102.00 104.00

2.26 3.39 4.52 5.65 6.78 7.91 9.04 10.17 11.30 12.43 13.56 14.69 15.82 16.95 18.08 19.21 20.34 21.47 22.60 23.73 24.86 25.99 27.12 28.25 29.38 30.51 31.64 32.77 33.90 35.03 36.16 37.29 38.42 39.55 40.68 41.81 42.94 44.07 45.20 46.33 47.46 48.59 49.72 50.85 51.98 53.11 54.24 55.37 56.50 57.63 58.76

1.58 2.37 3.16 3.95 4.74 5.53 6.32 7.11 7.90 8.69 9.48 10.27 11.06 11.85 12.64 13.43 14.22 15.01 15.80 16.59 17.38 18.17 18.96 19.75 20.54 21.33 22.12 22.91 23.70 24.49 25.28 26.07 26.86 27.65 28.44 29.23 30.02 30.81 31.60 32.39 33.18 33.97 34.76 35.55 36.34 37.13 37.92 38.71 39.50 40.29 41.08 REF #: 2938462

* If, because of your disability, you are hospital confined as an inpatient, benefits begin on the first day of inpatient confinement.

Find your Annual/Monthly Earnings above to determine your Maximum Monthly Benefit. If your Annual/Monthly Earnings are not shown, use the next lower Annual/Monthly Earnings and corresponding Maximum Monthly Benefit. Or, you may refer to the Plan Highlights to calculate your Maximum Monthly Benefit based on your earnings.

Page 27

PECOS-BARSTOW-TOYAH INDEPENDENT SCHOOL DISTRICT Costs below are based on a Monthly payroll deduction (Employer billing mode is based on 12 Payments per year) Product: Educator Select Income Protection Plan

Plan A ADEA II Duration of Benefits

Injury (Days) Sickness (Days) Annual Earnings

Monthly Earnings

Maximum Monthly Benefit

95400 97200 99000 100800 102600 104400 106200 108000 109800 111600 113400 115200 117000 118800 120600 122400 124200 126000 127800 129600 131400 133200 135000 136800 138600 140400 142200 144000

7950 8100 8250 8400 8550 8700 8850 9000 9150 9300 9450 9600 9750 9900 10050 10200 10350 10500 10650 10800 10950 11100 11250 11400 11550 11700 11850 12000

5300 5400 5500 5600 5700 5800 5900 6000 6100 6200 6300 6400 6500 6600 6700 6800 6900 7000 7100 7200 7300 7400 7500 7600 7700 7800 7900 8000

14* 14*

30* 30*

Elimination Period (Days) 60 60

90 90

180 180

153.17 156.06 158.95 161.84 164.73 167.62 170.51 173.40 176.29 179.18 182.07 184.96 187.85 190.74 193.63 196.52 199.41 202.30 205.19 208.08 210.97 213.86 216.75 219.64 222.53 225.42 228.31 231.20

131.97 134.46 136.95 139.44 141.93 144.42 146.91 149.40 151.89 154.38 156.87 159.36 161.85 164.34 166.83 169.32 171.81 174.30 176.79 179.28 181.77 184.26 186.75 189.24 191.73 194.22 196.71 199.20

106.00 108.00 110.00 112.00 114.00 116.00 118.00 120.00 122.00 124.00 126.00 128.00 130.00 132.00 134.00 136.00 138.00 140.00 142.00 144.00 146.00 148.00 150.00 152.00 154.00 156.00 158.00 160.00

59.89 61.02 62.15 63.28 64.41 65.54 66.67 67.80 68.93 70.06 71.19 72.32 73.45 74.58 75.71 76.84 77.97 79.10 80.23 81.36 82.49 83.62 84.75 85.88 87.01 88.14 89.27 90.40

41.87 42.66 43.45 44.24 45.03 45.82 46.61 47.40 48.19 48.98 49.77 50.56 51.35 52.14 52.93 53.72 54.51 55.30 56.09 56.88 57.67 58.46 59.25 60.04 60.83 61.62 62.41 63.20 REF #: 2938462

* If, because of your disability, you are hospital confined as an inpatient, benefits begin on the first day of inpatient confinement.

Find your Annual/Monthly Earnings above to determine your Maximum Monthly Benefit. If your Annual/Monthly Earnings are not shown, use the next lower Annual/Monthly Earnings and corresponding Maximum Monthly Benefit. Or, you may refer to the Plan Highlights to calculate your Maximum Monthly Benefit based on your earnings.

Page 28

A New Dimension in Supplemental Cancer Insurance

Administrative Office: P.O. Box 1604 • Duncan, OK 73534-1604

Toll Free: 1-800-366-8354

National Marketing Office - Worksite: P.O. Box 10190 • Kansas City, MO 64171 Toll Free: 1-877-523-0176

A Promise In an era where many financial services companies are concerned with bottom- line results at the expense of customer service and loyalty, we come from the old school. We take great pride in providing the finest services to our employer groups, policyholders, business associates, agents - to everyone with whom we come in contact.

The following is not an exhaustive list of terms and conditions but only serves as a depiction of benefits and exclusions. Interested parties should consult the contract for a complete listing of terms and conditions.

FOR GROUP PRESENTATION PURPOSES ONLY LG-6040

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BASE POLICY BENEFITS BENEFIT PROVISIONS. We will pay the benefits described in the Certificate for the treatment of an Insured Person’s Cancer, provided he or she is covered under an issued Certificate which remains in force. Payment will be made in accordance with all applicable policy provisions. Benefits are payable for a positive diagnosis that begins after the Effective Date. The positive diagnosis must be for Cancer as defined in the policy.

1. POSITIVE DIAGNOSIS BENEFIT. We will pay the Actual Charge but not to exceed $300 per Calendar Year for one test that

confirms the Positive Diagnosis of Cancer in an Insured Person. This benefit is not payable for multiple diagnoses of the same Cancer or for Cancer that metastasizes or for recurrence of the same Cancer.

2. NATIONAL CANCER INSTITUTE DESIGNATED COMPREHENSIVE CANCER TREATMENT CENTER EVALUATION/CONSULTATION BENEFIT We will pay the Actual Charge, but not to exceed a lifetime maximum of $750, if an

Insured Person is diagnosed with Internal Cancer and seeks evaluation or consultation from a National Cancer Institute designated Comprehensive Cancer Treatment Center. If the Comprehensive Cancer Treatment Center is located more than 30 miles from the Insured Person’s place of residence, We will also pay the transportation and lodging expenses incurred but not to exceed a lifetime maximum of $350.

This benefit is not payable on the same day a Second or Third Surgical Opinion Benefit is payable and is in lieu of the Non-Local Transportation and Lodging Expense Benefits of the Policy. This benefit is payable one time during the lifetime of the Insured Person.

3. SECOND AND THIRD SURGICAL OPINION EXPENSE BENEFIT We will pay the Actual Charge for a written

second surgical opinion concerning the recommendation of Cancer surgery and if the second surgical opinion is in conflict with that of the Physician originally recommending the surgery and the Insured Person desires a third opinion, We will the Actual Charge for a written third surgical opinion. The Physician providing the second or third surgical opinion cannot be associated with the Physician who originally recommended the surgery. This benefit is not payable the same day the National Cancer Institute Evaluation/Consulting Benefit is payable.

4. MEDICAL IMAGING, TREATMENT PLANNING AND MONITORING EXPENSE BENEFIT We will pay the Actual Charge, but not to exceed $1,000 per Calendar Year, for laboratory tests, diagnostic X-rays, medical images, when used in Cancer treatment plannings related to Radiation Treatment, Chemotherapy or Immunotherapy.

5. ANTI-NAUSEA MEDICATION EXPENSE BENEFIT We will pay the Actual Charge for anti-nausea medication, but not to

exceed $150 per calendar month, when an Insured Person is prescribed such medication as the result of Radiation Treatment, Chemotherapy or Immunotherapy treatments for Cancer.

6. COLONY STIMULATING FACTOR OR IMMUNOGLOBULIN EXPENSE BENEFIT We will pay the Actual Charge

but not to exceed $1,000 per Calendar Month for Colony Stimulating Factor Drugs or Immunoglobulins prescribed by a Physician or Oncologist during an Insured Person’s Cancer treatment regimen for which benefits are payable under the Radiation, Chemotherapy and Immunotherapy Benefit of this Policy or rider attached to it.

7. OUTPATIENT HOSPITAL OR AMBULATORY SURGICAL CENTER EXPENSE BENEFIT We will pay the

Actual Charge from an Ambulatory Surgical Center or Outpatient department of a Hospital for the use of its facilities for the performance of a surgical procedure covered under this Policy but not to exceed $350 per day.

8. PROSTHESIS EXPENSE BENEFIT

(A.) Surgically Implanted Breast Prosthesis We will pay the Actual Charge for a surgically implanted prosthetic device required and prescribed to restore normal body contour lost as the direct result of an Insured Person’s breast removal for the treatment of Cancer. The Surgically Implanted Breast Prosthesis Benefit does not include coverage for breast reconstruction surgery which may be covered under the Surgical Schedule within the Surgical and Anesthesia Benefits Rider.

(B.) Non-Surgically Implanted Prosthesis We will pay the Actual Charge incurred not to exceed $2,000 per amputation for an artificial limb or other non-surgically implanted prosthetic device that is prescribed and required to restore normal body function lost as the direct result of an Insured Person’s amputation for the treatment of Cancer . We will pay a lifetime maximum of $2,000 per amputation. The cost of replacement of a prosthetic device is not covered. Hairpieces or wigs are not covered under this benefit.

9. NON-LOCAL TRANSPORTATION EXPENSE BENEFIT We will pay the Actual Charge, but not to exceed the coach

fare on a Common Carrier for the Insured Person and one adult companion’s travel to a Hospital, Radiation Therapy Treatment Center, Chemotherapy Treatment Center, Oncology Clinic or any other specialized treatment center where the Insured Person receives treatment for Cancer. This benefit is payable only if the treatment is not available Locally but is available Non-Locally. The adult companion may include the live donor of bone marrow or stem cells used in a bone marrow or stem cell transplant for the Insured Person. At the option of the Insured Person, We will pay a single private vehicle mileage allowance of $.50 per mile for Non-Local transportation in lieu of the common carrier coach fare.

Page 30

10. LODGING EXPENSE BENEFIT We will pay the Actual Charge not to exceed $75 per day for a room in a motel, hotel or other

appropriate lodging facility (other than a private residence), when an Insured Person receives treatment for Cancer at a Non-Local Hospital, Radiation Therapy Treatment Center, Chemotherapy Treatment Center, Oncology Clinic or any other specialized treatment center. The room must be occupied by the Insured Person or an adult companion which may include the live donor of bone marrow or stem cells used in a bone marrow or stem cell transplant for the Insured Person. This benefit is not payable for lodging expense incurred more than 24 hours before the treatment nor for lodging expense incurred more than 24 hours following treatment. This benefit is limited to 100 days per Calendar Year.

11. INPATIENT BLOOD, PLASMA AND PLATELETS EXPENSE BENEFIT We will pay the Actual Charge not to

exceed $300 per day for the procurement cost, administration, processing and cross matching of blood, plasma or platelets administered to an Insured Person in the treatment of Cancer while an Inpatient.

12. OUTPATIENT BLOOD, PLASMA AND PLATELETS EXPENSE BENEFIT We will pay the Actual Charge not to exceed $300 per day for the procurement cost, administration, processing and cross matching of blood, plasma or platelets administered to an Insured Person in the treatment of Cancer while an Outpatient.

13. BONE MARROW DONOR EXPENSE BENEFIT We will pay the Daily Hospital Confinement Benefit shown on the

Certificate Schedule for each day a live donor, other than the Insured Person, is confined in a Hospital for the harvesting of bone marrow or stem cells used in a bone marrow or stem cell transplant for the treatment of an Insured Person’s Cancer.

14. BONE MARROW OR STEM CELL TRANSPLANT EXPENSE BENEFIT We will pay the Actual Charge not to

exceed a lifetime maximum of $15,000 for surgical and anesthesia procedures (including the harvesting and subsequent re-infusion of blood cells or peripheral stem cells) performed for a bone marrow transplant and/or a peripheral stem cell transplant for the treatment of an Insured Person’s Cancer. This benefit will be paid in lieu of the Surgical Expense Benefit and the Anesthesia Expense Benefit which may be described in a rider attached to an issued Certificate.

15. AMBULANCE EXPENSE BENEFIT We will pay the Actual Charge for ambulance service if an Insured Persons is transported to a Hospital where he or she is admitted as an inpatient for the treatment of Cancer . The ambulance service must be provided by a licensed professional ambulance company or an ambulance owned by the Hospital.

16. INPATIENT OXYGEN EXPENSE BENEFIT We will pay the Actual Charge not to exceed $300 per Hospital confinement for oxygen prescribed by a Physician and received by an Insured Person while confined in a Hospital for the treatment of Cancer.

17. ATTENDING PHYSICIAN EXPENSE BENEFIT We will pay the Actual Charge not to exceed $40 per day for the

professional services of a Physician or Oncologist rendered to an Insured Person while he or she is confined in a Hospital for the treatment of Cancer. This benefit is payable only if the Physician or Oncologist personally visits the Hospital room occupied by the Insured Person and the amount stated is the maximum amount that will be payable for each day of Hospital confinement regardless of the number of visits made by one or more Physicians or Oncologists.

18. INPATIENT PRIVATE DUTY NURSING EXPENSE BENEFIT We will pay the Actual Charge not to exceed $150 per day for the full time service of a Nurse that is required and ordered by a Physician when an Insured Person is confined in a Hospital for the treatment of Cancer. The Nurse must provide services other than those normally provided by the Hospital and the Nurse may not be an employee of the Hospital or an Immediate Family Member of the Insured Person.

19. OUTPATIENT PRIVATE DUTY NURSING EXPENSE BENEFIT We will pay the Actual Charge not to exceed $150

per day limited to the same number of days of the prior Hospital confinement for the full time service of a Nurse that is required and ordered by a Physician when an Insured Person is confined indoors at home as the result of Cancer . This benefit is not payable if the services of the Nurse are custodial in nature or to assist the Insured Person in the activities of daily living. This benefit is not payable when the Nurse is a member of the Insured Person’s Immediate Family. Charges must begin following a period of Hospital confinement for which benefits are payable under this Certificate.

20. CONVALESCENT CARE FACILITY EXPENSE BENEFIT We will pay the Actual Charge not to exceed $100 per day

for an Insured Person’s confinement in a Convalescent Care Facility. The maximum number of days for which this benefit is payable will be the number of days in the last Period of Hospital Confinement that immediately preceded admission to a Convalescent Care Facility. The Convalescent Care Facility Confinement must: be due to Cancer ; begin within 14 days after the Insured Person has been discharged from a Hospital for the treatment of Cancer ; be authorized by a Physician as being medically necessary for the treatment of Cancer.

21. RENTAL OR PURCHASE OF MEDICAL EQUIPMENT EXPENSE BENEFIT We will pay the lesser of the Actual

Charge not to exceed $1,500 per Calendar Year for either the rental or purchase of covered medical equipment designed for home use, required and ordered by the Insured Person’s attending Physician as the direct result of the treatment of Cancer. Covered medical equipment includes wheel chair, oxygen equipment, respirator, braces, crutches or hospital bed.

Page 31

22. HOME HEALTH CARE EXPENSE BENEFIT We will pay benefits for the following Covered Charges when a Insured

Person requires Home Health Care for the treatment of Cancer.

1. Home Health Care Visits - We will pay the Actual Charge for Home Health Care Visits not to exceed $75 for each day on which one or more such visits occur. We will not pay this benefit for more than 60 days in any Calendar Year.

2. Medicine and Supplies - We will pay the Actual Charge not to exceed $450 in any Calendar Year for drugs, medicine, and medical supplies provided by or on behalf of a Home Health Care Agency.

3. Services of a Nutritionist - We will pay the Actual Charge not to exceed a lifetime maximum of $300 for the services of a nutritionist to set up programs for special dietary needs.

23. HOSPICE CARE EXPENSE BENEFIT We will pay the Actual Charge for Hospice Care not to exceed $100 per day, when such

care is required because of Cancer . This benefit is payable whether confinement is required in a Hospice Center or services are provided in the Insured Person’s home by a Hospice Team. Eligibility for payments will be based on the following conditions being met:(1) the Insured Person has been given a prognosis as being Terminally Ill with an estimated life expectancy of 6 months or less; and (2) We have received a written summary of such prognosis from the attending Physician. We will not pay this benefit while the Insured Person is confined to a Hospital or Convalescent Care Facility. The lifetime maximum benefit is 365 days of Hospice Care

24. HAIRPIECE EXPENSE BENEFIT We will pay the Actual Charge not to exceed a lifetime maximum of $150 for the purchase of a wig or hairpiece that is required as the direct result of hair loss due to Cancer treatment.

25. PHYSICAL, SPEECH, AUDIO THERAPY AND PSYCHOTHERAPY EXPENSE BENEFIT

We will pay the Actual Charge not to exceed $25 per therapy session for: 1. Physical therapy treatments given by a license Physical Therapist, or 2. Speech therapy given by a licensed Speech Pathologist/Therapist; or 3. Audio therapy given by a licensed Audiologist; or 4. Psychotherapy given by a licensed Psychologist. These sessions may be given at an institute of physical medicine and rehabilitation, a Hospital, or the Insured Person’s home. These treatments must be given on an Outpatient basis unless the primary purpose of a Hospital confinement is for treatment of Cancer other than with physical, speech or audio therapy or psychotherapy. Benefits may not exceed $1,000 per Calendar Year.

26. WAIVER OF PREMIUM. We will waive the premiums starting on the first premium due date following a 60 day period of Total

Disability of the Named Insured due to Cancer. The Named Insured must: (a) be receiving treatment for such Cancer for which benefits are payable under this Certificate; and (b) remain disabled for 60 consecutive days. We will waive premiums for as long as the Named Insured remains Totally Disabled.

THIS IS A CANCER ONLY POLICY, which should be used to supplement your existing health care protection.

RENEWABILITY. Coverage will terminate when the Group Master Policy terminates or when required premium remains unpaid after expiration of the Grace Period.

PREMIUM RATES. We may change the premium rates for coverage only if we also change the rates for all other Certificates issued under the Group Master Policy.

EXCLUSIONS AND LIMITATIONS. No benefits will be paid under the Certificate or any attached riders for: 1. any loss due to any disease or illness other than Cancer, or a listed covered Specified Disease; 2. care and treatment received outside the territorial limits of the United States; 3. treatment by any program engaged in research that does not meet the criteria for Experimental Treatment as defined; 4. treatment that has not been approved by a Physician as being medically necessary; or 5. losses or medical expenses incurred prior to the Certificate Effective Date of an Insured Person’s coverage regardless of the Date of Positive Diagnosis.

PRE-EXISTING CONDITIONS LIMITATION. Relative to any Insured Person, We will not pay benefits for expenses resulting from Pre-existing Conditions during the 12 months after coverage becomes effective for such Insured Person.

“Pre-existing Condition” means Cancer, or a listed Specified Disease if that optional rider is issued, which was diagnosed by a Physician or for which medical consultation, advice or treatment was recommended by or received from or sought from a Physician within 1 year prior to the effective date of coverage for each Insured Person.

Insurance coverage is provided by form number series LG-6040 and associated riders. This advertisement highlights some features of the Certificate and riders, but is not the insurance contract. An issued Master Group Policy, Certificate and riders set forth, in detail, the rights and obligations of both the insured and the insurance company. Please read the policy, certificate and riders for detailed coverage information.

Page 32

PLAN A Maximum

PLAN B Maximum

PLAN C Maximum

$50 Per Calendar Year

$50 Per Calendar Year

$50 Per Calendar Year

$100 Per Calendar Year

$100 Per Calendar Year

$100 Per Calendar Year

$2,500 Once per Lifetime $3,750 Once per Lifetime

$5,000 Once per Lifetime $7,500 Once per Lifetime

$5,000 Once per Lifetime $7,500 Once per Lifetime

$10,000 Per Calendar Year

$15,000 Per Calendar Year

$20,000 Per Calendar Year

Surgical Expense We will pay the Surgical Expense benefit for a surgical procedure for the treatment of an Insured Person’s Cancer (except Skin Cancer) according to the Surgical Schedule shown in this rider.

However, in no event will the amount payable exceed the maximum Surgical Expense benefit shown on the Certificate Schedule, nor will it exceed the expense incurred.

Anesthesia Expense We will pay the anesthesia expense incurred, not to exceed 25% of the covered Surgical Expense benefit for the operation performed. This includes the services of an anesthesiologist or of an anesthetist under supervision of a physician for the purpose of administering anesthesia.

Breast Reconstruction with transverse rectus adominis myocutaneous flap (TRAM), single pedicle, including closure of donor site, with microvascular anastomosis (supercharging) is one of the surgical procedures listed in the Surgical Schedule. If this procedure is performed on an Insured Person as the result of a mastectomy for which We paid a Surgical Expense benefit for the treatment of Breast Cancer, We will pay the expense incurred not to exceed $900 per $1,000 of the Surgical Benefit issued.

Skin Cancer Surgery Expense We will pay the expense incurred, not to exceed the procedure amount listed in this rider ($125 to $750 depending on the procedure) when a surgical operation is performed on an Insured Person for treatment of a diagnosed Skin Cancer. This benefit is payable in lieu of any benefits for Surgical Expense and Anesthesia Expense which are not applicable to Skin Cancer.

$3,000 Procedure Maximum

$4,000 Procedure Maximum

$4,000 Procedure Maximum

$750 Procedure Maximum $2,700 Procedure Maximum

$1,000 Procedure Maximum $3,600 Procedure Maximum

$1,000 Procedure Maximum $3,600 Procedure Maximum

Per Procedure

Per Procedure

Per Procedure

Confinements of 30 Days or Less We will pay the Daily Hospital Confinement benefit amount shown on the Certificate Schedule for each of the first 30 days in each period of hospital confinement during which an Insured Person is confined to a hospital, including a government or charity hospital, for the treatment of Cancer.

Confinements of 31 Days or More If an Insured Person is continuously confined to a hospital, including a government or charity hospital, for longer than 30 consecutive days for the treatment of Cancer, We will pay two times the Daily Hospital Confinement benefit amount shown on the Certificate Schedule. This benefit payment will begin on the 31st continuous day of such confinement and continue for each day of confinement until the Insured Person is discharged from the Hospital.

Benefits for an Insured Dependent Child under Age 21 The amount payable under this benefit will be double the Daily Hospital Confinement benefit shown on the Certificate Schedule if the Insured Person so confined is a dependent child under the age of 21.

$200 Per Day

$300 Per Day

$300 Per Day

$400 Per Day

$600 Per Day

$600 Per Day

$400/ $800 Per Day

$600/ $1,200 Per Day

$600/ $1,200 Per Day

ADDITIONAL BENEFIT AMOUNTS ANNUAL CANCER SCREENING BENEFIT RIDER (form LG-6041)

A. Basic Benefit We will pay the expense incurred, but not to exceed the maximum benefit amount shown on the Certificate Schedule, once per calendar year per Insured Person for screening tests performed to determine whether Cancer exists in an Insured Person. Covered annual Cancer screening tests include but are not limited to: mammogram, pap smear, breast ultrasound, ThinPrep, biopsy, chest x-ray, thermography, colonoscopy, flexible sigmoidoscopy, hemocult stool specimen, PSA (blood test for prostate cancer), CEA (blood tests for colon cancer), CA125 (blood test for ovarian cancer), CA15-3 (blood test for breast cancer), serum protein electrophesis (blood test for myeloma).

B. Additional Benefit We will pay the expense incurred, but not to exceed two times the maximum benefit amount per calendar year as shown on the Certificate Schedule, for one additional invasive diagnostic procedure required as the result of an abnormal cancer screening test for which benefits are payable under the Basic Benefit above for an Insured Person. This additional benefit is payable regardless of the results of the additional diagnostic procedure. However, the amount payable will be reduced dollar for dollar for any amount payable under the Positive Diagnosis Benefit contained in the base Certificate.

FIRST OCCURRENCE BENEFIT RIDER (form LG-6043)

If an Insured Person receives a positive diagnosis of Internal Cancer, We will pay the First Occurrence benefit amount shown on the Certificate Schedule.

If the Insured Person receiving the positive diagnosis of Internal Cancer is a child under the age of 21, we will pay one and one-half times the First Occurrence benefit amount shown on the Certificate Schedule.

ANNUAL RADIATION, CHEMOTHERAPY, IMMUNOTHERAPY and EXPERIMENTAL TREATMENT BENEFIT RIDER (form LG-6045)

We will pay the expense incurred, but not to exceed the maximum benefit amount shown on the Certificate Schedule, per calendar year per Insured Person for Radiation Treatment, Chemotherapy, Hormonal Therapy, Immunotherapy or Experimental Treatment. The Radiation Treatment, Chemotherapy, Hormonal Therapy, Immunotherapy or Experimental Treatment must be for the treatment of an Insured Person’s Cancer. The benefit amount shown on the Certificate Schedule is the maximum calendar year benefit available per Insured Person regardless of the number or types of Cancer treatments received in the same year.

SURGICAL BENEFIT RIDER (form LG-6048)

DAILY HOSPITAL CONFINEMENT BENEFIT RIDER (form LG-6042)

This page is an Insert to be used ONLY with Brochure Form LG-6040. If you do not have this Brochure, ask that your agent provide one for you. All exclusions, limitations, definitions and terms of renewability of the Group Limited Benefit Cancer Certificate (form LG-6040) apply to these riders. THESE ARE LIMITED RIDERS

PECOS-BARSTOW-TOYAH ISD FOR GROUP PRESENTATION PURPOSES ONLY

Page 33

ADDITIONAL BENEFITS AMOUTNS SPECIFIED DISEASE BENEFIT RIDER (form LG-6052) If an Insured Person is first diagnosed with one or more covered Specified Diseases and is hospitalized for the definitive treatment of any covered Specified Disease, We will pay benefits according to the provisions of this rider.

COVERS THESE 38 SPECIFIED DISEASES Addison’s Disease Amyotrophic Lateral Sclerosis Botulism Bovine Spongiform Encephalopathy Budd-Chiari Syndrome Cystic Fibrosis Diptheria Encephalitis Epilepsy Hansen’s Disease Histoplasmosis Legionnaire’s Disease Lyme Disease

Lupus Erythematosus Malaria Meningitis Multiple Sclerosis Muscular Dystrophy Myasthenia Gravis Neimann-Pick Disease Osteomyelitis Poliomyelitis Q Fever Rabies Reye’s Syndrome Rheumatic Fever

Rocky Mountain Spotted Fever Sickle Cell Anemia Tay-Sachs Disease Tetanus Toxic Epidermal Necrolysis Tuberculosis Tularemia Typhoid Fever Undulant Fever West Nile Virus Whipple’s Disease Whooping Cough

BENEFITS If an Insured Person is first diagnosed with one or more covered Specified Diseases and is hospitalized for the definitive treatment of any covered Specified Disease, We will pay benefits according to the provisions of this rider. An applicant may select 1, 2 or 3 units of coverage.

Initial Hospitalization Benefit We will pay a benefit of $1,500 per unit of coverage selected when an Insured Person is confined to a hospital (for 12 or more hours, not applicable in SD) as a result of receiving treatment for a Specified Disease. This benefit is payable only once per period of confinement and once per calendar year for each Insured Person.

Hospital Confinement Benefit We will pay a benefit of $300 per day per unit of coverage selected when an Insured Person is hospitalized during any continuous period of 30 days or less for the treatment of a covered Specified Disease. Benefits will double per day beginning with the 31st day of continuous confinement.

If the hospital confinement follows a previously covered confinement, it will be deemed a continuation of the first confinement unless it is the result of an entirely different Specified Disease, or unless the confinements are separated by 30 days or more.

This page is an Insert to be used ONLY with Brochure Form LG-6040. If you do not have this Brochure, ask that your agent provide one for you. All exclusions, limitations, definitions and terms of renewability of the Group Limited Benefit Cancer Certificate (form LG-6040) apply to these riders. THESE ARE LIMITED RIDERS

PECOS-BARSTOW-TOYAH ISD FOR GROUP PRESENTATION PURPOSES ONLY

EMPLOYEE

SINGLE PARENT

EMPLOYEE AND SPOUSE

BASE PLAN A

$22.40

$27.34

$37.66

$37.66

BASE PLAN B

$30.93

$37.11

$51.40

$51.40

BASE PLAN C

$34.76

$41.57

$57.71

$57.71

MONTHLY RATES

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FAMILY

OPTIONAL BENEFITS YOU MAY SELECT FOR ADDITIONAL PREMIUM $600 Per Day

HOSPITAL INTENSIVE CARE UNIT BENEFIT RIDER (form LG-6047) Intensive Care Unit Benefit We will pay the daily Hospital Intensive Care Unit Benefit shown on the Certificate Schedule for an Insured Person’s confinement in an ICU for sickness or injury.

Double Intensive Care Unit Benefit We will pay double the daily Hospital Intensive Care Unit benefit amount shown on the Certificate Schedule for an Insured Person’s confinement in an ICU as a result of Cancer. We will also double this ICU benefit for only the initial ICU confinement resulting from an Insured Person’s travel related injury, provided that the ICU confinement begins within 24 hours of the accident causing the travel related injury. A travel related injury includes being struck by an automobile, bus, truck, van, motorcycle, train or airplane; or being involved in an accident where the Insured Person was the operator or passenger in or on such vehicle.

$1,200 Per Day

$300 Per Day

Step Down Unit Benefit We will pay one-half of the daily Hospital Intensive Care Unit benefit amount shown on the Certificate Schedule for an Insured Person’s confinement in a Step Down Unit for a sickness or injury.

Additional Limitations and Exclusions for the Hospital Intensive Care Unit Benefit Rider If the rider is issued and coverage is in force, it will provide benefits if an Insured Person goes into a hospital Intensive Care Unit (including a Cardiac Intensive Care Unit or Neonatal Intensive Care Unit). Benefits start the first day of confinement in an ICU for sickness or injury. Any combination of benefits payable under this rider is limited to a maximum of 45 days per each period of confinement.

ALL BENEFITS CONTAINED IN THIS HOSPITAL INTENSIVE CARE UNIT BENEFIT RIDER REDUCE BY ONE-HALF AT AGE 75.

Benefits are not payable for any ICU or Step Down Unit confinement that results from intentional self-inflicted injury; or the Insured Person’s being intoxicated or under the influence of alcohol, drugs or any narcotics, unless administered on and according to the advice of a medical practitioner.

THIS IS A LIMITED RIDER.

This page is an Insert to be used ONLY with Brochure Form LG-6040. If you do not have this Brochure, ask that your agent provide one for you. All exclusions, limitations, definitions and terms of renewability of the Group Limited Benefit Cancer Certificate (form LG-6040) apply to these riders. THESE ARE LIMITED RIDERS

PECOS-BARSTOW-TOYAH ISD

MONTHLY RATES Base Plan A with ICU Base Plan B with ICU Base Plan C with ICU

FOR GROUP PRESENTATION PURPOSES ONLY

EMPLOYEE $25.19 $33.72 $37.55

SINGLE PARENT $31.17 $40.94 $45.41

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EMPLOYEE AND SPOUSE $42.94 $56.68 $62.99

FAMILY $42.94 $56.68 $62.99

B E W E L L . B E S M A R T. B E P R O T E C T E D .

Allstate at Work

SM

heart/stroke insurance HeartCare Plus and HeartCare Direct No one likes to think about getting heart disease. But 61,800,000 Americans have one or more types of cardiovascular disease according to current estimates.1 While you may not be able to prevent the disease, you can help protect yourself from its costs.

The American Heart Association estimates the total direct and indirect costs of Cardiovascular Diseases and Stroke in 2002 in the United States to be $329.2 billion.1 You can protect yourself and your family from these costs. HeartCare Plus and HeartCare Direct insurance covers a portion of the costs for ambulance, surgery and physicians.

HeartCare Plus and HeartCare Direct insurance helps you: ■

Manage the high expenses of treatment

■

Preserve your savings

■

Protect your family from financial hardship

■

Concentrate on getting well

1American

Heart Association - 2002 Heart Stroke Statistical Update.

THIS IS NOT A POLICY OF WORKERS’COMPENSATION INSURANCE. THE EMPLOYER DOES NOT BECOME A SUBSCRIBER TO THE WORKERS’ COMPENSATION SYSTEM BY PURCHASING THIS POLICY, AND IF THE EMPLOYER IS A NON-SUBSCRIBER, THE EMPLOYER LOSES THOSE BENEFITS WHICH WOULD OTHERWISE ACCRUE UNDER THE WORKERS’ COMPENSATION LAWS. THE EMPLOYER MUST COMPLY WITH THE WORKERS’ COMPENSATION LAW AS IT PERTAINS TO NON-SUBSCRIBERS AND THE REQUIRED NOTIFICATIONS THAT MUST BE FILED AND POSTED.

D-7803

Page 36

B E W E L L . B E S M A R T. B E P R O T E C T E D.

why it makes sense It’s probably crossed your mind that you or your family may need treatment for heart disease or stroke. And you may have thought about the ways it would affect your life and your loved ones. But have you considered how cardiovascular diseases could impact your financial security.

how it works EXPLANATION OF BENEFITS

1/2 UNIT

1 UNIT

Hospital Confinement

$100 each day

$200 each day

$12.50 each day

$25 each day

$12.50 each day

$25 each day

$50 each day

$100 each day

$25 each day

$50 each day

$100

$200

$50

$100

$75

$150

$375

$750

$500

$1,000

$1,250

$2,500

$1,250

$2,500

$50,000

$100,000

Amount shown per day for each day a covered person is admitted and confined as an inpatient in a hospital due to a Heart Attack, Heart Disease or Stroke.

Physician’s Attendance

Amount shown per day for the services of a physician during a covered hospital confinement. Payable only for the number of days the hospital confinement benefit is payable.

Inpatient Drugs and Medicine

Medical insurance often stops short of considering these costs “essential” but some of these costs may be covered with Allstate Workplace Division’s HeartCare Plus and HeartCare Direct Insurance.

HeartCare Plus and HeartCare Direct Insurance Might Be Right For You If: ■

Amount shown per day for drugs or medicine required during a covered hospital confinement. Payable only for the number of days the hospital confinement benefit is payable.

Private Duty Nursing

Amount shown per day for private nursing care and attendance by a nurse during a covered hospital confinement, subject to a maximum of 60 days per continuous hospital confinement. Must be required and authorized by attending physician.

There are cardiovascular diseases in your family’s history

Physiotherapy

■

You don’t have much money set aside for an unexpected cardiovascular illness

Amount shown per day for physiotherapy performed by a licensed physical therapist during a covered hospital confinement, subject to a maximum of 60 days per continuous hospital confinement.

■

You want to help keep your family financially secure

■

You want coverage you can take with you if you leave your job

Oxygen

Amount shown for the use of oxygen equipment during a covered hospital confinement, subject to a maximum of 1 payment per continuous hospital confinement.

What You Get HeartCare Plus Policy and HeartCare Direct ■ Pays you benefits that can be used for non-medical expenses that health insurance might not cover

Cardiograms

Amount shown for an electrocardiogram, echocardiogram, phonocardiogram or vectorcardiogram required during a covered hospital confinement, subject to a maximum of 1 payment per continuous hospital confinement.

■

Benefits are paid as you go and cover the costs of specific treatments and expenses (up to the maximum allowed) as they happen

■

Supplemental coverage, it works in addition to other insurance you may have, such as medical and disability income

Amount shown for a cerebral or carotid angiogram required during a covered hospital confinement, subject to a maximum of 1 payment per continuous hospital confinement.

■

Guaranteed renewable for life, subject to change in premiums by class

Coronary Angioplasty

■

Coverage for yourself or your entire family

HeartCare Plus Policy Only ■ Pays in addition to your Workers’ Compensation ■

Premiums can be made using pre-tax dollars under Section 125

Cerebral or Carotid Angiogram

Amount shown for a coronary angioplasty procedure, regardless of the number of blood vessels repaired during the procedure.

Pacemaker Insertion

Amount shown for the initial insertion of a permanent pacemaker.

Thromboendarterectomy

Amount shown for a thromboendarterectomy operation.

■

Plan is portable. It’s a benefit that you can keep if you change jobs or retire by paying premiums directly to Allstate Workplace Division.

Optional Riders for HeartCare Plus and HeartCare Direct ■ Optional riders which can be added to your base policy are: an optional intensive care benefit which pays benefits for an intensive care confinement due to any covered accident or disease, and a cancer initial diagnosis benefit, which pays a one-time benefit when a covered person is positively diagnosed with cancer (other than skin cancer).

Exclusions and Limitations apply.

Coronary Artery Bypass Graft Operation

Amount shown for a coronary artery bypass graft operation, regardless of the number of grafts performed during the operation.

Heart Transplant

Amount shown for the implantation of a natural human heart.

This benefit is only payable once per covered person.

Page 37

EXPLANATION OF BENEFITS

1/2 UNIT

1 UNIT

Second Surgical Opinion

$50

$100

Amount shown for transfer by ambulance to a hospital or emergency room for the treatment of a covered condition.

Non-Air Ambulance Air Ambulance

$100 $200

$200 $400

Cardiac Catheterization

$250

$500

$100

$200

Amount shown for a second opinion obtained after a positive diagnosis that results in the physician recommending surgery for a covered illness.

Ambulance

Amount shown for a cardiac catheterization procedure.

Blood, Plasma and Platelets

Amount shown for the administration of blood, plasma or platelets during a covered hospital confinement, subject to a maximum of 1 payment per continuous hospital confinement.

Non-Local Transportation

$100

$200

$2,500 maximum

$5,000 maximum

Amount shown for a covered hospital confinement which is obtained more than 100 miles from the covered person’s home because the prescribed treatment cannot be obtained locally. This is subject to a maximum of 1 payment per continuous hospital confinement Surgery and Anesthesia 1. Surgery. Amount shown in the surgical schedule for a surgery

performed in a hospital or ambulatory surgical center. For a surgical procedure not listed in the surgical schedule, we pay $17 per unit of coverage ($8.50 per half unit) multiplied by the 1964 California Relative Value Schedule (C.R.V.S.) unit value for the procedure, subject to maximum of amount shown. If no 1964 C.R.V.S. unit value exists for the procedure, then the payment amount will be based upon relative difficulty and payment amounts for other procedures, up to maximum amount shown.

Two or more surgical or invasive procedures done at the same time and through a common incision or entry point are considered one operation and benefit is paid for the one with the largest total benefit.

2. Anesthesia. Additional percentage shown of the amount paid for

25%

25%

$125

$250

$25 each day

$50 each day

$100

$200

Transportation benefit is paid and a family member stays in a motel, hotel, or any other accommodation acceptable to us, in order to be near the covered person, subject to a maximum of 60 days per continuous hospital confinement.

2.Transportation. Amount shown when the Non-Local Transportation benefit is paid and a family member travels more than 100 miles from their home to be near the covered person for a portion of their continuous hospital confinement. This is subject to a maximum of 1 payment per continuous hospital confinement.

Termination of Insurance

If the insured’s spouse is a covered person, the spouse’s coverage ends upon valid decree of divorce. If your child is a covered person, the child’s coverage ends on the policy anniversary next following the date the child is no longer eligible, which is either when the child marries or reaches age 21 (25 if a full time student at an educational institution of higher learning beyond high school). Coverage does not terminate on an unmarried child who: 1. is incapable of selfsustaining employment by reason of mental retardation or physical handicap; 2. is chiefly dependent upon you for support and maintenance. Dependent coverage continues as long as this policy remains in force and the dependent child remains in such condition.

The policy provides benefits only for Heart Attack, Heart Disease or Stroke.This policy does not cover any other disease or sickness or incapacity other than Heart Attack, Heart Disease or Stroke even though such disease, sickness or incapacity may be caused, complicated or otherwise affected by Heart Attack, Heart Disease or Stroke. If a covered confinement is due to more than one covered condition, benefits will be payable as though the confinement were due to one condition. If a confinement due to a covered disease is also due to a condition that is not covered, benefits will be payable only for the part of confinement attributable to the covered condition.

Pre-Existing Condition Limitation

benefit described in “1” above is paid for a surgery performed at an ambulatory surgical center.These benefits do not pay for surgeries covered by other benefits in the policy.

Family Member Lodging and Transportation 1. Lodging. Amount shown per day when the Non-Local

The policy will remain in effect when renewal premiums are paid as they are due or during the grace period. Renewal premiums will be at the premium rates in effect on the renewal date.We can change the premium rates on premiums becoming due after the first premium. However, we can only change the rate on this policy by making the rate change for all such policies in a class. Once the policy has been issued, we cannot place any restrictive riders on it or cancel or refuse to renew your policy if you maintain it continuously in force. If we do change rates on all like policies in your class, we will mail you a notice of this change.

Notice will be mailed at least 31 days prior to such change.

It will be mailed to your address as shown on our records.

No change in premiums is effective unless this notice is mailed.

Exclusions and Limitations

surgery benefit described in “1” above for anesthesia received during the surgery.

3. Ambulatory Surgical Center. Amount shown when surgery

Renewability

Page 38

A pre-existing condition is the existence of: symptoms which would cause an ordinarily prudent person to seek diagnosis, care or treatment within a 1 year period preceding the effective date of coverage of the insured person or a condition for which medical advice or treatment was recommended by or received from a physician within a 1 year period preceding the effective date of the coverage of the insured person. ■ If a covered person has a pre-existing condition as defined, we do not pay benefits for such conditions under this policy or any riders attached to this policy during the 12 month period beginning on the date that person became a covered person. If the loss is not due to a pre-existing condition, then the pre-existing condition limitation does not apply. All losses are subject to the Incontestability provision. Exclusions and limitations to the policy also apply to the riders. This brochure highlights some features of the policy, but is not the insurance contract. Only the actual policy provisions control. The policy itself sets forth, in detail, the rights and obligations of both the insured and the insurance company.

D-7876

BE WELL.

B E S M A R T.

B E P R O T E C T E D.

heartcare plus premiums for texas

When you buy heartcare plus insurance, you decide which coverage you want. You can choose the one that’s right for your budget and your coverage needs. The units of coverage you select will determine your benefit amounts and your corresponding premium.

FAMILY (if covered) Weekly

$4.15

1 unit

INDIVIDUAL Weekly

$8.00

1 unit

FAMILY (if covered) Weekly

$8.98

1/2 unit

INDIVIDUAL Monthly

$17.32

1/2 unit

FAMILY (if covered) Monthly

$17.96

1 unit

INDIVIDUAL Monthly

1 unit

FAMILY (if covered) Monthly

Plan A - HeartCare Plus Policy (HSP2) INDIVIDUAL Weekly

$4.00

1/2 unit

■ Monthly

Premium: _____________________________ ■ Weekly

Issue Ages 18-64.

$34.64

$2.08

■ Family

Total Premium

1/2 unit

Name: __________________________________________________

■ Individual ■ 1 unit

The HeartCare Plus Policy You Have Selected

■ 1/2 unit

This premium insert is incomplete without brochure D-7803, which describes the benefits, exclusions and limitations of the heartcare plus insurance policy.This is not an application for coverage. Please see your agent for details. Benefits are subject to all of the terms, conditions and provisions of the policy. All terms defined and used in the policy apply unless otherwise provided.This insert highlights some features of the policy, but is not the insurance contract. Only the actual policy provisions control. The policy itself sets forth, in detail, the rights and obligations of both the insured and the insurance company.

HeartCare Plus Insurance Policy provided by form HSP2, or state variations thereof. Underwritten by American Heritage Life Insurance Company. Allstate Workplace Division is the marketing name used by American Heritage Life Insurance Company (Home Office, Jacksonville, FL), a wholly owned subsidiary of The Allstate Corporation. ©2002 American Heritage Life Insurance Company allstate.com

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Page 40

SVL1_Value|Supplemental Life Insurance This this text box here. A post process uses the text above to do a "Find/Replace" of variable text and the header.

Template: Life_BHS

Supplemental Life Insurance

Benefit Highlights

Pecos-Barstow-Toyah Independent School District What is Supplemental Life Insurance?

Supplemental Life Insurance is coverage that you pay for.

Supplemental Life Insurance pays your beneficiary (please see below) a benefit if you die while you are covered.

This highlight sheet is an overview of your Supplemental Life Insurance. Once a group policy is issued to your employer, a certificate of insurance will be available to explain your coverage in detail.

Am I eligible?

You are eligible if you are an active full time employee who works at least 20 hours per week on a regularly scheduled basis.

When can I enroll?

You can enroll during your scheduled enrollment period, within 31 days of the date you have a change in family status, or within 31 days of the completion of your eligibility waiting period as stated in your group policy.

When is it effective?

Coverage goes into effect subject to the terms and conditions of the policy. You must be actively at work with your employer on the day your coverage takes effect.

How much Supplemental Life Insurance can I purchase?

Am I guaranteed coverage?

You can purchase Supplemental Life Insurance in increments of $10,000.

The maximum amount you can purchase cannot be more than the lesser of 5 times your annual Earnings or $500,000. Annual Earnings are as defined in The Hartford’s contract with your employer.

If you enroll during your initial enrollment period or are newly eligible and elect an amount that exceeds the guaranteed issue amount of $150,000, you will need to provide evidence of insurability that is satisfactory to The Hartford before the excess can become effective.

If you enroll after your initial enrollment period, evidence of insurability will be required for all coverage amounts.

What is a beneficiary?

Your beneficiary is the person (or persons) or legal entity (entities) who receives a benefit payment if you die while you are covered by the policy. You must select your beneficiary when you complete your enrollment application; your selection is legally binding.

Are there other limitations to enrollment?

If you do not enroll within 31 days of your first day of eligibility, you will be considered a late entrant. Typically, late entrants may need to show evidence of insurability and may be responsible for the cost of physical exams or other associated costs if they are required.

The Hartford® is The Hartford Financial Services Group, Inc. and its subsidiaries, including issuing companies Hartford Life Insurance Company and Hartford Life and Accident Insurance Company. Policies sold in New York are underwritten by Hartford Life Insurance Company. Home Office of both companies is Simsbury, CT. Pecos-Barstow-Toyah Independent School District Life BHS 00044136 Creation Date: 12/19/2013 Page 1 of 3 Version 11/12

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44136-0

Spouse Supplemental Life Insurance

If you elect Supplemental Life Insurance for yourself, you may choose to purchase Spouse Supplemental Life Insurance in increments of $5,000, to a maximum of $250,000.

Coverage cannot exceed 50% of the amount of your Employee voluntary/supplemental life insurance coverage. You may not elect coverage for your spouse if they are in active full-time military service or is already covered as an employee under this policy.

If your spouse is confined in a hospital or elsewhere because of disability on the date his or her insurance would normally have become effective, coverage (or an increase in coverage) will be deferred until that dependent is no longer confined and has performed all the normal activities of a healthy person of the same age for at least 15 consecutive days.

If you enroll during your initial enrollment period or are newly eligible and elect an amount that exceeds the guaranteed issue amount of $50,000, your spouse will need to provide evidence of insurability that is satisfactory to The Hartford before the excess can become effective. If you enroll after your initial enrollment period, your spouse will need to provide evidence of insurability that is satisfactory to The Hartford before the excess can become effective.

Child(ren) Supplemental Life Insurance

If you elect Supplemental Life Insurance for yourself, you may choose to purchase Child(ren) Supplemental Life Insurance coverage in the amount(s) of $10,000 for each child – no medical information is required.

• If your dependent child(ren) is confined in a hospital or elsewhere because of disability on the date his or her insurance would normally have become effective, coverage (or an increase in coverage) will be deferred until that dependent is no longer confined and has performed all the normal activities of a healthy person of the same age for at least 15 consecutive days.

• • Child(ren) at least 15 days but not yet age 6 months are limited to a reduced benefit of $100.

Does my coverage reduce as I get older?

by 35% at 65, and 50% at 70. All coverage cancels at retirement.

Can I keep my life coverage if I leave my employer?

Yes, subject to the contract, you have the option of: • Converting your group life coverage to your own individual policy (policies).

• If you leave your employer, portability is an option that allows you to continue your life insurance coverage. To be eligible, you must terminate your employment prior to Social Security Normal Retirement Age. This option allows you to continue all or a portion of your life insurance coverage under a separate portability term policy.

Portability is subject to a minimum of $5,000 and a maximum of $250,000 and does include coverage for your spouse and child(ren). To elect portability, you must apply and pay the premium within 31 days of the termination of your life insurance.

Evidence of insurability will not be required.

Dependent spouse portability is subject to a maximum of $50,000.

Dependent child(ren) portability is subject to a maximum of $10,000.

The Hartford® is The Hartford Financial Services Group, Inc. and its subsidiaries, including issuing companies Hartford Life Insurance Company and Hartford Life and Accident Insurance Company. Policies sold in New York are underwritten by Hartford Life Insurance Company. Home Office of both companies is Simsbury, CT. Pecos-Barstow-Toyah Independent School District Life BHS 00044136 Creation Date: 12/19/2013 Page 2 of 3 Version 11/12

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What is the living benefits option?

Do I still pay my life insurance premiums if I become disabled?

If you are diagnosed as terminally ill with a 12 month life expectancy, you may be eligible to receive payment of a portion of your life insurance. The remaining amount of your life insurance would be paid to your beneficiary when you die.

If you become totally disabled before age 60 and your disability lasts for at least 9 months, your life insurance premium may be waived. The premium for your dependent’s coverage will also be waived if you are disabled and approved for waiver of premium. Coverage for your dependents will end if the policy terminates.

Important Details As is standard with most term life insurance, this insurance coverage includes certain limitations and exclusions: • the amount of your coverage may be reduced when you reach certain ages.

• death by suicide (two years).

Other exclusions may apply depending upon your coverage. Once a group policy is issued to your employer, a certificate of insurance will be available to explain your coverage in detail.

This benefit highlights sheet is an overview of the insurance being offered and is provided for illustrative purposes only and is not a contract. It in no way changes or affects the policy as actually issued. Only the insurance policy issued to the policyholder (your employer) can fully describe all of the provisions, terms, conditions, limitations and exclusions of your insurance coverage. In the event of any difference between the benefit highlights sheet and the insurance policy, the terms of the insurance policy apply.

The Hartford® is The Hartford Financial Services Group, Inc. and its subsidiaries, including issuing companies Hartford Life Insurance Company and Hartford Life and Accident Insurance Company. Policies sold in New York are underwritten by Hartford Life Insurance Company. Home Office of both companies is Simsbury, CT. Pecos-Barstow-Toyah Independent School District Life BHS 00044136 Creation Date: 12/19/2013 Page 3 of 3 Version 11/12

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Hartford Voluntary Life / AD&D Rates Pecos-Barstow-Toyah Independent School District Monthly Payroll Deduction EMPLOYEE LIFE RATES

Age Band 0-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75+

$10,000

$20,000

$30,000

$40,000

$50,000

$60,000

$70,000

$80,000

$100,000

$0.45 $0.44 $0.58 $0.85 $1.29 $2.06 $3.36 $5.23 $6.94 $11.11 $19.52 $35.34

$0.90 $0.88 $1.16 $1.70 $2.58 $4.12 $6.72 $10.46 $13.88 $22.22 $39.04 $70.68

$1.35 $1.32 $1.74 $2.55 $3.87 $6.18 $10.08 $15.69 $20.82 $33.33 $58.56 $106.02

$1.80 $1.76 $2.32 $3.40 $5.16 $8.24 $13.44 $20.92 $27.76 $44.44 $78.08 $141.36

$2.25 $2.20 $2.90 $4.25 $6.45 $10.30 $16.80 $26.15 $34.70 $55.55 $97.60 $176.70

$2.70 $2.64 $3.48 $5.10 $7.74 $12.36 $20.16 $31.38 $41.64 $66.66 $117.12 $212.04

$3.15 $3.08 $4.06 $5.95 $9.03 $14.42 $23.52 $36.61 $48.58 $77.77 $136.64 $247.38

$3.60 $3.52 $4.64 $6.80 $10.32 $16.48 $26.88 $41.84 $55.52 $88.88 $156.16 $282.72

$4.50 $4.40 $5.80 $8.50 $12.90 $20.60 $33.60 $52.30 $69.40 $111.10 $195.20 $353.40

Any amount over $150,000 will be medically underwritten. You must complete an Evidence of Insuarbility Form SPOUSE LIFE RATES $5,000

$10,000

$15,000

$20,000

$25,000

$30,000

$35,000

$40,000

$50,000

$0.23 $0.22 $0.29

$0.45 $0.44 $0.58

$0.68 $0.66 $0.87

$0.90 $0.88 $1.16

$1.13 $1.10 $1.45

$1.35 $1.32 $1.74

$1.58 $1.54 $2.03

$1.80 $1.76 $2.32

$2.25 $2.20 $2.90

35-39

$0.43

$0.85

$1.28

$1.70

$2.13

$2.55

$2.98

$3.40

$4.25

40-44

$0.65

$1.29

$1.94

$2.58

$3.23

$3.87

$4.52

$5.16

$6.45

45-49 50-54 55-59 60-64 65-69 70-74 75+

$1.03 $1.68 $2.62 $3.47 $5.56 $9.76 $17.67

$2.06 $3.36 $5.23 $6.94 $11.11 $19.52 $35.34

$3.09 $5.04 $7.85 $10.41 $16.67 $29.28 $53.01

$4.12 $6.72 $10.46 $13.88 $22.22 $39.04 $70.68

$5.15 $8.40 $13.08 $17.35 $27.78 $48.80 $88.35

$6.18 $10.08 $15.69 $20.82 $33.33 $58.56 $106.02

$7.21 $11.76 $18.31 $24.29 $38.89 $68.32 $123.69

$8.24 $13.44 $20.92 $27.76 $44.44 $78.08 $141.36

$10.30 $16.80 $26.15 $34.70 $55.55 $97.60 $176.70

Age Band 0-24 25-29 30-34

CHILD LIFE RATES $10,000 $2.00 Per Child Unit AD&D Rates Individual Family

$.04 per $1,000 $.06 per $1,000

NOTE: FINAL RATES MAY VARY SLIGHTLY DUE TO ROUNDING.

THESE GRIDS ARE PRICES OF FREQUENTLY SELECTED AMOUNTS. YOU MAY CHOOSE ANY INCREMENT OF $10,000 UP TO $500,000.(NOT TO EXCEED 5 TIMES YOUR ANNUAL SALARY) FOR SPOUSE ANY INCREMENT OF $5,000 UP TO $50,000 (NOT TO EXCEED 50% OF EMPLOYEE LIFE AMOUNT) TO PURCHASE AN AMOUNT OTHER THAN THOSE LEVELS INDICATED ABOVE, SIMPLY ADD LEVELS TOGETHER

Page 44

What would their lives be like without you?

Without you, will they be able to keep your home?

When someone dies, family income may be significantly reduced.

Keeping up with expenses may be a challenge.

How will your children’s lives change?

Young children need love and care. Teenagers have college dreams.

Growing up happy comes with a healthy price tag.

Without you, how will you keep their dreams alive?

If you need Long Term Care, will choice be important to you?

You deserve the peace of mind that comes from knowing you can choose among home healthcare, assisted living, adult day care and nursing care.

Long Term Care expenses can add up quickly.

Trustmark Universal LifeEventsÂŽ Page 45

U L E

If they need you...

Will their dreams die if you do?

ou love your family and want what’s best for Y them. Without you or your spouse there could be a devastating impact on your family’s financial security.1 If your income disappeared, how long would it take before your loved ones faced financial hardship?

Could life insurance help?

Would your savings help pay for your home?

What about college?

ost American families don’t have enough savings.2 M In fact, we spend more than we earn. If your household income decreased due to death, would your family’s lifestyle be at risk?

Would $50,000 help?

Will funeral expenses add to your grief?

any families aren’t prepared for the death of a loved M one — especially a child. If the unthinkable happened, could you afford a burial?

Would $5,000 help?

Will your Long Term Care options be limited?

ong Term Care services can be very expensive. Peace L of mind comes from knowing that you can choose among Long Term Care options without having to worry about causing a financial or emotional burden on your family.

Would $2,000 a month help?

...you need life insurance.

Page 46

Let’s Face It

LifeEvents in Action

Few families are financially prepared for premature death or needing Long Term Care. Yet it happens every day – often without warning.

(Example: 35-year-old, $8/week premium)

What Can Help?

Trustmark Universal LifeEvents® is permanent life insurance that is designed to match your needs throughout your lifetime. It pays a higher death benefit during your working years when expenses are high and you need maximum protection. Then, at age 70 when your financial needs are lower, your death benefit reduces.3 However, your Living Benefit for Long Term Care (LTC) never reduces. That means you’ll have maximum protection during retirement when you are more likely to need it. Your LTC Benefit helps supplement the cost of home healthcare, assisted living, adult day care and nursing home care.

LifeEvents Traditional UL

Face Amount

$75,881

$51,387

Death Benefit $75,881

$51,387

LTC Benefit

$75,881

$51,387

$75,881

$51,387

Death Benefit $25,294

$51,387

Before Age 70

Age 70+ LTC Benefit

Permanent Life Insurance With Universal LifeEvents, your coverage is fully portable so you can take it with you if you change jobs, retire, or become disabled.

How Much Life Insurance Do You Need?

The average insured American has life insurance equal to about four times their gross annual income.4 You may need more or less coverage. To find out, estimate what your family would need to meet their expenses – today and tomorrow. Then, subtract your earnings. The difference is the amount of life insurance you need. Here are some expenses and earnings to consider:

Expenses

1/3

of face

For the same premium, LifeEvents gives you a higher death benefit during working years compared to traditional Universal Life insurance.

Earnings Savings

Medical Mortgage/Rent

Other Debt

–

Pay to

er of:

the ord

Spousal Earnings

=

Your Life Insurance Need

College Funeral

Food

Investments

What Other Benefits Are Available?

• Accidental Death – Doubles your death benefit if death occurs by accident • Waiver of Premium – Waives your premiums if you become totally disabled • Children’s Term – Covers children, from newborn to 23 years old • T erminal Illness Benefit – Advances up to 75% of your death benefit if your doctor determines that your life expectancy is 24 months or less • E Z Value – Guaranteed automatic increases to Death Benefit and all Living Benefits Financial Impact of Premature Death, LIMRA International, 2003. 2 U.S. Department of Commerce, 2007. 3 If you enroll at or after age 57, your higher death benefit will continue for 14 years before it reduces. 4 LIMRA International, 2005.

1

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How does Universal LifeEvents insurance help? ®

If you’re like most people, family is your number one priority. Imagine how you would feel if something happened to you and they weren’t protected. With Universal LifeEvents, you’ll feel confident knowing the promises you made are the promises you’ll keep – even when you can’t be there to see them through.

EZ Value Option EZ Value automatically increases your benefits to keep pace with your increasing needs – without additional underwriting. Your death benefit increases each year by the amount of insurance an additional $1 or $2 weekly premium would buy.

Death Benefit Growth $148,973 $118,771 $75,881

Additional Benefits

(Check Your Benefits) Long Term Care Benefit (LTC) – Pays 4% of your death benefit for up to 25 months for home healthcare, assisted living, nursing home care and adult day care. Payments reduce the death benefit.

EZ Value – Raises your coverage automatically without additional underwriting.

Accidental Death Benefit – Doubles your death benefit if death occurs by accident.

Waiver of Premium – Waives your premiums if you become totally disabled.

Children’s Term – Covers all your children, newborn to 23 years old, and is convertible to Universal Life Insurance without evidence of insurability.

Built-in Features

3 Permanent Life Insurance – Pays a death benefit to

Initial Benefit

5th Year

10th Year

Example: Guaranteed benefit increases with $1 increase in weekly premium per year for 10 years.

Actual values will vary by age, smoking, benefits selected and current interest rate.

Universal LifeEvents Benefits Summary Name: ____________________________________________ UL Coverage

Death Benefit

Premium /

Employee

$

$

Spouse

$

$

secure your family’s future. It doesn’t terminate with age.

3 LifeEvents – Matches your insurance needs throughout your lifetime.

3 Complete Portability – Take your policy with you. It’s yours to keep even if you change jobs or retire.

3 Terminal Illness Benefit – Advances up to 75% of your death benefit if your doctor determines your life expectancy is 24 months or less.

3 Family Coverage – Available to protect your spouse, children and grandchildren – even if you choose not to participate.

3 Convenient Payroll Deduction – No bills to watch for and no checks to mail.

TOTAL PAYROLL DEDUCTION

Underwritten by Trustmark Insurance Company Underwritten by Trustmark Insurance Company Rated A- (EXCELLENT) A.M. Best Rated A- (EXCELLENT) Rated A- (STRONG)A.M. FitchBest Rated A- (STRONG) Fitch 400 Field Drive • Lake Forest, IL 60045 400 Field Drive • Lake Forest, IL 60045 trustmarkinsurance.com trustmarkinsurance.com

This provides a brief description of your benefits and is not a contract. Benefits, exclusions and limitations may vary by state, or may be named differently.

See GUL/IUL.205 and riders for exact terms, provisions and exclusions and limitations that apply to the LTC Rider. A complete computer-prepared policy illustration will be delivered with your policy or certificate. Coverage may expire prior to age 100 even if the premium shown is paid as scheduled. © 2010 Trustmark Insurance Company

P485-522

Page 48

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Page 50

Health Care Expense Account Sample Expenses

Medical Expenses Acupuncture Addiction programs Adoption (medical expenses for baby birth) Alternative healer fees Ambulance Body scans Breast pumps Care for mentally handicapped Chiropractor Co-payments Crutches Diabetes (i.e. insulin, glucose monitor) Eye patches Fertility treatment First aid (i.e. bandages, gauze) Hearing aids & batteries Hypnosis (for treatment of illness) Incontinence products (ie Depends, Serene) Joint support bandages and hosiery Lab fees Monitoring device (blood pressure, cholesterol) Physical exams Pregnancy tests Prescription drugs Psychiatrist/Psychologist (for mental illness) Physical therapy Speech therapy Vaccinations Vaporizers or humidifiers Weight loss program fees (if prescribed by physician) Wheelchair

Dental Expenses Artificial teeth Co-payments Deductible Dental work Dentures Orthodontia expenses Preventative care at dentist office Bridges, crowns, etc.

Vision Expenses Braille – books & magazines Contact lenses Contact lens solutions Eye exams Eye glasses Laser surgery Office fees Guide dog and its upkeep, other animal aid

Items listed below generally do not qualify for reimbursement Personal Hygiene (i.e. deodorant, soap, body powder, shaving cream, sanitary products) Addiction products Allergy relief (oral meds, nasal spray) Antacids and heartburn relief Anti-itch and hydrocortisone creams Athlete’s foot treatment Arthritis pain relieving creams Cold medicines (i.e. syrups, drops, tablets) Cosmetic surgery Cosmetics (i.e. makeup, lipstick, cotton swabs, cotton balls, baby oil) Counseling (i.e. marriage/family counseling) Dental care – routine (i.e. toothpaste, toothbrushes, dental floss, anti-bacterial mouthwashes, fluoride rinses, breath strips, teeth whitening/bleaching, etc.)

Exercise equipment Fever & pain reducers (i.e. Aspirin, Tylenol) Hair care (i.e. hair color, shampoo, conditioner, brushes, hair loss products)

Health club or fitness program fees Homeopathic supplement or herbs Household or domestic help Laser hair removal Laxatives Massage therapy Motion sickness medication Nutritional and dietary supplements (i.e. bars, milkshakes, power drinks, Pedialyte) Skin care (i.e. sun block, moisturizing lotion, lip balm) Sleep aids (i.e. oral meds, snoring strips) Smoking cessation relief (i.e. patches, gum) Stomach & digestive relief (i.e. Pepto-Bismol, Imodium) Tooth and mouth pain relief (Orajel, Anbesol) Vitamins Wart removal medication Weight reduction aids (i.e. Slimfast, appetite suppressant

These expenses may be eligible if they are prescribed by a physician (if medically necessary for a specific condition)

For Additional Information, Visit www.nbsbenefits.com Welfare-547 (1/12)

_______________________________________________________________________________________________________

8523 S Redwood Rd, West Jordan, UT 84088 ● (800) 274-0503 ● Fax (801) 355-0928 ● www.NBSbenefits.com

Page 51

How the FSA Plan Works You designate an annual election of pre-tax dollars to be deposited into your health and dependent-care spending accounts. Your total election is divided by the number of pay periods in the Plan year and deducted equally from each paycheck before taxes are calculated. By the end of the Plan year, your total election will be fully deposited.

However, you may make a claim for eligible health FSA expenses as soon as they are incurred during the Plan year.

Eligible claims will be paid up to your total annual election even if you have not yet contributed that amount to your account.

Get Your Money 1. Complete and sign a claim form (available on our website) or an online webclaim.

2. Attach documentation; such as an itemized bill or an Explanation of Benefits (EOB) statement from a health insurance provider.

3. Fax or mail signed form and documentation to NBS. 4. Receive your non-taxable reimbursement after your claim is processed either by check or direct deposit.

NBS Flexcard—FSA Pre-paid Benefit Card Your employer may sponsor the use of the NBS Flexcard, making access to your flex dollars easier than ever. You may use the card to pay merchants or service providers that accept credit cards, so there is no need to pay cash up front then wait for reimbursement.

Account Information

Enrollment Considerations

Participants may call NBS and talk to a representative during our regular business hours, Monday–Friday, 7am to 6pm Mountain Time. Participants can also obtain account information using the Automated Voice Response Unit, 24 hours a day, 7 days a week at (801) 838-7324 or toll free (888) 353-9125. For immediate access to your account information at any time, log on to our website NBSbenefits.com. Information includes:

After the the enrollment period ends, you may increase, decrease, or stop your contribution only when you experience a qualifying “change of status” (marriage status, employment change, dependent change). Be conservative in the total amount you elect to avoid forfeiting money that may be left in your account at the end of the year. Your employer may allow a short grace period after the Plan year ends for you to submit qualified claims for any unused funds.

• • • •

Detailed claim history and processing status Health Care and Dependent Care account balances Claim forms, worksheets, etc.

Online Claim Submission

NATIONAL BENEFIT SERVICES, LLC 8523 South Redwood Road West Jordan, UT 84088 Phone: 800-274-0503

Fax: 800-478-1528

Email: Service@NBSbenefits.com

NBSbenefits.com Page 52

WWW.MYBENEFITSHUB.COM/PECOS-BARSTOW-TOYAHISD