2017 Benefit Guide ESC Region 1

ESC REGION 1

BENEFIT GUIDE EFFECTIVE: 09/01/2017 - 08/31/2018 WWW.MYBENEFITSHUB.COM/ REGION1

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Table of Contents Benefit Contact Information How to Enroll Annual Benefit Enrollment 1. Benefit Updates 2. Section 125 Cafeteria Plan Guidelines 3. Annual Enrollment 4. Eligibility Requirements 5. Helpful Definitions TRS ActiveCare Aetna United Healthcare Dental United Healthcare Vision The Standard Disability Washington National Cancer AUL a OneAmerica Company Life and AD&D APL Accident The Hartford Critical Illness Bay Bridge Heart & Stroke Genworth Financial Long Term Care NBS Flexible Spending Accounts (FSAs) Nationwide ID Theft Protection

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FLIP TO...

PG. 4 HOW TO HOW TO ENROLL ENROLL

PG. 6 SUMMARY PAGES

PG. 12 YOUR BENEFITS

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Benefit Contact Information

Benefit Contact Information ESC REGION 1 BENEFITS

CANCER

LONG TERM CARE

Financial Benefit Services (800) 583-6908 www.mybenefitshub.com/region1

Washington National Insurance Company (800) 525-7662 www.washingtonnational.com

Genworth Financial 1-866-659-1970 www.Genworth.com

MEDICAL

CRITICAL ILLNESS

ID THEFT

TRS Active Care - Aetna (800) 222-9205 www.trsactivecareaetna.com

The Hartford 800-523-2233 Claims: 866-547-4205 www.thehartford.com

Nationwide (800) 248-9000 http://www.legaleaseplan.com/region1

DENTAL

ACCIDENT

FLEXIBLE SPENDING ACCOUNTS

UnitedHealthcare (800) 638-3120 https://www.myuhcvision.com

American Public Life (800) 256-8606 www.ampublic.com

National Benefit Services (800) 274-0503 www.nbsbenefits.com

VISION

BASIC AND VOLUNTARY LIFE

UnitedHealthcare (800) 638-3120 https://www.myuhcvision.com

AUL a OneAmerica Company (800) 537-6442 https://www.oneamerica.com

DISABILITY

HEART & STROKE

The Standard (800) 368-1135 Claims Number: 855-757-4717 www.standard.com

Bay Bridge (800) 845-7519 http://www.baybridgeadministrators.com/

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MOBILE ENROLLMENT Enrollment made simple through your smartphone or tablet.

Text “FBS ESC1” to 313131 and get access to everything you need to complete your benefits enrollment: 

Benefit Information



Online Support



Interactive Tools



And more.

PLAY VIDEO

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Text “FBS ESC1” to 313131 OR SCAN

How to Log In

1 BENEFIT INFO

INTERACTIVE TOOLS

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www.mybenefitshub.com/region1

CLICK LOGIN

ENTER USERNAME & PASSWORD All login credentials have been RESET to the default described below:

Username: 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.

ONLIINE SUPPORT

If you have less than six (6) characters in your last name, use your full 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.

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Annual Benefit Enrollment

SUMMARY PAGES

Benefit Updates - What’s New: 

NEW!! The annual maximum has been increased from $2,550 to $2,600 effective 9/1/17.



NEW!! Cancer Plan by Washington National: Cancer insurance is designed to be a supplement to help with costs not covered by your medical plan. There are 2 plan options available.



NEW!! Critical Illness by The Hartford- Critical Illness is designed to help employees offset the financial effects of a catastrophic illness with a lump sum benefit if an insured is diagnosed with a covered critical illness.

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If you currently participate in a Healthcare or Dependent Care FSA, you MUST re-elect a new contribution amount every year to continue to participate. You can view account balance using the CHECK FSA link on the Benefit website or use the NBS smart phone app.

   

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Benefits elections will become effective 9/1/2017 (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 31 days of event).

Login and complete your supplemental benefit enrollment from 08/01/2017 - 08/15/2017 Enrollment assistance is available by calling Financial Benefit Services at 866-914-5202 to speak to an enrollment representative Monday—Friday, 8 AM—5 PM from 08/01/2017—08/15/2017. Bilingual assistance is available.

Update your profile information: home address, phone numbers, email.

IMPORTANT!! Due to the Affordable Care Act (ACA) reporting requirements, please add your dependent’s social security numbers in the online enrollment system. If you have questions, please contact your Benefits Administrator.

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SUMMARY PAGES

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 STATUS (CIS):

Changes in benefit elections can occur only if you experience a 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.

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).

Change in Number of Tax Dependents

A change in number of dependents includes the following: birth, adoption and placement for adoption.

You can add existing dependents not previously enrolled whenever a dependent gains 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 requirements Gain/Loss of Dependents under an employer's plan may include change in age, student, marital, employment or tax dependent Eligibility Status status.

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 Judgment/Decree/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 Gain or loss of Medicare/Medicaid coverage may trigger a permitted election change.

Government Programs

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SUMMARY PAGES

Annual Enrollment During your annual enrollment period, you have the opportunity

Where can I find forms?

to review, change or continue benefit elections each year.

For benefit summaries and claim forms, go to your school

Changes are not permitted during the plan year (outside of

district’s benefit website: www.mybenefitshub.com/region1.

annual enrollment) unless a Section 125 qualifying event occurs.

Click on the benefit plan you need information on (i.e., Dental) and you can find the forms you need under the



Changes, additions or drops may be made only during the

Benefits and Forms section.

annual enrollment period without a qualifying event.

How can I find a Network Provider?

 Employees must review their personal information and verify that dependents they wish to provide coverage for are

district’s website: www.mybenefitshub.com/region1. Click on

included in the dependent profile. Additionally, you must

the benefit plan you need information on (i.e., Dental) and

notify your employer of any discrepancy in personal and/or benefit information.



For benefit summaries and claim forms, go to your school

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

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

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 time frame will result in the forfeiture of coverage.

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.

If the insurance carrier provides ID cards, but there are no changes to the plan, you typically will not receive a new ID card each year.

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.

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SUMMARY PAGES

Employee Eligibility Requirements

Dependent Eligibility Requirements

Supplemental Benefits: Eligible employees must work 20 or more

Dependent Eligibility: You can cover eligible dependent

regularly scheduled hours each work week.

children under a benefit that offers dependent coverage, provided you participate in the same benefit, through the

Eligible employees must be actively at work on the plan effective

maximum age listed below. Dependents cannot be double

date for new benefits to be effective, meaning you are physically

covered by married spouses within ESC Region 1 or as both

capable of performing the functions of your job on the first day of

employees and dependents.

work concurrent with the plan effective date. For example, if your 2017 benefits become effective on September 1, 2017, you must be actively-at-work on September 1, 2017 to be eligible for your new benefits.

PLAN

CARRIER

MAXIMUM AGE

Medical

Aetna

To Age 26

Heart & Stroke

Bay Bridge

Student up through age 25

Accident

APL

To Age 26

Cancer

Washington National

To Age 26

Critical Illness

The Hartford

To Age 26

Dental

United Healthcare

To Age 26

Identity Theft

Nationwide

To age 19 or to 25 if full time student

Vision

United Healthcare

To Age 26

Voluntary Life and AD&D

AUL a OneAmerica Company

To Age 26

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 must provide a physician’s statement confirming your dependent’s disability. Contact your HR/Benefit Administrator to request a continuation of coverage.

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SUMMARY PAGES

Helpful Definitions Actively at Work

In-Network

You are performing your regular occupation for the employer

Doctors, hospitals, optometrists, dentists and other providers

on a full-time basis, either at one of the employer’s usual

who have contracted with the plan as a network provider.

places of business or at some location to which the employer’s business requires you to travel. If you will not be actively at work beginning 9/1/2017 please notify your benefits administrator.

Annual Enrollment The period during which existing employees are given the opportunity to enroll in or change their current elections.

Annual Deductible The amount you pay each plan year before the plan begins to pay covered expenses.

Out of Pocket Maximum The most an eligible or insured person can pay in co-insurance for covered expenses.

Plan Year September 1st through August 31st

Pre-Existing Conditions Applies to any illness, injury or condition for which the participant has been under the care of a health care provider, taken prescriptions drugs or is under a health care provider’s orders to take drugs, or received medical care or services

Calendar Year January 1st through December 31st

Co-insurance After any applicable deductible, your share of the cost of a covered health care service, calculated as a percentage (for example, 20%) of the allowed amount for the service.

Guaranteed Coverage The amount of coverage you can elect without answering any medical questions or taking a health exam. Guaranteed coverage is only available during the initial eligibility period.

Actively-at-work and/or pre-existing condition exclusion provisions do apply, as applicable by carrier.

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(including diagnostic and/or consultation services).

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2017 – 2018 TRS-ActiveCare Plan Highlights Effective September 1, 2017 through August 31, 2018 | In-Network Level of Benefits*

Deductible (per plan year) In-Network Out-of-Network Out-of-Pocket Maximum (per plan year; medical and prescription drug deductibles, copays, and coinsurance count toward the out-of-pocket maximum) In-Network Out-of-Network Coinsurance In-Network Participant pays (after deductible) Out-of-Network Participant pays (after deductible) Office Visit Copay Participant pays Diagnostic Lab Participant pays

Preventive Care See below for examples Teladoc® Physician Services

High-Tech Radiology (CT scan, MRI, nuclear medicine) Participant pays Inpatient Hospital (preauthorization required) (facility charges) Participant pays Emergency Room (true emergency use) Participant pays Outpatient Surgery Participant pays Bariatric Surgery Physician charges (only covered if performed at an IOQ facility) Participant pays Annual Vision Examination (one per plan year; performed by an ophthalmologist or optometrist using calibrated instruments) Participant pays Annual Hearing Examination Participant pays Preventive Care Routine physicals – annually age 12 and over Mammograms – 1 every year age 35 and over Smokingcessationcounseling– 8 visits per 12 months

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• Well-child care – unlimited up to age 12 • Colonoscopy – 1 every 10 years age 50 and over •Healthydiet/obesitycounseling– unlimited to

• Well woman exam & pap smear – annually age 18 and over • Prostatecancer screening–1 per year age 50 and over • Breastfeeding support – 6 lactation counseling visits

Drug Deductible Short-Term Supply at a Retail Location

Extended-Day Supply at Mail Order or Retail-Plus Pharmacy Location (60- to

90-day supply)****

Specialty Medications Short-Term Supply of a Maintenance Medication at Retail Location (up to a 31-day supply)

What is a maintenance medication?

Maintenance drugs are prescriptions commonly used to treat conditions that are considered chronic or long-term. These conditions usually require regular, daily use of medicines. Examples of maintenance drugs are those used to treat high blood pressure, heart disease, asthma and diabetes.

When does the convenience fee apply?

For example, if you are covered under TRS-ActiveCare Select, the first time you fill a 31-day supply of a generic maintenance drug at a retail pharmacy you will pay $20, then you will pay $35 each month that you fill a 31-day supply of that generic maintenance drug at a retail pharmacy. A 90-day supply of that same generic maintenance medication would cost $45, and you would save $225 over the year by filling a 90-day supply.

Premium Information for ALEX You will need to enter the applicable amount – YOUR ANNUAL COST – from the table below into ALEX when prompted. To determine this cost, ask your Benefits Administrator for your monthly cost (this is the amount you will owe each month after your employer contributes to your coverage). Then multiply your monthly cost by 12 to get YOUR ANNUAL COST (use this amount for ALEX) Individual

$351

$514

$714

+Spouse

$991

$1,264

$1,694

+Children

$671

$834

$1,062

+Family

$1,316

$1,589

$2,004

A specialist is any physician other than family practitioner, internist, OB/GYN or pediatrician. *Illustrates benefits when in-network providers are used. For some plans non-network benefits are also available; there is no coverage for non-network benefits under the ActiveCare Select or ActiveCare Select Whole Health Plan; see Enrollment Guide for more information. Non-contracting providers may bill for amounts exceeding the allowable amount for covered services.

Participants will be responsible for this balance bill amount, which maybe considerable. **For ActiveCare 1-HD, certain generic preventive drugs are covered at 100%. Participants do not have to meet the deductible ($2,500 - individual, $5,000 - family) and they pay nothing out of pocket for these drugs. The list of drugs is on the TRS-ActiveCare website. ***If a participant obtains a brand-name drug when a generic equivalent is available, they are responsible for the generic copay plus the cost difference between the brand-name drug and the generic drug.

13 ****Participants can fill 32-day to 90-day supply through mail order.

UNITED HEALTHCARE

Dental

YOUR BENEFITS PACKAGE

PLAY VIDEO

About this Benefit Dental insurance is a coverage that helps defray the costs of dental care. It insures against the expense of routine care, treatment and dental disease.

Good dental care may improve your overall health.

Also Women with gum disease may be at greater risk of giving birth to a preterm or low birth weight baby.

This is a general overview of your plan benefits. If the terms of this outline differ from your policy, the policy will govern. Additional plan details on covered expenses, limitations and exclusions are included in the summary plan description located on the 14 ESC Region 1 Benefits Website: www.mybenefitshub.com/region1

Dental PPO Rates Employee

$0.00

Employee + Spouse

$28.80

Employee + Child(ren)

$25.46

Employee + Family

$53.35

UnitedHealthcare Insurance Company (30100)ÂŽ Voluntary Options PPO 30 /covered dental services NON-ORTHODONTICS NETWORK NON-NETWORK Individual Annual Deductible Family Annual Deductible Maximum (the sum of all Network and Non-Network benefits will not exceed Annual maximum) New enrollee's waiting period

$50 $50 $0 $150 $150 $0 $1,500 per person per Calendar $1,500 per person per Calendar $1,000 per person per Lifetime Year Year

$0 $0 $1,000 per person per Lifetime

None No (In Network) No Child Only (Up to Age 19) Yes

Annual deductible applies to preventive and diagnostic services Annual Deductible Applies to Orthodontic Services Orthodontic Eligibility Requirement CMM-Annual Roll-Over

COVERED SERVICES *

Dental Plan New Standard/3P216/U90 ORTHODONTICS NETWORK NON-NETWORK

NETWORK PLAN PAYS**

NETWORK PLAN PAYS***

No (Out Network)

BENEFIT GUIDELINES

DIAGNOSTIC SERVICES Periodic Oral Evaluation Radiographs Lab and Other Diagnostic Tests

100% 100% 100%

100% 100% 100%

See Exclusions and Limitations section for benefit guidelines.

100% 100% 100% 100%

100% 100% 100% 100%

See Exclusions and Limitations section for benefit guidelines.

80% 80% 80% 80% 80%

80% 80% 80% 80% 80%

See Exclusions and Limitations section for benefit guidelines.

50% 50% 50% 50% 50%

50% 50% 50% 50% 50%

See Exclusions and Limitations section for benefit guidelines.

50%

50%

PREVENTIVE SERVICES Prophylaxis (Cleaning) Fluoride Treatment (Preventive) Sealants Space Maintainers

BASIC SERVICES Restorations (Amalgams or Composite)* Emergency Treatment/General Services Simple Extractions Oral Surgery (incl. surgical extractions) Endodontics

MAJOR SERVICES Periodontics Inlays/Onlays/Crowns Dentures and Removable Prosthetics Fixed Partial Dentures (Bridges) Implants

ORTHODONTIC SERVICES Diagnose or correct misalignment of the teeth or bite

# This plan includes a roll-over maximum benefit. Some of the unused portion of your annual maximum may be available in future periods. * Your dental plan provides that where two or more professionally acceptable dental treatments for a dental condition exist, your plan bases reimbursement on the least costly treatment alternative. If you and your dentist have agreed on a treatment which is more costly than the treatment on which the plan benefit is based, you will be responsible for the difference between the fee for service rendered and the fee covered by the plan. In addition, a pre-treatment estimate is recommended for any service estimated to cost over $500; please consult your dentist. ** The network percentage of benefits is based on the discounted fee negotiated with the provider. *** The non-network percentage of benefits is based on the usual and customary fees in the geographic areas in which the expenses are incurred. In accordance with the Illinois state requirement, a partner in a Civil Union is included in the definition of Dependent. For a complete 15 description of Dependent Coverage, please refer to your Certificate of Coverage

Dental PPO UnitedHealthcare Insurance Company (30100)ÂŽ Voluntary Options PPO 20 /covered dental services NON-ORTHODONTICS NETWORK NON-NETWORK Individual Annual Deductible Family Annual Deductible Maximum (the sum of all Network and Non-Network benefits will not exceed Annual maximum) New enrollee's waiting period

$50 $150 $1,500 per person per Calendar Year

$50 $0 $150 $0 $1,500 per person per Calendar $1,000 per person per Lifetime Year

$0 $0 $1,000 per person per Lifetime

None No (In Network) No Child Only (Up to Age 19) Yes

Annual deductible applies to preventive and diagnostic services Annual Deductible Applies to Orthodontic Services Orthodontic Eligibility Requirement CMM-Annual Roll-Over

COVERED SERVICES *

Dental Plan New Standard/3P217/MAC ORTHODONTICS NETWORK NON-NETWORK

NETWORK PLAN PAYS**

No (Out Network)

NON-NETWORK PLAN PAYS***

BENEFIT GUIDELINES

100%

100%

100% 100%

100% 100%

See Exclusions and Limitations section for benefit guidelines.

100%

100%

100% 100% 100%

100% 100% 100%

100%

100%

100%

100%

100%

100%

100%

100%

100%

100%

60%

60%

60% 60% 60% 60%

60% 60% 60% 60%

50%

50%

DIAGNOSTIC SERVICES Periodic Oral Evaluation Radiographs Lab and Other Diagnostic Tests

PREVENTIVE SERVICES Prophylaxis (Cleaning) Fluoride Treatment (Preventive) Sealants Space Maintainers

See Exclusions and Limitations section for benefit guidelines.

BASIC SERVICES Restorations (Amalgams or Composite)* Emergency Treatment/General Services Simple Extractions Oral Surgery (incl. surgical extractions) Endodontics

See Exclusions and Limitations section for benefit guidelines.

MAJOR SERVICES Periodontics Inlays/Onlays/Crowns Dentures and Removable Prosthetics Fixed Partial Dentures (Bridges) Implants

See Exclusions and Limitations section for benefit guidelines.

ORTHODONTIC SERVICES Diagnose or correct misalignment of the teeth or bite

# This plan includes a roll-over maximum benefit. Some of the unused portion of your annual maximum may be available in future periods. * Your dental plan provides that where two or more professionally acceptable dental treatments for a dental condition exist, your plan bases reimbursement on the least costly treatment alternative. If you and your dentist agreed on a treatment which is more costly than the treatment on which the plan benefit is based, you will be responsible for the difference between the fee for service rendered and the fee covered by the plan. In addition, a pre-treatment estimate is recommended for any service estimated to cost over $500; please consult your dentist. **The network percentage of benefits is based on the discounted fees negotiated with the provider. ***The benefit percentage applies to the schedule of maximum allowable charges. Maximum allowable charges are limitations on billed charges in the geographic area in which the expenses are incurred.

In accordance with the Illinois state requirement, a partner in a Civil Union is included in the definition of Dependent. For a complete description of Dependent Coverage, please refer to your Certificate of Coverage.

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Dental PPO UnitedHealthcare/Dental Exclusions and Limitations Dental Services described in this section are covered when such services are: A. Necessary; B. Provided by or under the direction of a Dentist or other appropriate provider as specifically described; C. The least costly, clinically accepted treatment, and D. Not excluded as described in the Section entitled. General Exclusions.

GENERAL LIMITATIONS 1.

PERIODIC ORAL EVALUATION Limited to 2 times per consecutive 12 months.

2.

COMPLETE SERIES OR PANOREX RADIOGRAPHS Limited to 1 time per consecutive 36 months.

3.

BITEWING RADIOGRAPHS Limited to 1 series of films per calendar year.

4.

EXTRAORAL RADIOGRAPHS Limited to 2 films per calendar year.

5.

DENTAL PROPHLYAXIS Limited to 2 times per consecutive 12 months.

6.

FLUORIDE TREATMENTS Limited to covered persons under the age of 16 years, and limited to 2 times per consecutive 12 months.

7.

SPACE MAINTAINERS Limited to covered persons under the age of 16 years, limited to 1 per consecutive 60 months. Benefit includes all adjustments within 6 months of installation.

8.

SEALANTS Limited to covered persons under the age of 16 years, and once per first or second permanent molar every consecutive 36 months.

9.

RESTORATIONS (Amalgam or Composite) Multiple restorations on one surface will be treated as a single filling.

10. PIN RETENTION Limited to 2 pins per tooth; not covered in addition to cast restoration.

11. INLAYS AND ONLAYS Limited to 1 time per tooth per consecutive 60 months. Covered only when a filling cannot restore the tooth.

12. CROWNS Limited to 1 time per tooth per consecutive 60 months. Covered only when a filling cannot restore the tooth.

13. POST AND CORES Covered only for teeth that have had root canal therapy.

14. SEDATIVE FILLINGS Covered as a separate benefit only if no other service, other than x-rays and exam, were performed on the same tooth during the visit.

15. SCALING AND ROOT PLANING Limited to 1 time per quadrant per consecutive 24 months.

16. ROOT CANAL THERAPY Limited to 1 time per tooth per lifetime.

17. PERIODONTAL MAINTENANCE Limited to 2 times per consecutive 12 months following active or adjunctive periodontal therapy, exclusive of gross debridement.

18. FULL DENTURES Limited to 1 time every consecutive 60 months. No additional allowances for precision or semi-precision attachments.

19. PARTIAL DENTURES Limited to 1 time every consecutive 60 months. No additional allowances for precision or semi-precision attachments.

20. RELINING AND REBASING DENTURES Limited to relining/rebasing performed more than 6 months after the initial insertion. Limited to 1 time per consecutive 12 months.

21. REPAIRS TO FULL DENTURES, PARTIAL DENTURES, BRIDGES Limited to repairs or adjustments performed more than 12 months after the initial insertion.

22. Limited to 1 per consecutive 6 months.

23. PALLIATIVE TREATMENT Covered as a separate benefit only if no other service, other than the exam and radiographs, were performed on the same tooth during the visit.

24. OCCLUSAL GUARDS Limited to 1 guard every consecutive 36 months and only covered if prescribed to control habitual grinding.

25. FULL MOUTH DEBRIDEMENT Limited to 1 time every consecutive 36 months.

26. GENERAL ANESTHESIA Covered only when clinically necessary.

27. OSSEOUS GRAFTS Limited to 1 per quadrant or site per consecutive 36 months.

28. PERIODONTAL SURGERY Hard tissue and soft tissue periodontal surgery are limited to 1 quadrant or site per consecutive 36 months per surgical area.

29. REPLACEMENT OF COMPLETE DENTURES, FIXED OR REMOVABLE PARTIAL DENTURES, CROWNS, INLAYS OR ONLAYS Replacement of complete dentures, fixed or removable partial dentures, crowns, inlays or onlays previously submitted for payment under the plan is limited to 1 time per consecutive 60 months from initial or supplemental placement. This includes retainers, habit appliances, and any fixed or removable interceptive orthodontic appliances.

8.

9.

10.

11.

12.

13.

14.

15.

16.

17.

18.

19.

20.

21.

22.

23.

24.

25.

26.

27.

procedure is considered to be Experimental, Investigational or Unproven in the treatment of that particular condition.

Drugs/medications, obtainable with or without a prescription, unless they are dispensed and utilized in the dental office during the patient visit.

Setting of facial bony fractures and any treatment associated with the dislocation of facial skeletal hard tissue.

Treatment of benign neoplasms, cysts, or other pathology involving benign lesions, except excisional removal. Treatment of malignant neoplasms or Congenital Anomalies of hard or soft tissue, including excision.

Replacement of complete dentures, fixed and removable partial dentures or crowns if damage or breakage was directly related to provider error. This type of replacement is the responsibility of the Dentist. If replacement is Necessary because of patient non -compliance, the patient is liable for the cost of replacement.

Services related to the temporomandibular joint (TMJ), either bilateral or unilateral.

Upper and lower jaw bone surgery (including that related to the temporomandibular joint). No Coverage is provided for orthognathic surgery, jaw alignment, or treatment for the temporomandibular joint.

Charges for failure to keep a scheduled appointment without giving the dental office 24 hours notice.

Expenses for Dental Procedures begun prior to the Covered Person becoming enrolled under the Policy.

Fixed or removable prosthodontic restoration procedures for complete oral rehabilitation or reconstruction.

Attachments to conventional removable prostheses or fixed bridgework. This includes semi-precision or precision attachments associated with partial dentures, crown or bridge abutments, full or partial overdentures, any internal attachment associated with an implant prosthesis, and any elective endodontic procedure related to a tooth or root involved in the construction of a prosthesis of this nature.

Procedures related to the reconstruction of a patient's correct vertical dimension of occlusion (VDO).

Occlusal guards used as safety items or to affect performance primarily in sportsrelated activities.

Placement of fixed partial dentures solely for the purpose of achieving periodontal stability.

Services rendered by a provider with the same legal residence as a Covered Person or who is a member of a Covered Person's family, including spouse, brother, sister, parent or child.

Dental Services otherwise Covered under the Policy, but rendered after the date individual Coverage under the Policy terminates, including Dental Services for dental conditions arising prior to the date individual Coverage under the Policy terminates.

Acupuncture; acupressure and other forms of alternative treatment, whether or not used as anesthesia.

Orthodontic service Coverage does not include the installation of a space maintainer, any treatment related to treatment of the temporomandibular joint, or a surgical procedure to correct a malocclusion, replacement of retainers, habit appliances, and any fixed or removable interceptive orthodontic appliances previously submitted for payment under the plan.

Foreign Services are not Covered unless required as an Emergency.

Dental Services received as a result of war or any act of war, whether declared or undeclared or caused during service in the armed forces of any country.

Services for injuries or conditions covered by Worker’s Compensation or employer liability laws, and services that are provided without cost to the Covered Person by any municipality, county, or other political subdivision. Covered Person by any municipality, county, or other political subdivision. This exclusion does not apply to any services covered by Medicaid or Medicare.

GENERAL EXCLUSIONS The following are not covered: 1.

Dental Services that are not Necessary.

2.

Hospitalization or other facility charges.

3.

Any Dental Procedure performed solely for cosmetic/aesthetic reasons. (Cosmetic procedures are those procedures that improve physical appearance.)

4.

Reconstructive surgery, regardless of whether or not the surgery is incidental to a dental disease, injury, or Congenital Anomaly, when the primary purpose is to improve physiological functioning of the involved part of the body.

5.

Any Dental Procedure not directly associated with dental disease.

6.

Any Dental Procedure not performed in a dental setting.

7.

Procedures that are considered to be Experimental, Investigational or Unproven. This includes pharmacological regimens not accepted by the American Dental Association (ADA) Council on Dental Therapeutics. The fact that an Experimental, Investigational or Unproven Service, treatment, device or pharmacological regimen is the only available treatment for a particular condition will not result in Coverage if the

17

UNITED HEALTHCARE YOUR BENEFITS PACKAGE

Vision

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About this Benefit Vision insurance provides coverage for routine eye examinations and may cover all or part of the costs associated with contact lenses, eyeglasses and vision correction, depending on the plan.

75% of U.S. residents between age 25 and 64 require some sort of vision correction.

This is a general overview of your plan benefits. If the terms of this outline differ from your policy, the policy will govern. Additional plan details on covered expenses, limitations and exclusions are included in the summary plan description located on the 18 ESC Region 1 Benefits Website: www.mybenefitshub.com/region1

Vision - High Plan Monthly Premiums

Out-of-Network Reimbursements Up To: (copays do not apply)

EE Only

$9.58 Monthly

EE + Spouse

$18.74 Monthly

Exams

$40.00

EE + Child(ren)

$20.57 Monthly

Frames

$45.00

EE + Family

$25.59 Monthly

Single Vision Lenses

$40.00

Bifocal Lenses

$60.00

Co-Pays for In-Network Services Exam

$10

Trifocal Lenses

$80.00

Materials

$0

Lenticular Lenses Elective Contacts in Lieu of Eye Glasses3 Necessary Contacts in Lieu of Eye Glasses4

$80.00

Benefit Frequency Comprehensive Exam

Once every 12 months

Spectacle Lenses

Once every 12 months

Frames Contact Lenses in Lieu of Eye Glasses

Once every 12 months Once every 12 months

Frame Benefit (for frames that exceed the allowance, and additional 30% discount may be applied to the coverage)2

Private Practice Provider

$130.00 retail frame allowance

Retail Chain Provider

$130.00 retail frame allowance

Lens Options Standard scratch-resistant coating -- covered in full. Other optional lens upgrades may be offered at a discount. (Discount varies by provider.)

Contact Lens Benefit3 Selection contact lenses The fitting/evaluation fees, contact lenses, and up to two follow-up visits are covered in full after copay (if applicable). If you choose disposable contacts, up to 4 boxes are included when obtained from a network provider.

Non selection contact lenses | $105.00 An allowance is applied toward the fitting/evaluation fees and purchase of contact lenses outside the covered selection. Materials copay (if applicable) is waived.

Necessary contact lenses4 Covered in full after applicable copay.

Up to $105.00 $210.00

Discounts Laser Vision - UnitedHealthcare has partnered with the Laser Vision Network of America (LVNA) to provide our members with access to discounted laser vision correction providers.

Members receive 15% off usual and customary pricing or 5% off promotional pricing at more than 550 network provider locations and even greater discounts through set pricing at LasikPlus locations. For more information, call 1-888-563-4497 or visit us at www.uhclasik.com.

Additional Material - At a participating network provider you will receive up to a 20% discount on an additional pair of eyeglasses or contact lenses. This program is available after your vision benefits have been exhausted. Please note that this discount shall not be considered insurance, and that UnitedHealthcare shall neither pay nor reimburse the provider or member for any funds owed or spent. Additional materials do not have to be purchased at the time of initial material purchase.

Hearing Aids – As a UnitedHealthcare plan member, you can save on high-quality hearing aids when you buy them from hi HealthInnovations™. To find out more go to hiHealthInnovations.com. When placing your order use promo code myVision to get the special price discount.

1

On all orders processed through a company owned and contracted Lab network.

30% discount available at participating network provider locations. May exclude certain frame manufacturers. Please verify all discounts with your provider.

Contact lenses are in lieu of eyeglass lenses and/or eyeglass frames. Coverage for Selection contact lenses does not apply at Costco, Walmart or Sam’s Club locations. The allowance for Non -selection contact lenses will be applied toward the fitting/evaluation fee and purchase of all contacts.

4 Necessary contact lenses are determined at the provider’s discretion for one or more of the following conditions: Following cataract surgery without intraocular lens implant; to correct extreme vision problems that cannot be corrected with eyeglass lenses and/or frames; with certain conditions such as anisometropia, keratoconus, irregular corneal/astigmatism, aphakia, facial deformity; or corneal deformity. If your provider considers your contacts necessary, you should ask your provider to contact UnitedHealthcare vision confirming the reimbursement that UnitedHealthcare will make before you purchase such contacts.

5 Actual tax savings will depend upon your individual tax bracket.

6 Approximate retail value illustrated: Exam & Refraction ($65), Single Vision Lenses ($80), and Frames ($130). Average retail costs may vary by provider.

7 For purposes of this calculation, Employee + Child(ren) is calculated with three (3) members.

8 For purposes of this sample calculation, Employee + Family is calculated with four (4) members.

2 3

19

Vision - Low Plan Monthly Premiums

Out-of-Network Reimbursements Up To: (copays do not apply)

EE Only

$7.11 Monthly

EE + Spouse

$13.53 Monthly

Exams

$40.00

EE + Child(ren)

$15.00 Monthly

Frames

$45.00

EE + Family

$17.40 Monthly

Single Vision Lenses

$40.00

Bifocal Lenses

$60.00

Co-Pays for In-Network Services Exam

$10

Trifocal Lenses

$80.00

Materials

$25

Lenticular Lenses Elective Contacts in Lieu of Eye Glasses3 Necessary Contacts in Lieu of Eye Glasses4

$80.00

Benefit Frequency Comprehensive Exam

Once every 12 months

Spectacle Lenses

Once every 12 months

Frames Contact Lenses in Lieu of Eye Glasses

Once every 12 months Once every 12 months

Frame Benefit (for frames that exceed the allowance, and additional 30% discount may be applied to the coverage)2

Private Practice Provider

$130.00 retail frame allowance

Retail Chain Provider

$130.00 retail frame allowance

Lens Options Standard scratch-resistant coating - covered in full. Other optional lens upgrades may be offered at a discount. (Discount varies by provider.)

Contact Lens Benefit3 Selection contact lenses The fitting/evaluation fees, contact lenses, and up to two follow-up visits are covered in full after copay (if applicable). If you choose disposable contacts, up to 4 boxes are included when obtained from a network provider.

Non selection contact lenses | $125.00 An allowance is applied toward the fitting/evaluation fees and purchase of contact lenses outside the covered selection. Materials copay (if applicable) is waived.

Up to $125.00 $210.00

Discounts Laser Vision - UnitedHealthcare has partnered with the Laser Vision Network of America (LVNA) to provide our members with access to discounted laser vision correction providers.

Members receive 15% off usual and customary pricing or 5% off promotional pricing at more than 550 network provider locations and even greater discounts through set pricing at LasikPlus locations. For more information, call 1-888-563-4497 or visit us at www.uhclasik.com.

Additional Material - At a participating network provider you will receive up to a 20% discount on an additional pair of eyeglasses or contact lenses. This program is available after your vision benefits have been exhausted. Please note that this discount shall not be considered insurance, and that UnitedHealthcare shall neither pay nor reimburse the provider or member for any funds owed or spent. Additional materials do not have to be purchased at the time of initial material purchase.

Hearing Aids – As a UnitedHealthcare plan member, you can save on high-quality hearing aids when you buy them from hi HealthInnovations™. To find out more go to hiHealthInnovations.com. When placing your order use promo code myVision to get the special price discount.

Necessary contact lenses4 Covered in full after applicable copay.

1

On all orders processed through a company owned and contracted Lab network.

30% discount available at participating network provider locations. May exclude certain frame manufacturers. Please verify all discounts with your provider.

3 Contact lenses are in lieu of eyeglass lenses and/or eyeglass frames. Coverage for Selection contact lenses does not apply at Costco, Walmart or Sam’s Club locations. The allowance for Non-selection contact lenses will be applied toward the fitting/evaluation fee and purchase of all contacts.

4 Necessary contact lenses are determined at the provider’s discretion for one or more of the following conditions: Following cataract surgery without intraocular lens implant; to correct extreme vision problems that cannot be corrected with eyeglass lenses and/or frames; with certain conditions such as anisometropia, keratoconus, irregular corneal/astigmatism, aphakia, facial deformity; or corneal deformity. If your provider considers your contacts necessary, you should ask your provider to contact UnitedHealthcare vision confirming the reimbursement that UnitedHealthcare will make before you purchase such contacts.

5 Actual tax savings will depend upon your individual tax bracket.

6 Approximate retail value illustrated: Exam & Refraction ($65), Single Vision Lenses ($80), and Frames ($130). Average retail costs may vary by provider.

7 For purposes of this calculation, Employee + Child(ren) is calculated with three (3) members.

8 For purposes of this sample calculation, Employee + Family is calculated with four (4) members.

2

20

Vision - High and Low Plan Important To Remember NETWORK  Always identify yourself as a UnitedHealthcare vision member when making your appointment.  Your participating provider will help you determine which contact lenses are available in the UnitedHealthcare selection.  Your contact lens allowance is applied to the fitting/ evaluation fees as well as the purchase of non-selection contact lenses. For example, if your allowance is  $125.00 and the fitting/evaluation fee is $35, you will have $90.00 toward the purchase of contact lenses. The allowance may be separated at some retail chain locations between the examining physician and the optical store.

Evaluation and fitting fee may vary among providers and type of fitting. Your material copay is waived when purchasing non-selection contacts.  Patient options such as UV, progressive lenses, etc., which are not covered-in-full, may be available at a discount at participating providers.

CHOICE AND ACCESS OF VISION CARE PROVIDERS UnitedHealthcare offers its vision program through a national network including both private practice and retail chain providers. To access the Provider Locator service, visit our website at www.myuhcvision.com or call 800-638-3120, 24 hours a day, seven days a week. You may also view your benefits, search for a provider or print an ID card online at myuhcvision.com.

Retain this UnitedHealthcare vision benefit summary which includes detailed benefit information and instructions on how to use the program. Please refer to your Certificate of Coverage for a full explanation of benefits.

Network Provider - copays and non-covered patient options are paid to provider by program participant at the time of service.

Non-Network Provider - participant pays full fee to the provider, and UnitedHealthcare reimburses the participant for services rendered up to the maximum allowance. Copays do not apply to non-network benefits. All receipts must be submitted at the same time to the following address: UnitedHealthcare Attn.

Claims Department P.O. Box 30978 Salt Lake City, UT 84130 FAX: 248.733.6060. Written proof of loss should be given to the Company within 90 days after the date of loss. If it was not reasonably possible to give written proof in the time required, the company will not reduce or deny the claim for this reason.

However, proof must be filed as soon as reasonably possible, no later than 1 year after the date of service unless the covered person was legally incapacitated.

21

THE STANDARD YOUR BENEFITS PACKAGE

Disability

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About this Benefit Disability insurance protects one of your most valuable assets, your paycheck. This insurance will replace a portion of your income, in the event that you become physically unable to work due to sickness or injury for an extended period of time.

Just over 1 in 4 of today's 20 year -olds will become disabled before they retire.

34.6 months is the duration of the average disability claim.

This is a general overview of your plan benefits. If the terms of this outline differ from your policy, the policy will govern. Additional plan details on covered expenses, limitations and exclusions are included in the summary plan description located on the 22 ESC Region 1 Benefits Website: www.mybenefitshub.com/region1

Disability Voluntary Long Term Disability Insurance Standard Insurance Company has developed this document to provide you with information about the optional insurance coverage you may select through ESC Region 1. Written in non-technical language, this is not intended as a complete description of the coverage. If you have additional questions, please refer to the group Voluntary Long Term Disability Insurance for Educators and Administrators brochure included in your packet or check with your human resources representative.

Eligibility To become insured, you must be: A regular employee of the Region 1 Education Service Center, excluding temporary or seasonal employees, full-time members of the armed forced, leased employees or independent contractors  Actively at work at least 30 hours each week  A citizen or resident of the Unites States or Canada



Employee Coverage Effective Date Please contact your benefit administrator for more information regarding the following requirements that must be satisfied for your insurance to become effective. You must satisfy:  Eligibility requirements  An eligibility waiting period  An evidence of insurability requirement, if applicable  An active work requirement. This means that if you are not actively at work on the day before the scheduled effective date of insurance, your insurance will not become effective until the day after you complete one full day of active work as an eligible employee.

Benefit Amount You may select a monthly benefit amount in $100 increments from $300 to $8,000; based on the tables and guidelines presented in the Rates section of these Coverage Highlights. The monthly benefit amount must not exceed 66 2/3 percent of your monthly earnings.

Benefits are payable for non-occupational disabilities only.

Occupational disabilities are not covered.

Plan Maximum Monthly Benefit: 66 2/3 percent of predisability earnings Plan Minimum Monthly Benefit: 25 percent of your LTD benefit before reduction by deductible income.

Benefit Waiting Period The benefit waiting period is the period of time that you must be continuously disabled before benefits become payable. Benefits are not payable during the benefit waiting period. The maximum benefit period is the period for which benefits are payable. The benefit waiting period options associated with your plan include: Option

Accidental Other Injury Disabilities

Maximum Benefit Period

Options 1-3: Maximum Benefit Period of 3 years for Sickness If you become disabled before age 64, LTD benefits may continue during disability for 3 years. If you become disabled at age 64 or older, the benefit duration is determined by your age when disability begins: Age

Maximum Benefit Period

64 65 66 67 68 69+

2 years 6 months 2 years 1 year 9 months 1 year 6 months 1 year 3 months 1 year

Options 1-4: Maximum Benefit Period of To SSNRA for Sickness and/ or Accident If If you become disabled before age 62, LTD benefits may continue during disability until you reach the Social Security Normal Retirement Age (SSNRA). If you become disabled at age 62 or older, the benefit duration is determined by your age when disability begins: Age Maximum Benefit Period 62 63 64 65 66 67 68 69+

To SSNRA or 3 years 6 months, whichever is longer To SSNRA or 3 years, whichever is longer To SSNRA or 2 years 6 months, whichever is longer 2 years 1 year 9 months 1 year 6 months 1 year 3 months 1 year

First Day Hospital Benefit With this benefit, if an insured employee is admitted as a hospital inpatient for at least four hours during the Benefit Waiting Period, the Benefit Waiting Period will be satisfied. Benefits become payable on the date of the hospitalization; the maximum benefit period also begins on that date. This feature is included only on LTP plans with Benefit Waiting Periods of 30 days or less.

Preexisting Condition Exclusion A general description of the Pre-existing Condition Exclusion is included in the Group Voluntary Long Term Disability insurance for Educators and Administrators brochure. If you have questions, please check with your benefit administrator.

Pre-existing Condition Period: The 180-day period just before your insurance become effective Exclusions Period: 12 months.

Preexisting Condition Waiver

1

0 days

3 days

3 years for Sickness and To SSNRA for Accident

For the first 90 days of disability, The Standard will pay full benefits even if you have a preexisting condition. After 90 days, The Standard will continue benefits only if the preexisting condition exclusion does not apply.

2

14 days

14 days

3 years for Sickness and To SSNRA for Accident

Own Occupation Period

3

30 days

30 days

3 years for Sickness and To SSNRA for Accident

4

90 days

90 days

To SSNRA for both Sickness and Accident

For the plan’s definition of disability, as described in your brochure, the own occupation period is the first 24 months for which LTD benefits are paid.

23

Disability Any Occupation Period

When Benefits End

The any occupation period begins at the end of the own occupation period and continues until the end of the maximum benefit period.

LTD benefits end automatically on the earliest of:  The date you are no longer disabled  The date your maximum benefit period ends  The date you die  The date benefits become payable under any other LTD plan under which you become insured through employment during a period of temporary recovery  The date you fail to provide proof of continued disability and entitlement to benefits

Other LTD Benefits

 





 



Employee Assistance Program (EAP) - This program offers support, guidance and resources that help an employee resolve personal issues and meet life’s challenges.

Family Care Expense Adjustment - Disabled employees faced with the added expense of family care when returning to work may receive combined income from LTD benefits and work earnings in excess of I00 percent of indexed predisability earnings during the first 12 months immediately after a disabled employee's return to work.

Special Dismemberment Provision—If an employee suffers a lost as a result of an accident, the employee will be considered disabled for the applicable Minimum Benefit Period and can extend beyond the end of the Maximum Benefit Period.

Reasonable Accommodation Expense Benefit—Subject to The Standard’s prior approval, this benefit allows us to pay up to $25,000 of employer’s expenses toward work-site modifications that result in a disabled employee’s return to work.

Survivor Benefit—A Survivor Benefit may also be payable. This benefit can help to address a family’s financial need in the event of the employee’s death.

Return to Work (RTW) Incentive - The Standard’s RTW Incentive is one of the most comprehensive in the employee benefits history. For the first 12 months after returning to work, the employee’s LTD benefit will not be reduced by work earnings until work earnings pays the LTD benefit exceed 100 percent of predisability earnings. After that period, only 50 percent of work earnings are deducted.

Rehabilitation Plan Provision—Subject to The Standard’s prior approval, rehabilitation incentives may include training and education expense, family (child and elder) care expenses, and job-related and job search expenses.

24

Rates Employees can select a monthly LTD benefit ranging from a minimum of $300 to a maximum amount based on how much they earn. Follow these steps, referencing the attached charts, to find the monthly cost for your desired level of monthly LTD benefit and benefit waiting period: 1. Find the maximum LTD benefit by locating the amount of your earnings in either the Annual Earnings or Monthly Earnings column. The LTD benefit amount shown associated with these earnings is the maximum amount you can receive. If your earnings fall between two amounts, you must select the lower amount.

2. Select the desired monthly LTD benefit between the minimum of $300 and the determined maximum amount, making sure not exceed the maximum for your earnings.

3. In the same row, select the desired benefit waiting period to see the monthly cost for that selection.

If you have questions regarding how to determine your monthly LTD benefit, the benefit waiting period, or the premium payment of your desired benefit, please contact your human resources representative.

Group Insurance Certificate If you become insured, you will receive a group insurance certificate containing a detailed description of the insurance coverage. The information presented above is controlled by the group policy and does not modify it in any way. The controlling provisions are in the group policy issued by Standard Insurance Company.

Disability Option 1: Maximum Benefit Period for 3 Years for Sickness & To SSNRA for Accident You are eligible for If your gross a maximum annual salary is at monthly benefit of: least:

Under 30

Ages 30- 34

Ages 35- 39

Ages 40-44

Ages 45-49

Ages 50 - 54

Ages 55- 59

Ages 60 +

$5,400

$300

$5.50

$7.01

$8.34

$9.63

$10.31

$11.15

$12.54

$16.34

$7,200

$400

$7.33

$9.35

$11.12

$12.84

$13.75

$14.87

$16.73

$21.78

$9,000

$500

$9.16

$11.68

$13.90

$16.05

$17.19

$18.59

$20.91

$27.23

$10,800

$600

$11.00

$14.02

$16.68

$19.26

$20.63

$22.31

$25.09

$32.68

$12,600

$700

$12.83

$16.36

$19.46

$22.47

$24.06

$26.03

$29.27

$38.12

$14,400

$800

$14.66

$18.69

$22.24

$25.68

$27.50

$29.74

$33.45

$43.57

$16,200

$900

$16.49

$21.03

$25.02

$28.89

$30.94

$33.46

$37.63

$49.01

$18,000

$1,000

$18.33

$23.37

$27.80

$32.10

$34.38

$37.18

$41.81

$54.46

$19,800

$1,100

$20.16

$25.70

$30.58

$35.31

$37.81

$40.90

$46.00

$59.90

$21,600

$1,200

$21.99

$28.04

$33.36

$38.52

$41.25

$44.62

$50.18

$65.35

$23,400

$1,300

$23.82

$30.38

$36.14

$41.73

$44.69

$48.34

$54.36

$70.80

$25,200

$1,400

$25.66

$32.71

$38.92

$44.94

$48.13

$52.05

$58.54

$76.24

$27,000

$1,500

$27.49

$35.05

$41.70

$48.15

$51.57

$55.77

$62.72

$81.69

$28,800

$1,600

$29.32

$37.39

$44.48

$51.36

$55.00

$59.49

$66.90

$87.13

$30,600

$1,700

$31.15

$39.72

$47.27

$54.57

$58.44

$63.21

$71.08

$92.58

$32,400

$1,800

$32.99

$42.06

$50.05

$57.78

$61.88

$66.93

$75.27

$98.03

$34,200

$1,900

$34.82

$44.40

$52.83

$60.99

$65.32

$70.64

$79.45

$103.47

$36,000

$2,000

$36.65

$46.73

$55.61

$64.20

$68.75

$74.36

$83.63

$108.92

$37,800

$2,100

$38.48

$49.07

$58.39

$67.41

$72.19

$78.08

$87.81

$114.36

$39,600

$2,200

$40.32

$51.41

$61.17

$70.62

$75.63

$81.80

$91.99

$119.81

$41,400

$2,300

$42.15

$53.74

$63.95

$73.83

$79.07

$85.52

$96.17

$125.26

$43,200

$2,400

$43.98

$56.08

$66.73

$77.04

$82.50

$89.23

$100.35

$130.70

$45,000

$2,500

$45.82

$58.42

$69.51

$80.26

$85.94

$92.95

$104.54

$136.15

$46,800

$2,600

$47.65

$60.75

$72.29

$83.47

$89.38

$96.67

$108.72

$141.59

$48,600

$2,700

$49.48

$63.09

$75.07

$86.68

$92.82

$100.39

$112.90

$147.04

$50,400

$2,800

$51.31

$65.43

$77.85

$89.89

$96.26

$104.11

$117.08

$152.49

$52,200

$2,900

$53.15

$67.76

$80.63

$93.10

$99.69

$107.82

$121.26

$157.93

$54,000

$3,000

$54.98

$70.10

$83.41

$96.31

$103.13

$111.54

$125.44

$163.38

$55,800

$3,100

$56.81

$72.44

$86.19

$99.52

$106.57

$115.26

$129.62

$168.83

$57,600

$3,200

$58.65

$74.77

$88.97

$102.73

$110.01

$118.98

$133.80

$174.27

$59,400

$3,300

$60.48

$77.11

$91.75

$105.94

$113.44

$122.69

$137.98

$179.72

$61,200

$3,400

$62.31

$79.45

$94.53

$109.15

$116.88

$126.41

$142.17

$185.16

$63,000

$3,500

$64.14

$81.78

$97.31

$112.36

$120.32

$130.13

$146.35

$190.61

$64,800

$3,600

$65.98

$84.12

$100.09

$115.57

$123.76

$133.85

$150.53

$196.06

$66,600

$3,700

$67.81

$86.46

$102.87

$118.78

$127.19

$137.57

$154.71

$201.50

$68,400

$3,800

$69.64

$88.79

$105.65

$121.99

$130.63

$141.28

$158.89

$206.95

$70,200

$3,900

$71.47

$91.13

$108.43

$125.20

$134.07

$145.00

$163.07

$212.39

$72,000

$4,000

$73.31

$93.47

$111.21

$128.41

$137.51

$148.72

$167.25

$217.84 25

Disability You are eligible for If your gross a maximum annual salary is monthly benefit of: at least:

Under 30

Ages 30- 34

Ages 35- 39

Ages 40-44

Ages 45-49

Ages 50 - 54

Ages 55- 59

Ages 60 +

$95.80

$113.99

$131.62

$140.94

$152.44

$171.43

$223.29

73,800

$4,100

$75.14

$75,600

$4,200

$76.97

$98.14

$116.77

$134.83

$144.38

$156.16

$175.62

$228.73

$77,400

$4,300

$78.80

$100.48

$119.55

$138.04

$147.82

$159.87

$179.80

$234.18

$79,200

$4,400

$80.64

$102.81

$122.33

$141.25

$151.26

$163.59

$183.98

$239.62

$81,000

$4,500

$82.47

$105.15

$125.12

$144.47

$154.70

$167.31

$188.16

$245.07

$82,800

$4,600

$84.30

$107.49

$127.90

$147.68

$158.13

$171.03

$192.34

$250.52

$84,600

$4,700

$86.14

$109.82

$130.68

$150.89

$161.57

$174.75

$196.52

$255.96

$86,400

$4,800

$87.97

$112.16

$133.46

$154.10

$165.01

$178.46

$200.70

$261.41

$88,200

$4,900

$89.80

$114.50

$136.24

$157.31

$168.45

$182.18

$204.89

$266.85

$90,000

$5,000

$91.63

$116.83

$139.02

$160.52

$171.88

$185.90

$209.07

$272.30

$91,800

$5,100

$93.47

$119.17

$141.80

$163.73

$175.32

$189.62

$213.25

$277.75

$93,600

$5,200

$95.30

$121.51

$144.58

$166.94

$178.76

$193.34

$217.43

$283.19

$95,400

$5,300

$97.13

$123.84

$147.36

$170.15

$182.20

$197.05

$221.61

$288.64

$97,200

$5,400

$98.96

$126.18

$150.14

$173.36

$185.63

$200.77

$225.79

$294.08

$99,000

$5,500

$100.80

$128.52

$152.92

$176.57

$189.07

$204.49

$229.97

$299.53

$100,800

$5,600

$102.63

$130.85

$155.70

$179.78

$192.51

$208.21

$234.15

$304.98

$102,600

$5,700

$104.46

$133.19

$158.48

$182.99

$195.95

$211.93

$238.34

$310.42

$104,400

$5,800

$106.29

$135.53

$161.26

$186.20

$199.38

$215.64

$242.52

$315.87

$106,200

$5,900

$108.13

$137.86

$164.04

$189.41

$202.82

$219.36

$246.70

$321.31

$108,000

$6,000

$109.96

$140.20

$166.82

$192.62

$206.26

$223.08

$250.88

$326.76

$109,800

$6,100

$111.79

$142.54

$169.60

$195.83

$209.70

$226.80

$255.06

$332.21

$111,600

$6,200

$113.63

$144.87

$172.38

$199.04

$213.14

$230.52

$259.24

$337.65

$114,400

$6,300

$115.46

$147.21

$175.16

$202.25

$216.57

$234.23

$263.42

$343.10

$115,200

$6,400

$117.29

$149.55

$177.94

$205.46

$220.01

$237.95

$267.61

$348.54

$117,000

$6,500

$119.12

$151.88

$180.72

$208.67

$223.45

$241.67

$271.79

$353.99

$118,800

$6,600

$120.96

$154.22

$183.50

$211.88

$226.89

$245.39

$275.97

$359.44

$120,600

$6,700

$122.79

$156.56

$186.28

$215.09

$230.32

$249.11

$280.15

$364.88

$122,400

$6,800

$124.62

$158.89

$189.06

$218.30

$233.76

$252.82

$284.33

$370.33

$124,200

$6,900

$126.45

$161.23

$191.84

$221.51

$237.20

$256.54

$288.51

$375.77

$126,000

$7,000

$128.29

$163.57

$194.62

$224.72

$240.64

$260.26

$292.69

$381.22

$127,800

$7,100

$130.12

$165.90

$197.40

$227.93

$244.07

$263.98

$296.87

$386.67

$129,600

$7,200

$131.95

$168.24

$200.18

$231.14

$247.51

$267.70

$301.06

$392.11

$131,400

$7,300

$133.78

$170.58

$202.96

$234.35

$250.95

$271.41

$305.24

$397.56

$133,200

$7,400

$135.62

$172.91

$205.74

$237.56

$254.39

$275.13

$309.42

$403.00

$135,000

$7,500

$137.45

$175.25

$208.53

$240.78

$257.83

$278.85

$313.60

$408.45

$136,800

$7,600

$139.28

$177.59

$211.31

$243.99

$261.26

$282.57

$317.78

$413.90

$138,600

$7,700

$141.12

$179.92

$214.09

$247.20

$264.70

$286.29

$321.96

$419.34

$140,400

$7,800

$142.95

$182.26

$216.87

$250.41

$268.14

$290.00

$326.14

$424.79

$142,200

$7,900

$144.78

$184.60

$219.65

$253.62

$271.58

$293.72

$330.33

$430.23

$144,000

$8,000

$146.61

$186.93

$222.43

$256.83

$275.01

$297.44

$334.51

$435.68

26

Disability Option 2: Maximum Benefit Period for 3 Years for Sickness & To SSNRA for Accident You are eligible for If your gross a maximum annual salary is at monthly benefit of: least:

Under 30

Ages 30- 34

Ages 35- 39

Ages 40-44

Ages 45-49

Ages 50 - 54

Ages 55- 59

Ages 60 +

$5,400

$300

$3.49

$4.57

$5.66

$6.71

$7.26

$7.74

$8.80

$11.20

$7,200

$400

$4.65

$6.10

$7.54

$8.95

$9.67

$10.32

$11.73

$14.94

$9,000

$500

$5.81

$7.62

$9.43

$11.19

$12.09

$12.89

$14.66

$18.67

$10,800

$600

$6.98

$9.15

$11.31

$13.43

$14.51

$15.47

$17.60

$22.41

$12,600

$700

$8.14

$10.67

$13.20

$15.67

$16.93

$18.05

$20.53

$26.14

$14,400

$800

$9.30

$12.20

$15.08

$17.90

$19.35

$20.63

$23.46

$29.88

$16,200

$900

$10.46

$13.72

$16.97

$20.14

$21.77

$23.21

$26.39

$33.61

$18,000

$1,000

$11.63

$15.25

$18.86

$22.38

$24.19

$25.79

$29.33

$37.35

$19,800

$1,100

$12.79

$16.77

$20.74

$24.62

$26.60

$28.37

$32.26

$41.08

$21,600

$1,200

$13.95

$18.30

$22.63

$26.85

$29.02

$30.95

$35.19

$44.82

$23,400

$1,300

$15.11

$19.82

$24.51

$29.09

$31.44

$33.52

$38.12

$48.55

$25,200

$1,400

$16.28

$21.35

$26.40

$31.33

$33.86

$36.10

$41.06

$52.29

$27,000

$1,500

$17.44

$22.87

$28.28

$33.57

$36.28

$38.68

$43.99

$56.02

$28,800

$1,600

$18.60

$24.40

$30.17

$35.81

$38.70

$41.26

$46.92

$59.76

$30,600

$1,700

$19.76

$25.92

$32.06

$38.04

$41.11

$43.84

$49.85

$63.49

$30,600

$1,700

$19.76

$25.92

$32.06

$38.04

$41.11

$43.84

$49.85

$63.49

$34,200

$1,900

$22.09

$28.97

$35.83

$42.52

$45.95

$49.00

$55.72

$70.96

$32,400

$1,800

$20.93

$27.45

$33.94

$40.28

$43.53

$46.42

$52.79

$67.23

$36,000

$2,000

$23.25

$30.50

$37.71

$44.76

$48.37

$51.58

$58.65

$74.70

$37,800

$2,100

$24.41

$32.02

$39.60

$47.00

$50.79

$54.15

$61.58

$78.43

$39,600

$2,200

$25.58

$33.55

$41.48

$49.23

$53.21

$56.73

$64.52

$82.17

$41,400

$2,300

$26.74

$35.07

$43.37

$51.47

$55.63

$59.31

$67.45

$85.90

$43,200

$2,400

$27.90

$36.60

$45.25

$53.71

$58.04

$61.89

$70.38

$89.64

$45,000

$2,500

$29.07

$38.12

$47.14

$55.95

$60.46

$64.47

$73.31

$93.37

$46,800

$2,600

$30.23

$39.64

$49.03

$58.19

$62.88

$67.05

$76.25

$97.11

$48,600

$2,700

$31.39

$41.17

$50.91

$60.42

$65.30

$69.63

$79.18

$100.84

$50,400

$2,800

$32.55

$42.69

$52.80

$62.66

$67.72

$72.21

$82.11

$104.58

$52,200

$2,900

$33.72

$44.22

$54.68

$64.90

$70.14

$74.79

$85.04

$108.31

$54,000

$3,000

$34.88

$45.74

$56.57

$67.14

$72.56

$77.36

$87.97

$112.05

$55,800

$3,100

$36.04

$47.26

$58.46

$69.38

$74.98

$79.94

$90.90

$115.79

$57,600

$3,200

$37.21

$48.79

$60.34

$71.62

$77.40

$82.52

$93.83

$119.52

$59,400

$3,300

$38.37

$50.31

$62.23

$73.85

$79.82

$85.10

$96.77

$123.26

$61,200

$3,400

$39.53

$51.84

$64.11

$76.09

$82.23

$87.67

$99.70

$126.99

$63,000

$3,500

$40.69

$53.36

$66.00

$78.33

$84.65

$90.25

$102.63

$130.73

$64,800

$3,600

$41.86

$54.89

$67.88

$80.57

$87.07

$92.83

$105.56

$134.46

$66,600

$3,700

$43.02

$56.41

$69.77

$82.81

$89.49

$95.41

$108.50

$138.20

$68,400

$3,800

$44.18

$57.94

$71.66

$85.04

$91.91

$97.99

$111.43

$141.93

$70,200

$3,900

$45.34

$59.46

$73.54

$87.28

$94.33

$100.57

$114.36

$145.67

$72,000

$4,000

$46.51

$60.99

$75.43

$89.52

$96.75

$103.15

$117.29 27 $149.40

Disability You are eligible for If your gross a maximum annual salary is monthly benefit of: at least:

Under 30

Ages 30- 34

Ages 35- 39

Ages 40-44

Ages 45-49

Ages 50 - 54

Ages 55- 59

Ages 60 +

$73,800 $75,600 $77,400 $79,200 $81,000 $82,800 $84,600 $86,400 $88,200 $90,000 $91,800 $93,600 $95,400 $97,200 $99,000 $100,800 $102,600 $104,400 $106,200 $108,000 $109,800 $111,600 $114,400 $115,200 $117,000 $118,800 $120,600 $122,400 $124,200 $126,000

$4,100 $4,200 $4,300 $4,400 $4,500 $4,600 $4,700 $4,800 $4,900 $5,000 $5,100 $5,200 $5,300 $5,400 $5,500 $5,600 $5,700 $5,800 $5,900 $6,000 $6,100 $6,200 $6,300 $6,400 $6,500 $6,600 $6,700 $6,800 $6,900 $7,000

$47.67 $48.83 $49.99 $51.16 $52.32 $53.48 $54.65 $55.81 $56.97 $58.13 $59.30 $60.46 $61.62 $62.78 $63.95 $65.11 $66.27 $67.43 $68.60 $69.76 $70.92 $72.09 $73.25 $74.41 $75.57 $76.74 $77.90 $79.06 $80.22 $81.39

$62.51 $64.04 $65.56 $67.09 $68.61 $70.13 $71.66 $73,18 $74.71 $76.23 $77.76 $79.28 $80.81 $82.33 $83.86 $85.38 $86.91 $88.43 $89.96 $91.48 $93.00 $94.53 $96.05 $97.58 $99.10 $100.63 $102.15 $103.68 $105.20 $106.73

$77.31 $79.20 $81.08 $82.97 $84.86 $86.74 $88.63 $90.51 $92.40 $94.28 $96.17 $98.05 $99.94 $101.83 $103.71 $105.60 $107.48 $109.37 $111.25 $113.14 $115.03 $116.91 $118.80 $120.68 $122.57 $124.45 $126.34 $128.23 $130.11 $132.00

$91.76 $94.00 $96.23 $98.47 $100.71 $102.95 $105.19 $107.42 $109.66 $111.90 $114.14 $116.38 $118.61 $120.85 $123.09 $125.33 $127.57 $129.80 $132.04 $134.28 $136.52 $138.76 $140.99 $143.23 $145.47 $147.71 $149.95 $152.18 $154.42 $156.66

$99.17 $101.58 $104.00 $106.42 $108.84 $111.26 $113.68 $116.10 $118.51 $120.93 $123.35 $125.77 $128.19 $130.61 $133.03 $135.45 $137.86 $140.28 $142.70 $145.12 $147.54 $149.96 $152.38 $154.79 $157.21 $159.63 $162.05 $164.47 $166.89 $169.31

$105.73 $108.30 $110.88 $113.46 $116.04 $118.62 $121.20 $123.78 $126.35 $128.93 $131.51 $134.09 $136.67 $139.25 $141.83 $144.41 $146.98 $149.56 $152.14 $154.72 $157.30 $159.88 $162.46 $165.03 $167.61 $170.19 $172.77 $175.35 $177.93 $180.51

$120.23 $123.16 $126.09 $129.02 $131.96 $134.89 $137.82 $140.75 $143.68 $146.62 $149.55 $152.48 $155.41 $158.35 $161.28 $164.21 $167.14 $170.08 $173.01 $175.94 $178.87 $181.80 $184.74 $187.67 $190.60 $193.53 $196.47 $199.40 $202.33 $205.26

$153.14 $156.87 $160.61 $164.34 $168.08 $171.81 $175.55 $179.28 $183.02 $186.75 $190.49 $194.22 $197.96 $201.69 $205.43 $209.16 $212.90 $216.63 $220.37 $224.10 $227.84 $231.57 $235.31 $239.04 $242.78 $246.51 $250.25 $253.98 $257.72 $261.45

$127,800 $129,600 $131,400 $133,200 $135,000 136,800 $138,600 $140,400 $142,200 $144,000

$7,100 $7,200 $7,300 $7,400 $7,500 $7,600 $7,700 $7,800 $7,900 $8,000

$82.55 $83.71 $84.87 $86.04 $87.20 $88.36 $89.53 $90.69 $91.85 $93.01

$108.25 $109.78 $111.30 $112.83 $114.35 $115.87 $117.40 $118.92 $120.45 $121.97

$133.88 $135.77 $137.65 $139.54 $141.43 $143.31 $145.20 $147.08 $148.97 $150.85

$158.90 $161.14 $163.37 $165.61 $167.85 $170.09 $172.33 $174.56 $176.80 $179.04

$171.73 $174.14 $176.56 $178.98 $181.40 $183.82 $186.24 $188.66 $191.07 $193.49

$183.09 $185.66 $188.24 $190.82 $193.40 $195.98 $198.56 $201.14 $203.71 $206.29

$208.20 $211.13 $214.06 $216.99 $219.93 $222.86 $225.79 $228.72 $231.65 $234.59

$265.19 $268.92 $272.66 $276.39 $280.13 $283.86 $287.60 $291.33 $295.07 $298.80

28

Disability Option 3: Maximum Benefit Period for 3 Years for Sickness & To SSNRA for Accident You are eligible for If your gross annua maximum al salary is at least: monthly benefit of:

Under 30

Ages 30- 34

Ages 35- 39

Ages 40-44

Ages 45-49

Ages 50 - 54

Ages 55- 59

Ages 60 +

$5,400

$300

$1.93

$2.64

$3.51

$4.41

$4.92

$5.41

$6.41

$8.72

$7,200

$400

$2.58

$3.52

$4.68

$5.88

$6.56

$7.21

$8.55

$11.63

$9,000

$500

$3.22

$4.40

$5.85

$7.35

$8.21

$9.02

$10.69

$14.53

$10,800

$600

$3.87

$5.28

$7.02

$8.82

$9.85

$10.82

$12.83

$17.44

$12,600

$700

$4.51

$6.16

$8.19

$10.29

$11.49

$12.63

$14.97

$20.35

$14,400

$800

$5.16

$7.04

$9.36

$11.76

$13.13

$14.43

$17.11

$23.25

$16,200

$900

$5.80

$7.92

$10.53

$13.23

$14.77

$16.23

$19.24

$26.16

$18,000

$1,000

$6.45

$8.80

$11.70

$14.70

$16.41

$18.04

$21.38

$29.07

$19,800

$1,100

$7.09

$9.68

$12.86

$16.16

$18.05

$19.84

$23.52

$31.97

$21,600

$1,200

$7.74

$10.56

$14.03

$17.63

$19.69

$21.64

$25.66

$34.88

$23,400

$1,300

$8.38

$11.44

$15.20

$19.10

$21.33

$23.45

$27.80

$37.79

$25,200

$1,400

$9.02

$12.32

$16.37

$20.57

$22.98

$25.25

$29.94

$40.69

$27,000

$1,500

$9.67

$13.20

$17.54

$22.04

$24.62

$27.06

$32.07

$43.60

$28,800

$1,600

$10.31

$14.08

$18.71

$23.51

$26.26

$28.86

$34.21

$46.51

$30,600

$1,700

$10.96

$14.96

$19.88

$24.98

$27.90

$30.66

$36.35

$49.41

$32,400

$1,800

$11.60

$15.84

$21.05

$26.45

$29.54

$32.47

$38.49

$52.32

$34,200

$1,900

$12.25

$16.72

$22.22

$27.92

$31.18

$34.27

$40.63

$55.23

$36,000

$2,000

$12.89

$17.60

$23.39

$29.39

$32.82

$36.07

$42.77

$58.13

$37,800

$2,100

$13.54

$18.48

$24.56

$30.86

$34.46

$37.88

$44.90

$61.04

$39,600

$2,200

$14.18

$19.36

$25.73

$32.33

$36.10

$39.68

$47.04

$63.95

$41,400

$2,300

$14.83

$20.24

$26.90

$33.80

$37.75

$41.49

$49.18

$66.85

$43,200

$2,400

$15.47

$21.12

$28.07

$35.27

$39.39

$43.29

$51.32

$69.76

$45,000

$2,500

$16.12

$22.00

$29.24

$36.74

$41.03

$45.09

$53.46

$72.67

$46,800

$2,600

$16.76

$22.88

$30.41

$38.21

$42.67

$46.90

$55.60

$75.57

$48,600

$2,700

$17.40

$23.76

$31.58

$39.68

$44.31

$48.70

$57.73

$78.48

$50,400

$2,800

$18.05

$24.64

$32.75

$41.15

$45.95

$50.50

$59.87

$81.38

$52,200

$2,900

$18.69

$25.52

$33.92

$42.62

$47.59

$52.31

$62.01

$84.29

$54,000

$3,000

$19.34

$26.40

$35.09

$44.09

$49.23

$54.11

$64.15

$87.20

$55,800

$3,100

$19.98

$27.28

$36.26

$45.56

$50.87

$55.91

$66.29

$90.11

$57,600

$3,200

$20.63

$28.16

$37.43

$47.03

$52.51

$57.72

$68.43

$93.01

$59,400

$3,300

$21.27

$29.04

$38.60

$48.50

$54.15

$59.52

$70.57

$95.92

$61,200

$3,400

$21.92

$29.92

$39.77

$49.97

$55.79

$61.32

$72.70

$98.83

$63,000

$3,500

$22.56

$30.80

$40.94

$51.44

$57.44

$63.13

$74.84

$101.73

$64,800

$3,600

$23.21

$31.68

$42.11

$52.91

$59.08

$64.93

$76.98

$104.64

$66,600

$3,700

$23.85

$32.56

$43.28

$54.38

$60.72

$66.74

$79.12

$107.55

$68,400

$3,800

$24.50

$33.44

$44.45

$55.85

$62.36

$68.54

$81.26

$110.45

$70,200

$3,900

$25.14

$34.32

$45.62

$57.32

$64.00

$70.34

$83.40

$113.36

$72,000

$4,000

$25.79

$35.20

$46.79

$58.79

$65.64

$72.15

$85.53

$116.27 29

Disability You are eligible for If your gross annual a maximum salary is at least: monthly benefit of:

Under 30

Ages 30- 34

Ages 35- 39

Ages 40-44

Ages 45-49

Ages 50 - 54

Ages 55- 59

Ages 60 +

$73,800

$4,100

$26.43

$36.08

$47.96

$60.26

$67.28

$73.95

$87.67

$119.17

$75,600 $77,400 $79,200 $81,000 $82,800 $84,600 $86,400 $88,200 $90,000 $91,800 $93,600 $95,400 $97,200 $99,000 $100,800 $102,600 $104,400 $106,200 $108,000 $109,800 $111,600 $114,400 $115,200 $117,000 $118,800 $120,600

$4,200 $4,300 $4,400 $4,500 $4,600 $4,700 $4,800 $4,900 $5,000 $5,100 $5,200 $5,300 $5,400 $5,500 $5,600 $5,700 $5,800 $5,900 $6,000 $6,100 $6,200 $6,300 $6,400 $6,500 $6,600 $6,700

$27.08 $27.72 $28.37 $29.01 $29.65 $30.30 $30.94 $31.59 $32.23 $32.88 $33.52 $34.17 $34.81 $35.46 $36.10 $36.75 $37.39 $38.04 $38.68 $39.32 $39.97 $40.61 $41.26 $41.90 $42.55 $43.19

$36.96 $37.84 $38.72 $39.60 $40.48 $41.36 $42.24 $43.12 $44.00 $44.88 $45.76 $46.64 $47.52 $48.40 $49.28 $50.16 $51.04 $51.92 $52.80 $53.68 $54.56 $55.44 $56.32 $57.20 $58.08 $58.96

$49.13 $50.30 $51.47 $52.64 $53.80 $54.97 $56.14 $57.31 $58.48 $59.65 $60.82 $61.99 $63.16 $64.33 $65.50 $66.67 $67.84 $69.01 $70.18 $71.35 $72.52 $73.69 $74.86 $76.03 $77.20 $78.37

$61.73 $63.20 $64.67 $66.14 $67.60 $69.07 $70.54 $72.01 $73.48 $74.95 $76.42 $77.89 $79.36 $80.83 $82.30 $83.77 $85.24 $86.71 $88.18 $89.65 $91.12 $92.59 $94.06 $95.53 $97.00 $98.47

$68.92 $70.56 $72.20 $73.85 $75.49 $77.13 $78.77 $80.41 $82.05 $83.69 $85.33 $86.97 $88.61 $90.26 $91.90 $93.54 $95.18 $96.82 $98.46 $100.10 $101.74 $103.38 $105.02 $106.67 $108.31 $109.95

$75.75 $77.56 $79.36 $81.17 $82.97 $84.77 $86.58 $88.38 $90.18 $91.99 $93.79 $95.59 $97.40 $99.20 $101.01 $102.81 $104.61 $106.42 $108.22 $110.02 $111.83 $113.63 $115.43 $117.24 $119.04 $120.85

$89.81 $91.95 $94.09 $96.23 $98.36 $100.50 $102.64 $104.78 $106.92 $109.06 $111.19 $113.33 $115.47 $117.61 $119.75 $121.89 $124.02 $126.16 $128.30 $130.44 $132.58 $134.72 $136.85 $138.99 $141.13 $143.27

$122.08 $124.99 $127.89 $130.80 $133.71 $136.61 $139.52 $142.43 $145.33 $148.24 $151.15 $154.05 $156.96 $159.87 $162.77 $165.68 $168.59 $171.49 $174.40 $177.31 $180.21 $183.12 $186.03 $188.93 $191.84 $194.7

$122,400 $124,200 $126,000 $127,800 $129,600 $131,400 $133,200

$6,800 $6,900 $7,000 $7,100 $7,200 $7,300 $7,400

$43.84 $44.48 $45.13 $45.77 $46.42 $47.06 $47.71

$59.84 $60.72 $61.60 $62.48 $63.36 $64.24 $65.12

$79.54 $80.71 $81.88 $83.05 $84.22 $85.39 $86.56

$99.94 $101.41 $102.88 $104.35 $105.82 $107.29 $108.76

$111.59 $113.23 $114.87 $116.51 $118.15 $119.79 $121.43

$122.65 $124.45 $126.26 $128.06 $129.86 $131.67 $133.47

$145.41 $147.55 $149.68 $151.82 $153.96 $156.10 $158.24

$197.65 $200.56 $203.47 $206.37 $209.28 $212.19 $215.09

$135,000

$7,500

$48.35

$66.00

$87.73

$110.23

$123.08

$135.28

$160.38

$218.00

$136,800 $138,600 $140,400 $142,200 $144,000

$7,600 $7,700 $7,800 $7,900 $8,000

$48.99 $49.64 $50.28 $50.93 $51.57

$66.88 $67.76 $68.64 $69.52 $70.40

$88.89 $90.06 $91.23 $92.40 $93.57

$111.69 $113.16 $114.63 $116.10 $117.57

$124.72 $126.36 $128.00 $129.64 $131.28

$137.08 $138.88 $140.69 $142.49 $144.29

$162.51 $164.65 $166.79 $168.93 $171.07

$220.91 $223.81 $226.72 $229.63 $232.53

30

Disability Option 4: Maximum Benefit Period of To SSNRA for both Sickness and Accident You are eligible for a If your gross annual maximum monthly salary is at least: benefit of:

Under 30

Ages 30- 34

Ages 35- 39

Ages 40-44

Ages 45-49

Ages 50 - 54

Ages 55- 59

Ages 60 +

$5,400

$300

$0.90

$1.09

$1.57

$2.22

$2.76

$3.54

$4.80

$6.77

$7,200

$400

$1.20

$1.46

$2.09

$2.96

$3.68

$4.72

$6.40

$9.03

$9,000 $10,800

$500 $600

$1.50 $1.80

$1.82 $2.19

$2.62 $3.14

$3.71 $4.45

$4.60 $5.51

$5.90 $7.08

$8.00 $9.60

$11.29 $13.55

$12,600

$700

$2.10

$2.55

$3.67

$5.19

$6.43

$8.26

$11.20

$15.81

$14,400

$800

$2.40

$2.92

$4.19

$5.93

$7.35

$9.44

$12.80

$18.07

$16,200

$900

$2.70

$3.28

$4.71

$6.67

$8.27

$10.62

$14.40

$20.32

$18,000

$1,000

$3.00

$3.65

$5.24

$7.41

$9.19

$11.80

$16.00

$22.58

$19,800

$1,100

$3.30

$4.01

$5.76

$8.15

$10.11

$12.98

$17.60

$24.84

$21,600

$1,200

$3.60

$4.38

$6.28

$8.89

$11.03

$14.16

$19.20

$27.10

$23,400

$1,300

$3.90

$4.74

$6.81

$9.64

$11.95

$15.34

$20.81

$29.36

$25,200

$1,400

$4.20

$5.10

$7.33

$10.38

$12.87

$16.52

$22.41

$31.61

$27,000

$1,500

$4.50

$5.47

$7.86

$11.12

$13.79

$17.70

$24.01

$33.87

$28,800

$1,600

$4.80

$5.83

$8.38

$11.86

$14.71

$18.88

$25.61

$36.13

$30,600

$1,700

$5.11

$6.20

$8.90

$12.60

$15.62

$20.05

$27.21

$38.39

$32,400

$1,800

$5.41

$6.56

$9.43

$13.34

$16.54

$21.23

$28.81

$40.65

$34,200

$1,900

$5.71

$6.93

$9.95

$14.08

$17.46

$22.41

$30.41

$42.91

$36,000

$2,000

$6.01

$7.29

$10.47

$14.82

$18.38

$23.59

$32.01

$45.16

$37,800

$2,100

$6.31

$7.66

$11.00

$15.57

$19.30

$24.77

$33.61

$47.42

$39,600

$2,200

$6.61

$8.02

$11.52

$16.31

$20.22

$25.95

$35.21

$49.68

$41,400

$2,300

$6.91

$8.39

$12.05

$17.05

$21.14

$27.13

$36.81

$51.94

$43,200

$2,400

$7.21

$8.75

$12.57

$17.79

$22.06

$28.31

$38.41

$54.20

$45,000

$2,500

$7.51

$9.12

$13.09

$18.53

$22.98

$29.49

$40.01

$56.46

$46,800

$2,600

$7.81

$9.48

$13.62

$19.27

$23.90

$30.67

$41.61

$58.71

$48,600

$2,700

$8.11

$9.84

$14.14

$20.01

$24.82

$31.85

$43.21

$60.97

$50,400

$2,800

$8.41

$10.21

$14.66

$20.75

$25.73

$33.03

$44.81

$63.23

$52,200

$2,900

$8.71

$10.57

$15.19

$21.49

$26.65

$34.21

$46.41

$65.49

$54,000

$3,000

$9.01

$10.94

$15.71

$22.24

$27.57

$35.39

$48.01

$67.75

$55,800

$3,100

$9.31

$11.30

$16.23

$22.98

$28.49

$36.57

$49.61

$70.01

$57,600

$3,200

$9.61

$11.67

$16.76

$23.72

$29.41

$37.75

$51.21

$72.27

$59,400

$3,300

$9.91

$12.03

$17.28

$24.46

$30.33

$38.93

$52.81

$74.53

$61,200

$3,400

$10.21

$12.40

$17.80

$25.21

$31.25

$40.11

$54.41

$76.78

$63,000

$3,500

$10.51

$12.76

$18.33

$25.95

$32.17

$41.29

$56.01

$79.04

$64,800

$3,600

$10.81

$13.13

$18.85

$26.69

$33.08

$42.47

$57.61

$81.30

$66,600

$3,700

$11.11

$13.49

$19.38

$27.43

$34.00

$43.65

$59.21

$83.56

$68,400

$3,800

$11.41

$13.86

$19.90

$28.17

$34.92

$44.83

$60.81

$85.82

$70,200

$3,900

$11.71

$14.22

$20.42

$28.91

$35.84

$46.01

$62.41

$88.08

$72,000

$4,000

$12.01

$14.59

$20.95

$29.65

$36.76

$47.19

$64.01

$90.33 31

Disability Option 4: Maximum Benefit Period of 3 Years of Sickness & To SSNRA for Accident You are eligible for If your gross a maximum annual salary is monthly benefit of: at least: $73,800 $75,600 $77,400 $79,200 $81,000 $82,800 $84,600 $86,400 $88,200 $90,000 $91,800 $93,600 $95,400 $97,200 $99,000 $100,800 $102,600 $104,400 $106,200 $108,000 $109,800 $111,600 $114,400 $115,200 $117,000 $118,800 $120,600 $122,400 $124,200 $126,000 $127,800 $129,600 $131,400 $133,200 $135,000 $136,800 $138,600 $140,400 $142,200 $144,000 32

$4,100 $4,200 $4,300 $4,400 $4,500 $4,600 $4,700 $4,800 $4,900 $5,000 $5,100 $5,200 $5,300 $5,400 $5,500 $5,600 $5,700 $5,800 $5,900 $6,000 $6,100 $6,200 $6,300 $6,400 $6,500 $6,600 $6,700 $6,800 $6,900 $7,000 $7,100 $7,200 $7,300 $7,400 $7,500 $7,600 $7,700 $7,800 $7,900 $8,000

Under 30

Ages 30- 34

Ages 35- 39

Ages 40-44

Ages 45-49

Ages 50 - 54

Ages 55- 59

Ages 60 +

$12.31 $12.61 $12.91 $13.21 $13.52 $13.82 $14.12 $14.42 $14.72 $15.02 $15.32 $15.62 $15.92 $16.22 $16.52 $16.82 $17.12 $17.42 $17.72 $18.02 $18.32 $18.62 $18.92 $19.22 $19.52 $19.82 $20.12 $20.42 $20.72 $21.02 $21.32 $21.62 $21.92 $22.22 $22.53 $22.83 $23.13 $23.43 $23.73 $24.03

$14.95 $15.32 $15.68 $16.05 $16.41 $16.77 $17.14 $17.50 $17.87 $18.23 $18.60 $18.96 $19.33 $19.69 $20.06 $20.42 $20.79 $21.15 $21.52 $21.88 $22.24 $22.61 $22.97 $23.34 $23.70 $24.07 $24.43 $24.80 $25.16 $25.53 $25.89 $26.26 $26.62 $26.99 $27.35 $27.71 $28.08 $28.44 $28.81 $29.17

$21.47 $21.99 $22.52 $23.04 $23.57 $24.09 $24.61 $25.14 $25.66 $26.18 $26.71 $27.23 $27.75 $28.28 $28.80 $29.33 $29.85 $30.37 $30.90 $31.42 $31.94 $32.47 $32.99 $33.51 $34.04 $34.56 $35.09 $35.61 $36.13 $36.66 $37.18 $37.70 $38.23 $38.75 $39.28 $39.80 $40.32 $40.85 $41.37 $41.89

$30.39 $31.14 $31.88 $32.62 $33.36 $34.10 $34.84 $35.58 $36.33 $37.07 $37.81 $38.55 $39.29 $40.03 $40.77 $41.51 $42.26 $43.00 $43.74 $44.48 $45.22 $45.96 $46.70 $47.45 $48.19 $48.93 $49.67 $50.41 $51.15 $51.89 $52.63 $53.38 $54.12 $54.86 $55.60 $56.34 $57.08 $57.82 $58.57 $59.31

$37.68 $38.60 $39.52 $40.44 $41.36 $42.27 $43.19 $44.11 $45.03 $45.95 $46.87 $47.79 $48.71 $49.63 $50.55 $51.46 $52.38 $53.30 $54.22 $55.14 $56.06 $56.98 $57.90 $58.82 $59.74 $60.65 $61.57 $62.49 $63.41 $64.33 $65.25 $66.17 $67.09 $68.01 $68.93 $69.84 $70.76 $71.68 $72.60 $73.52

$48.37 $49.55 $50.73 $51.91 $53.09 $54.26 $55.44 $56.62 $57.80 $58.98 $60.16 $61.34 $62.52 $63.70 $64.88 $66.06 $67.24 $68.42 $69.60 $70.78 $71.96 $73.14 $74.32 $75.50 $76.68 $77.86 $79.04 $80.22 $81.40 $82.58 $83.76 $84.94 $86.12 $87.30 $88.48 $89.65 $90.83 $92.01 $93.19 $94.37

$65.61 $67.21 $68.81 $70.41 $72.02 $73.62 $75.22 $76.82 $78.42 $80.02 $81.62 $83.22 $84.82 $86.42 $88.02 $89.62 $91.22 $92.82 $94.42 $96.02 $97.62 $99.22 $100.82 $102.42 $104.02 $105.62 $107.22 $108.82 $110.42 $112.02 $113.62 $115.22 $116.82 $118.42 $120.03 $121.63 $123.23 $124.83 $126.43 $128.03

$92.59 $94.85 $97.11 $99.37 $101.63 $103.88 $106.14 $108.40 $110.66 $112.92 $115.18 $117.43 $119.69 $121.95 $124.21 $126.47 $128.73 $130.98 $133.24 $135.50 $137.76 $140.02 $142.28 $144.53 $146.79 $149.05 $151.31 $153.57 $155.83 $158.08 $160.34 $162.60 $164.86 $167.12 $169.38 $171.63 $173.89 $176.15 $178.41 $180.67

Disability

33

WASHINGTON NATIONAL

Cancer

YOUR BENEFITS PACKAGE

PLAY VIDEO

About this Benefit Cancer insurance offers you and your family supplemental insurance protection in the event you or a covered family member is diagnosed with cancer. It pays a benefit directly to you to help with expenses associated with cancer treatment.

Breast Cancer is the most commonly diagnosed cancer in women.

If caught early, prostate cancer is one of the most treatable malignancies.

This is a general overview of your plan benefits. If the terms of this outline differ from your policy, the policy will govern. Additional plan details on covered expenses, limitations and exclusions are included in the summary plan description located on the 34 ESC Region 1 Benefits Website: www.mybenefitshub.com/region1

Plan C Plan A Individual $31.10

Single Parent $38.80

Plan B Family $58.10

Individual $33.80

Single Parent $42.60

Family $63.70

DIAGNOSIS BENEFIT First-occurrence express payment

$1,000

Additional units firstoccurrence express payment

$1,000 to $9,000

This benefit is payable when any covered family member is diagnosed with any type of internal cancer, except skin cancer, and submits acceptable proof of diagnosis. Children will receive a 50% increased benefit. This way, you will have immediate financial assistance to help with the extra expenses associated with cancer. In most areas, delivery is guaranteed within two days! This benefit is payable only once for each covered person.

Up to nine additional units ($1,000 per unit) are available for a maximum express payment benefit of $10,000. Children will receive a maximum benefit of $15,000.

IN HOSPITAL BENEFITS Inpatient hospital $200 per day, 1–30 days confinement includes U.S. $400 per day, 31+ days government hospitals

Inpatient drugs and diagnostic testing Attending physician

Transportation (insured)

Transportation (family member)

Family member lodging

Ambulance

Benefits are paid for each day you are confined as an inpatient in a hospital due to cancer. For confinements in a U.S. government hospital, this benefit amount is paid in lieu of all other benefits—except the first-occurrence express payment, transportation (covered person), transportation (family member) and lodging benefits.

Actual charges up to Benefits are paid for FDA-approved drugs and medicine, X-rays and laboratory and $40 per day diagnostic testing. Benefits are payable for up to the same number of days you receive benefits for hospital confinement.

Actual charges up to Benefits are paid per covered confinement for cancer-treatment services by a physician $30 per day other than your surgeon. Benefits are payable for up to the same number of days you receive benefits for hospital confinement.

Actual charges up to Benefits are paid for a one-way trip by coach-class plane, train, bus or car if you must $1,500 for coach- class plane, travel more than 100 miles one way within the continental U.S. (including Alaska, Hawaii train or and Puerto Rico). Transportation must be from your home to receive covered cancer bus transportation or 40 treatments that are prescribed by your physician and are not available locally. There is no cents per mile for limit to the number of trips. transportation by car National Cancer Institute (NCI) This transportation benefit also applies for consultation at a comprehensive or clinical cancer center recognized by the National Cancer Institute.

Actual charges up to Benefits are paid for one immediate family member for a one-way trip by coach-class $1,500 for coach- class plane, plane, train, bus or car if the same trip is not paid under the transportation (covered train or bus transportation or person) benefit. Transportation is limited to two one-way trips per period of confinement 40 cents per mile for from the family member’s home to the hospital in which the covered person is confined.

The hospital must be more than 100 miles one way within the continental U.S. from each transportation by car person’s home (including Alaska, Hawaii and Puerto Rico). This benefit is provided to the covered person for a family member to travel to and/or from the city where a covered person is confined to receive covered cancer treatments that are prescribed by a physician and are not available locally.

Actual charges up to Benefits are paid for one immediate family member’s lodging, in one room per day, for $60 per day up to 60 days per period of the covered person’s confinement. Lodging must be more than 100 miles one way within the continental U.S. from each person’s home (including Alaska, Hawaii and Puerto Rico). The benefit is provided to the covered person for a family member to lodge in the city where the covered person is confined to receive covered cancer treatments that are prescribed by a physician and are not available locally.

Actual charges up to This benefit is paid for each one-way trip to or from a hospital where you are confined as $200 per one-way trip an inpatient, for up to two one-way trips per confinement. Benefits include air ambulance when necessary to protect your health and safety and no other travel methods are available.

35

Plan C IN-OR OUT-OF-HOSPITAL BENEFITS Second and third surgical Actual charges up to opinion $225 per opinion Surgery $135 to $7,500

Reconstructive breast surgery Blood and plasma Anesthesia

Prosthetics (surgical) Prosthetics (nonsurgical) Radiation therapy

Chemotherapy (injected by medical personnel)

Benefits are paid for second and third medical evaluations of your need for surgery (other than for skin cancer) at your option.

Benefits are paid for each operation which diagnoses or treats cancer, based on the schedule listed in your certificate. If more than one procedure is performed through the same incision at the same time, we will pay for the one with the largest benefit amount.

Biopsy surgery Benefits also are paid for surgical biopsies leading to positive cancer diagnosis, based on the surgical schedule listed in your certificate.

Actual charges This benefit is paid up to the amount we paid for, and occurring within three years of, the mastectomy. $60 per unit Benefits are paid for each unit of blood you receive for cancer treatment. This includes donated blood, plasma and platelets. $34 to $1,875 Benefits are paid for each operation, based on the schedule listed in your certificate. If more than one surgical procedure is performed at the same time, we will pay for the anesthesia with the largest benefit amount. Benefits also are paid for surgical biopsy anesthesia leading to a positive cancer diagnosis, based on the schedule listed in your certificate.

Actual charges up to Benefits are paid for surgically implanted prosthetic devices needed due to, and received $2,000 per device within three years of, a covered surgery as prescribed by a physician due to cancer.

Actual charges up to Benefits are paid for nonsurgically implanted devices received within three years of a $250, lifetime maximum per covered surgery as prescribed by a physician due to cancer. Devices include voice boxes, covered person removable breast prostheses and ostomy pouches.

Actual charges up to Benefits include, but are not limited to, the insertion of an interstitial or intracavity $250 per day application of radium or radioisotopes. The surgery benefit provides additional amounts payable for insertion and removal. There is no monthly or lifetime maximum limit to this benefit.1 Actual charges up to Benefits include cytotoxic chemical substances and their administration. Injections must $250 per day be made by medical personnel in a physician’s office, clinic or hospital. Benefits are payable on the date of the treatment. Experimental treatments are covered as long as treatment is investigationally approved by the U.S. Food and Drug Administration. There is no monthly or lifetime maximum limit to this benefit.1

Chemotherapy (self-administered)

Actual charges up to $250 per drug

Benefits include self-injected medications, medications dispensed by a pump or implant, or oral chemotherapy, regardless of where it is administered. This benefit is limited to a monthly maximum of $2,000. Experimental treatments are covered as long as treatment is investigationally approved by the U.S. Food and Drug Administration. There is no lifetime maximum limit to this benefit.

Comfort drugs Actual charges up to Benefits are paid for outpatient medication prescribed to treat nausea associated with (outpatient) $100 per month cancer treatments.

Stem cell transplant Actual charges up to Benefits are paid for a stem cell transplant for the treatment of cancer. This benefit does $1,250, lifetime maximum not pay for a bone marrow transplant. We will pay this benefit once per lifetime for each covered person. per covered person Bone marrow transplant $5,000, lifetime maximum Benefits are paid for a bone marrow transplant for the treatment of cancer, including per covered person marrow donor expenses. This benefit does not pay for a stem cell transplant. We will pay this benefit once per lifetime for each covered person.

Wigs and hairpieces Actual charges up to This benefit is paid for a wig or hairpiece needed due to cancer treatments for which you $250, lifetime maximum per receive benefits under this certificate. covered person Skilled nursing facility Actual charges up to Benefits are paid when your doctor prescribes confinement to a skilled nursing facility, $100 per day due to cancer, within 14 days after a covered hospital confinement. Benefits are payable for up to the same number of days you received the hospital confinement benefit during the most recent hospital confinement.

Hospice

$100 per day for the first 60 Benefits are paid for care provided at home or in a hospice facility by a licensed hospice days; $50 per day for an to a terminally ill patient who is no longer receiving definitive cancer treatment and are unlimited number of days expected to live six months or less. thereafter

36

Plan C ALTERNATIVE CARE RIDER1 Integrative assessment and education benefit

Actual charges up to $250, one-time benefit

Benefits are paid for assessment and education services performed by an accredited practitioner of alternative care services.

Ameliorative benefit

Actual charges up to $50 per visit

Benefits are paid for visits to an accredited practitioner for acupuncture, massage therapy, biofeedback and hypnosis. This benefit is limited to 20 visits per calendar year.

Curative benefit

Actual charges up to $100 per visit

Lifestyle benefit

Actual charges up to $50 per visit

This benefit is paid for visits to the following types of accredited practitioners: naturopathic, homeopathic, ayurvedic and herbalist. The benefit is limited to 20 visits per calendar year. The benefit amount applies to charges for the visit with the practitioner, as well as charges for any nutritional medications and supplements.

Benefits are paid for an accredited practitioner for the following types of alternative care: smoking cessation, yoga, meditation, relaxation techniques, tai chi and nutritional counseling. The benefit is limited to 20 visits per calendar year.

Benefits are payable only upon the diagnosis of internal cancer. The diagnosis must be reconfirmed on a regular basis, either by proof of ongoing treatment or a doctor’s certification. This optional rider has an additional cost (form CHIC-8022GCRR

CANCER PREVENTATIVE CARE RIDER1 Cancer screening wellness $50 per calendar year Additional screening and $50 per calendar year treatment Skin cancer diagnosis $300 upon initial diagnosis Annual care4

$750 per year for up to five consecutive years per covered person

This benefit pays for one cancer test3 in a calendar year, even when it’s covered by other insurance.

This benefit is payable for a second cancer screening or preventive treatment based on an abnormal result of your initial screening that we paid for.

This one-time benefit is payable when skin cancer is diagnosed.

This benefit helps cover the cost of medical follow-up for cancer survivors. It activates on the anniversary of the base policy’s first-occurrence benefit payment. To receive the benefit, the covered person must be under the active care of a physician.

This optional rider has an additional cost (form CHIC-8063TX).

CANCER DEATH BENEFIT RIDER1 Cancer death

1

$5,000

The benefit is available when a covered person dies due to cancer. It is payable in addition to any other insurance, even when cancer is not diagnosed until after death.7

These riders are available only to members of Health Opportunity through Partnership in Education (HOPE).

Limitations and exclusions LIMITED BENEFIT POLICY The benefits described in the certificate or rider do not cover all nonmedical expenses. However, the benefit payment you receive can be used to pay any of your medical or nonmedical costs not paid by any other insurance.

You will be eligible for benefits if: cancer is first diagnosed while you are covered by this certificate; you incur a loss due to cancer while covered by this certificate; your loss is not excluded by name or specific description in this certificate.

Benefits are not payable for: any other disease, sickness or incapacity, even if the disease was caused, complicated or aggravated by cancer or cancer treatment; losses occurring before your effective date of coverage. The pre-existing condition exclusion is as follows: No benefits are payable for a pre-existing condition not otherwise excluded by name or specific description, during the first 12 months after the effective date of coverage for the covered person.

If the Alternative Care rider is chosen, we will not pay charges for nutritional medications and supplements prescribed or recommended by any accredited practitioner during the course of treatment, regardless of where they are dispensed, except under the curative benefit.

This insurance is available only to members of Health Opportunity through Partnership in Education (HOPE).

If an employer pays, or is treated as paying, all or part of the premium, the benefit may be considered taxable income unless excluded under one or more provisions of the Internal Revenue Code. You should consult your tax adviser for specific information.

This brochure is intended to be a brief, general description of coverage. For more complete details of coverage, including benefits, limitations and exclusions specific to your state, please review the certificate with your agent.

37

Plan D Plan A Individual $49.40

Single Parent $61.90

Plan B Family $92.60

Individual $52.10

Single Parent $65.70

Family $98.20

DIAGNOSIS BENEFIT First-occurrence express payment

$1,000

Additional units firstoccurrence express payment

$1,000 to $9,000

This benefit is payable when any covered family member is diagnosed with any type of internal cancer, except skin cancer, and submits acceptable proof of diagnosis. Children will receive a 50% increased benefit. This way, you will have immediate financial assistance to help with the extra expenses associated with cancer. In most areas, delivery is guaranteed within two days! This benefit is payable only once for each covered person.

Up to nine additional units ($1,000 per unit) are available for a maximum express payment benefit of $10,000. Children will receive a maximum benefit of $15,000.

IN HOSPITAL BENEFITS Inpatient hospital $250 per day, 1–30 days confinement includes U.S. $500 per day, 31+ days government hospitals

Inpatient drugs and diagnostic testing

Actual charges up to $50 per day

Attending physician

Actual charges up to $40 per day

Private nurse

Actual charges up to $125 per day

Transportation (covered person)

Actual charges up to $2,500 for coach- class plane, train or bus transportation or

Transportation (family member)

Family member lodging

Ambulance 38

Benefits are paid for each day you are confined as an inpatient in a hospital due to cancer. For confinements in a U.S. government hospital, this benefit amount is paid in lieu of all other benefits—except the first-occurrence express payment, transportation (covered person), transportation (family member) and lodging benefits.

Benefits are paid for FDA-approved drugs and medicine, X-rays and laboratory and diagnostic testing. Benefits are payable for up to the same number of days you receive benefits for hospital confinement.

Benefits are paid per covered confinement for cancer-treatment services by a physician other than your surgeon. Benefits are payable for up to the same number of days you receive benefits for hospital confinement.

Benefits are paid when your doctor prescribes the full-time services of an L.P.N., L.V.N. or R.N. during a covered hospital confinement. Services must be provided by someone other than a spouse or family member, and be other than those regularly furnished by the hospital.

Benefits are payable for up to the same number of days you receive benefits for hospital confinement.

Benefits are paid for a one-way trip by coach-class plane, train, bus or car if you must travel more than 100 miles one way within the continental U.S. (including Alaska, Hawaii and Puerto Rico). Transportation must be from your home to receive covered cancer treatments that are prescribed by your physician and are not available locally. There is no limit to the number of trips.

40 cents per mile for National Cancer Institute (NCI) transportation by car This transportation benefit also applies for consultation at a comprehensive or clinical cancer center recognized by the National Cancer Institute.

Actual charges up to Benefits are paid for one immediate family member for a one-way trip by coach-class plane, $2,500 for coach- class train, bus or car if the same trip is not paid under the transportation (covered person) benefit. plane, train or bus Transportation is limited to two one-way trips per period of confinement from the family transportation or 40 cents member’s home to the hospital in which the covered person is confined. The hospital must be per mile for transportation more than 100 miles one way within the continental U.S. from each person’s home (including Alaska, Hawaii and Puerto Rico). This benefit is provided to the covered person for a family by car member to travel to and/or from the city where a covered person is confined to receive covered cancer treatments that are prescribed by a physician and are not available locally.

Actual charges up to Benefits are paid for one immediate family member’s lodging, in one room per day, for up to $70 per day 60 days per period of the covered person’s confinement. Lodging must be more than 100 miles one way within the continental U.S. from each person’s home (including Alaska, Hawaii and Puerto Rico). The benefit is provided to the covered person for a family member to lodge in the city where the covered person is confined to receive covered cancer treatments that are prescribed by a physician and are not available locally.

Actual charges up to This benefit is paid for each one-way trip to or from a hospital where you are confined as an $250 per one-way trip inpatient, for up to two one-way trips per confinement. Benefits include air ambulance when necessary to protect your health and safety and no other travel methods are available.

Plan D IN - OR OUT OF HOSPITAL BENEFITS Second and third surgical Actual charges up to opinion $250 per opinion Surgery $135 to $9,000

Benefits are paid for second and third medical evaluations of your need for surgery (other than for skin cancer) at your option.

Benefits are paid for each operation which diagnoses or treats cancer, based on the schedule listed in your certificate. If more than one procedure is performed through the same incision at the same time, we will pay for the one with the largest benefit amount.

Biopsy surgery Benefits also are paid for surgical biopsies leading to positive cancer diagnosis, based on the surgical schedule listed in your certificate.

Reconstructive breast Actual charges This benefit is paid up to the amount we paid for, and occurring within three years of, the surgery mastectomy.

Blood and plasma $80 per unit Benefits are paid for each unit of blood you receive for cancer treatment. This includes donated blood, plasma and platelets.

Anesthesia $34 to $2,250 Benefits are paid for each operation, based on the schedule listed in your certificate. If more than one surgical procedure is performed at the same time, we will pay for the anesthesia with the largest benefit amount. Benefits also are paid for surgical biopsy anesthesia leading to a positive cancer diagnosis, based on the schedule listed in your certificate.

Prosthetics Actual charges up to Benefits are paid for surgically implanted prosthetic devices needed due to, and received (surgical) $3,000 per device within three years of, a covered surgery as prescribed by a physician due to cancer.

Prosthetics Actual charges up to Benefits are paid for nonsurgically implanted devices received within three years of a (nonsurgical) $250, lifetime maximum per covered surgery as prescribed by a physician due to cancer. Devices include voice boxes, covered person removable breast prostheses and ostomy pouches.

Radiation therapy Actual charges up to Benefits include, but are not limited to, the insertion of an interstitial or intracavity $300 per day application of radium or radioisotopes. The surgery benefit provides additional amounts payable for insertion and removal. There is no monthly or lifetime maximum limit to this benefit.

Chemotherapy (injected Actual charges up to Benefits include cytotoxic chemical substances and their administration. Injections must by medical personnel) $300 per day be made by medical personnel in a physician’s office, clinic or hospital. Benefits are payable on the date of the treatment. Experimental treatments are covered as long as treatment is investigationally approved by the U.S. Food and Drug Administration. There is no monthly or lifetime maximum limit to this benefit.

Chemotherapy Actual charges up to Benefits include self-injected medications, medications dispensed by a pump or implant, (self-administered) $300 per drug or oral chemotherapy, regardless of where it is administered. This benefit is limited to a monthly maximum of $2,400. Experimental treatments are covered as long as treatment is investigationally approved by the U.S. Food and Drug Administration. There is no lifetime maximum limit to this benefit.

Comfort drugs Actual charges up to Benefits are paid for outpatient medication prescribed to treat nausea associated with (outpatient) $150 per month cancer treatments.

Medical imaging $200 per calendar year This benefit is paid when a covered person receives an initial diagnosis or follow-up evaluation of internal cancer using a medical imaging exam. This includes but is not limited to CT scan, MRI, bone scan and PET scan. This benefit is limited to one payment for each calendar year for each covered person.

Stem cell transplant Actual charges up to Benefits are paid for a stem cell transplant for the treatment of cancer. This benefit does $2,500, lifetime maximum not pay for a bone marrow transplant. We will pay this benefit once per lifetime for each covered person. per covered person Bone marrow transplant $10,000, lifetime maximum Benefits are paid for a bone marrow transplant for the treatment of cancer, including per covered person marrow donor expenses. This benefit does not pay for a stem cell transplant. We will pay this benefit once per lifetime for each covered person.

Wigs and hairpieces Actual charges up to This benefit is paid for a wig or hairpiece needed due to cancer treatments for which you $250, lifetime maximum per receive benefits under this certificate. covered person

39

Plan D Home healthcare

Skilled nursing facility

Hospice

Wellness benefit

$40 per visit

Benefits are paid when you have been hospital-confined for the treatment of cancer and receive home healthcare by a licensed, certified provider within seven days of release from a hospital as prescribed by your physician. Benefits are paid for up to 10 visits per confinement and 30 visits per year. This benefit is not payable at the same time as the hospice benefit.

Actual charges up to Benefits are paid when your doctor prescribes confinement to a skilled nursing facility, $150 per day due to cancer, within 14 days after a covered hospital confinement. Benefits are payable for up to the same number of days you received the hospital confinement benefit during the most recent hospital confinement. $120 per day for the first 60 Benefits are paid for care provided at home or in a hospice facility by a licensed hospice days; $60 per day for an to a terminally ill patient who is no longer receiving definitive cancer treatment and are unlimited number of days expected to live six months or less. This benefit is not payable at the same time as the thereafter home healthcare benefit.

Actual charges up to $50 per calendar year

Benefits are paid for the following screenings for each covered person: mammogram, breast ultrasound, pap smear (lab and procedure), biopsy, chest x-ray, CEA/CA 125 (blood test for colon and ovarian cancer), PSA (blood test for prostate cancer), colonoscopy, etc.

This benefit is limited to one test per calendar year. The certificate contains a complete list of covered tests. This is a preventive benefit. Diagnosis of cancer is not required for this benefit to be payable. There is no lifetime maximum limit for this benefit.

ALTERNATIVE CARE RIDER1 Integrative assessment and education benefit

Actual charges up to $250, one-time benefit

Benefits are paid for assessment and education services performed by an accredited practitioner of alternative care services.

Ameliorative benefit

Actual charges up to $50 per visit

Benefits are paid for visits to an accredited practitioner for acupuncture, massage therapy, biofeedback and hypnosis. This benefit is limited to 20 visits per calendar year.

Curative benefit

Actual charges up to $100 per visit

Lifestyle benefit

Actual charges up to $50 per visit

This benefit is paid for visits to the following types of accredited practitioners: naturopathic, homeopathic, ayurvedic and herbalist. The benefit is limited to 20 visits per calendar year. The benefit amount applies to charges for the visit with the practitioner, as well as charges for any nutritional medications and supplements.

Benefits are paid for an accredited practitioner for the following types of alternative care: smoking cessation, yoga, meditation, relaxation techniques, tai chi and nutritional counseling. The benefit is limited to 20 visits per calendar year.

Benefits are payable only upon the diagnosis of internal cancer. The diagnosis must be reconfirmed on a regular basis, either by proof of ongoing treatment or a doctor’s certification. This optional rider has an additional cost (form CHIC-8022GCRR

CANCER PREVENTATIVE CARE RIDER1 Cancer screening wellness $50 per calendar year Additional screening and treatment Skin cancer diagnosis Annual care4

$50 per calendar year $300 upon initial diagnosis $750 per year for up to five consecutive years per covered person

This benefit pays for one cancer test3 in a calendar year, even when it’s covered by other insurance.

This benefit is payable for a second cancer screening or preventive treatment based on an abnormal result of your initial screening that we paid for.

This one-time benefit is payable when skin cancer is diagnosed.

This benefit helps cover the cost of medical follow-up for cancer survivors. It activates on the anniversary of the base policy’s first-occurrence benefit payment. To receive the benefit, the covered person must be under the active care of a physician.

This optional rider has an additional cost (form CHIC-8063TX).

CANCER DEATH BENEFIT RIDER1 Cancer death

40

$5,000

The benefit is available when a covered person dies due to cancer. It is payable in addition to any other insurance, even when cancer is not diagnosed until after death.7

Intensive Care Benefit Confinement to an intensive care unit (ICU) or a critical care unit (CCU) can result from:  Heart attack and stroke  Complications from surgery  Serious trauma accident  Other serious medical conditions Intensive care and critical care are among the most important types of care. So it’s important to have financial protection.  Approximately 27% of hospital stays involve admission to the

Limitations and exclusions

This certificate/rider does not cover confinement in facilities other than hospital intensive care units (ICUs) or sub-acute intensive care units; or confinement that results from:  Intoxication  Being under the influence of any narcotic, unless such narcotic is taken under the direction of a physician  Self-inflicted injury or suicide attempts  Participating in or attempting to participate in an illegal act or working at an illegal job 1 ICU.  Having been diagnosed or treated by a physician for HIV, AIDS or  Hospital stays involving ICU services are 2.5 times more costly than Aids-Related Complex (ARC) other hospital stays.1  Confinements related to a pre-existing condition occurring within  The average ICU admission includes nearly 5 days of the first year of coverage.

2 hospitalization.

Benefits will be paid for no more than a combined maximum of 30 days Hospital intensive care unit rider per period of confinement for hospital ICU or sub-acute ICU You may choose benefit level 1, 2 or 3. By choosing one of these three confinement. levels, you can receive three types of ICU benefits. (Premiums are based The daily benefit reduces by 50% at the age of 75. on the level selected.)

The blood and plasma benefit is payable for each day you receive whole blood, plasma, red cells, packed cells or platelets while confined to an ICU; processing, administrative, storage or laboratory charges are not Intensive care unit (per day) Level 1 Level 2 Level 3 covered. This benefit is payable up to the number of days confined to an Adult benefit $500 $750 $1,000 ICU. “Specified vehicular accidents” are defined as riding in, being struck by, Children < 1 year old 150 225 300 or lawfully operating an automobile, bus, truck, motorcycle, train or motorized aircraft.

Children > 1 year old 750 1,125 1,500 The ambulance benefit is not payable to or from a U.S. government Sub-acute intensive care unit hospital. Air ambulance must be necessary to protect your health and safety when other transportation is not available. (per day) This certificate is not a Medicare supplement policy. If you are eligible Adult benefit $200 $300 $400 for Medicare, review the Medicare Supplement Buyer’s Guide, available Children < 1 year old 60 90 120 from the company.

This is not a policy of workers’ compensation insurance. The employer Children > 1 year old 300 450 600 does not become a subscriber to the workers’ compensation system by purchasing this policy, and if the employer is a nonsubscriber, the Blood and plasma (actual charges not to exceed the daily employer loses those benefits which would otherwise accrue under the benefit) workers’ compensation laws. The employer must comply with the Daily benefit $25 $50 $75 workers’ compensation law as it pertains to the nonsubscribers and the required notifications that must be filed and posted.

This brochure is not the insurance contract. The certificate defines in With any benefit level you choose, this insurance provides the following detail the rights and obligations of both you and us. Therefore, it is very features: important that you read your certificate carefully.  Double benefits for specified vehicular accidents. The daily rate The intensive care benefits described are contained in forms CHIC-8046doubles for ICU treatment resulting from an accident in a car, truck, 1, CHIC-8046-2 and CHIC-8046-3, including state variations, where used. train or other vehicle (see reverse side for details) if the confinement occurs within 48 hours after the accident.  Ambulance benefit. Actual charges are paid up to $150 per period 1 HCUP Statistical Brief #185. December 2014. Agency for Healthcare Research and of confinement. This benefit applies when you receive care from a Quality, Rockville, MD. licensed surface or air-service carrier while you are being 2 Hunter, A., Johnson, L., & Coustasse, A. (2014). Reduction of intensive care unit transported to and from a hospital, other than a U.S. government length of stay: The case of early mobilization. The Health Care Manager, 33(2), hospital.

128-135.  First-day coverage. Your rider covers ICU confinements beginning These facts represent the U.S. population, are provided for information only and with the first day of hospitalization for accidental bodily injury and do not imply coverage under the policy or endorsement of the company or policy the second day for hospitalization resulting from any sickness. by the sources cited above.

41

AUL a ONEAMERICA COMPANY YOUR BENEFITS PACKAGE

Life and AD&D

PLAY VIDEO

About this Benefit Group term life is the most inexpensive way to purchase life insurance. You have the freedom to select an amount of life insurance coverage you need to help protect the well-being of your family.

Accidental Death & Dismemberment is life insurance coverage that pays a death benefit to the beneficiary, should death occur due to a covered accident.

Dismemberment benefits are paid to you, according to the benefit level you select, if accidentally dismembered.

Motor vehicle crashes are the

#1

cause of accidental deaths in the US, followed by poisoning, falls, drowning, and choking.

This is a general overview of your plan benefits. If the terms of this outline differ from your policy, the policy will govern. Additional plan details on covered expenses, limitations and exclusions are included in the summary plan description located on the 42 ESC Region 1 Benefits Website: www.mybenefitshub.com/region1

Life and AD&D coverage by AUL.

Group Term Life Including matching AD&D Coverage    

Waiver of premium benefit Accelerated life benefit Additional AD&D Benefits: Seat Belt, Air Bag, Repatriation, Child Higher Education, Child Care, Paralysis/Loss of Use, Severe Burns Optional Guaranteed issue amounts of dependent coverage as follows:

Portability Should your coverage terminate for any reason, you may be eligible to take this term life insurance with you without providing Evidence of Insurability. You must apply within 31 days from the last day you are eligible. The Portability option is available until you reach age 70.

OR

Eligible Employees This benefit is available for employees who are actively at work on the effective date and working a minimum of 30 hours per week.

Flexible Choices Since everyone's needs are different, this plan offers flexibility for you to choose a benefit amount that fits your needs and budget.

Accidental Death & Dismemberment (AD&D) If approved for this benefit, additional life insurance benefits may be payable in the event of an accident which results in the death or dismemberment as defined in the contract.

Guaranteed Issue Amounts This is the most coverage you can purchase without having to answer any health questions. If you decline insurance coverage now and decide to enroll later, you will need to provide Evidence of Insurability.

Employee Guaranteed Issue Amount

Less Than Age 70: $100,000

Age 70+: $25,000

Spouse Guaranteed Issue Amount

Less Than Age 70: $25,000

Age 70+: None

Child Guaranteed Issue Amount

Continuation of Coverage Options

$10,000

Conversion Should your life insurance coverage, or a portion of it, cease for any reason, you may be eligible to convert your Group Term Coverage to Individual Coverage without providing Evidence of Insurability. You must apply within 31 days from the last day you are eligible.

Accelerated Life Benefit If diagnosed with a terminal illness and have less than 12 months to live, you may apply to receive 25%, 50% or 75% of your life insurance benefit to use for whatever you choose.

Waiver of Premium If approved, this benefit waives your insurance premium in case you become totally disabled and are unable to collect a paycheck.

Reductions Upon reaching certain ages, your original benefit amount will reduce to a percentage as shown in the following schedule. The amounts of Dependent Life Insurance and Dependent AD&D Principal Sum will reduce according to the Employee's reduction schedule.

Age:

65

70

Reduces To:

65%

50%

Timely Enrollment Enrolling timely means you have enrolled during the initial enrollment period when benefits were first offered by AUL, or as a newly hired employee within 31 days following completion of any applicable waiting period.

Evidence of Insurability If you elect a benefit amount over the Guaranteed Issue Amount shown above, or you do not enroll timely, you will need to submit a Statement of Insurability form for review. Based on health history, you will be approved or declined for insurance 43

Life and AD&D Monthly Payroll Deduction Illustration About your benefit options:   

You may select a minimum benefit of $10,000 up to a maximum amount of $500,000, in increments of $1,000, not to exceed 7 times your annual base salary only, rounded to the next higher $10,000.

Amounts requested above $100,000 for an Employee, $25,000 for a Spouse, or any amount not requested timely will require Evidence of Insurability.

Employee must select coverage to select any Dependent coverage.

EMPLOYEE ONLY OPTIONS (based on Employee's age as of 09/01) Life Options

0-19

20-24

25-29

30-34

35-39

40-44

45-49

50-54

55-59

60-64

65-69

70-74

75+

$10,000

$.65

$.65

$.65

$.85

$.95

$1.25

$1.75

$2.55

$4.55

$6.75

$9.16

$15.25

$15.25

$20,000

$1.30

$1.30

$1.30

$1.70

$1.90

$2.50

$3.50

$5.10

$9.10

$13.50

$18.32

$30.50

$30.50

$30,000

$1.95

$1.95

$1.95

$2.55

$2.85

$3.75

$5.25

$7.65

$13.65

$20.25

$27.48

$45.75

$45.75

$40,000

$2.60

$2.60

$2.60

$3.40

$3.80

$5.00

$7.00

$10.20

$18.20

$27.00

$36.64

$61.00

$61.00

$50,000

$3.25

$3.25

$3.25

$4.25

$4.75

$6.25

$8.75

$12.75

$22.75

$33.75

$45.80

$76.25

$76.25

$60,000

$3.90

$3.90

$3.90

$5.10

$5.70

$7.50 $10.50 $15.30

$27.30

$40.50

$54.96

$91.50

$91.50

$70,000

$4.55

$4.55

$4.55

$5.95

$6.65

$8.75 $12.25 $17.85

$31.85

$47.25

$64.12 $106.75 $106.75

$80,000

$5.20

$5.20

$5.20

$6.80

$7.60

$10.00 $14.00 $20.40

$36.40

$54.00

$73.28 $122.00 $122.00

$90,000

$5.85

$5.85

$5.85

$7.65

$8.55

$11.25 $15.75 $22.95

$40.95

$60.75

$82.44 $137.25 $137.25

$100,000

$6.50

$6.50

$6.50

$8.50

$9.50

$12.50 $17.50 $25.50

$45.50

$67.50

$91.60 $152.50 $152.50

SPOUSE ONLY OPTIONS (based on Employee's Age as of 09/01) Life Options

0-19

20-24

25-29

30-34

35-39

40-44

45-49

50-54

55-59

60-64

65-69

70-74

75+

$10,000

$.65

$.65

$.65

$.85

$.95

$1.25

$1.75

$2.55

$4.55

$6.75

$9.15

$15.25

$15.25

$15,000

$.98

$.98

$.98

$1.28

$1.43

$1.88

$2.63

$3.83

$6.83

$10.13

$13.73

$22.88

$22.88

$20,000

$1.30

$1.30

$1.30

$1.70

$1.90

$2.50

$3.50

$5.10

$9.10

$13.50

$18.30

$30.50

$30.50

$25,000

$1.63

$1.63

$1.63

$2.13

$2.38

$3.13

$4.38

$6.38

$11.38

$16.88

$22.88

$38.13

$38.13

CHILD(REN) OPTIONS (Premium shown for Child(ren) reflects the cost for all eligible dependent children) Child(ren) 6 months to age 26

Child(ren) live birth to 6 months

Monthly Payroll Deduction Life Amount

Option 1:

$5,000

$1,000

$1.25

Option 2:

$10,000

$1,000

$2.50

44

Life and AD&D Voluntary Term Life Coverage including matching AD&D coverage Monthly Payroll Deduction Illustration About your benefit options:   

You may select a minimum benefit of $10,000 up to a maximum amount of $500,000, in increments of $10,000.

Employee must select coverage to select any Dependent coverage.

The Spouse benefit is equal to 50% of the amount elected by the Employee, the Child benefit is equal to 10% of the amount elected by the Employee.

Employee Only AD&D

Family AD&D

Volume

Monthly Deduction

Employee Volume

Spouse Volume

Child Volume

Monthly Deduction

$10,000 $20,000 $30,000

$0.30 $0.60 $0.90

$10,000 $20,000 $30,000

$5,000 $10,000 $15,000

$1,000 $2,000 $3,000

$0.50 $1.00 $1.50

$40,000 $50,000 $60,000 $70,000 $80,000 $90,000

$1.20 $1.50 $1.80 $2.10 $2.40 $2.70

$40,000 $50,000 $60,000 $70,000 $80,000 $90,000

$20,000 $25,000 $30,000 $35,000 $40,000 $45,000

$4,000 $5,000 $6,000 $7,000 $8,000 $9,000

$2.00 $2.50 $3.00 $3.50 $4.00 $4.50

$100,000

$3.00

$100,000

$50,000

$10,000

$5.00

$150,000 $200,000 $250,000 $300,000 $350,000

$4.50 $6.00 $7.50 $9.00 $10.50

$150,000 $200,000 $250,000 $300,000 $350,000

$75,000 $100,000 $125,000 $150,000 $175,000

$15,000 $20,000 $25,000 $30,000 $35,000

$7.50 $10.00 $12.50 $15.00 $17.50

$400,000 $450,000 $500,000

$12.00 $13.50 $15.00

$400,000 $450,000 $500,000

$200,000 $225,000 $250,000

$40,000 $45,000 $50,000

$20.00 $22.50 $25.00

45

AMERICAN PUBLIC LIFE YOUR BENEFITS PACKAGE

Accident

PLAY VIDEO

About this Benefit

2/3

Accident insurance is designed to supplement your medical insurance coverage by covering indirect costs that can arise with a serious, or a not-soserious, injury. Accident coverage is low cost protection available to you and your family without evidence of insurability.

of disabling injuries suffered by American workers are not work related.

American workers 36% ofreport they always or

usually live paycheck to paycheck.

This is a general overview of your plan benefits. If the terms of this outline differ from your policy, the policy will govern. Additional plan details on covered expenses, limitations and exclusions are included in the summary plan description located on the 46 ESC Region 1 Benefits Website: www.mybenefitshub.com/region1

A3 Supplemental Limited Benefit Accident Expense Insurance ESC Region 1

AMERICAN PUBLIC LIFE YOUR BENEFITS

Accident

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 Accidental Death - per unit Medical Expense Accidental Injury Benefit - per unit Daily Hospital Confinement Benefit Air and Ground Ambulance Benefit

DID YOU KNOW?

2/3 of disabling injuries suffered by American workers are not work American workers 36% ofreport they always or

Level 2 - 2 Units

Level 3 - 3 Units

Level 4 - 4 Units

$5,000

$10,000

$15,000

$20,000

actual charges up to actual charges up to actual charges up to actual charges up to $500 $1,000 $1,500 $2,000 $75 per day

$150 per day

$225 per day

$300 per day

actual charges up to actual charges up to actual charges up to actual charges up to $1,250 $2,500 $3,750 $5,000

Accidental Dismemberment Benefit Single finger or toe Multiple fingers or toes Single hand, arm, foot or leg Multiple hands, arms, feet or legs

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

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

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

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

Accidental Loss of Sight Benefit - per unit 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

Individual

Individual & Spouse

1 Parent Family

2 Parent Family

$10.80 $17.10 $21.50 $24.50

$19.40

$21.20 $34.90 $45.20 $52.00

$29.80 $47.60 $62.60 $72.40

About this Benefit Accident insurance is designed to supplement your medical insurance coverage by covering indirect costs that can arise with a serious, or a not-so-serious, injury. Accident coverage is low cost protection available to you and your family without evidence of insurability.

Level 1 - 1 Unit

Level 1 - 1 Unit Level 2 - 2 Units Level 3 - 3 Units Level 4 - 4 Units

$29.80 $38.90 $44.90

*Total premium includes the Plan selected and any applicable rider premium. The premium and amount of benefits vary dependent upon the Plan selected at time of application. Premiums are subject to increase with notice.

usually live paycheck to paycheck.

(03/16)

This is a general overview of your plan benefits. If the terms of this outline differ from your policy, the policy will govern. Additional plan details on covered expenses, limitations and exclusions are included in the summary plan description located on the ESC Region 1 Benefits Website: www.mybenefitshub.com/region1

47

APSB-22329(TX)-MGM/FBS ESC Region 1

A3 Supplemental Limited Benefit Accident Expense Insurance Limitations and Exclusions Eligibility This policy will be issued to only those persons who meet American Public Life Insurance Company’s insurability requirements. Persons not meeting APL’s insurability requirements will be excluded from coverage by an endorsement attached to the policy.

Base Policy and Optional Benefits

Exclusions 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) (2) (3)

No benefits are payable for a pre-existing condition. Preexisting condition means an Injury that pertains solely to an Accidental Bodily Injury which resulted from an accident sustained before the Effective Date of coverage. Pre-Existing Conditions specifically named or described as permanently excluded in any part of this contract are never covered.

(4)

A Hospital is not an institution which is primarily a place for alcoholics or drug addicts; the aged; a nursing, rest or convalescent nursing home; a mental institution or sanitarium; a facility contracted for or operated by the United States Government for treatment of members or ex-members of the armed forces (unless You are legally required to pay for services rendered in the absence of insurance); or, a long-term nursing unit or geriatrics ward.

(7)

(5) (6)

(8)

(9) (10)

Medical Expense Accidental Injury Benefit Expenses must commence within 60 days of the covered accident. The maximum benefit amount payable for any one accident for the Insured Person shall not exceed the Medical Expense Benefit.

Air and Ground Ambulance Benefit Emergency transportation must occur within 21 calendar days of the accident causing such Injury.

Daily Hospital Confinement Benefit

(11)

(12) (13) (14)

The maximum benefit period for this benefit is 30 days per covered accident.

(15)

Accidental Death

(16)

Accidental Death must result within 90 days of the covered accident causing the injury.

sickness, illness or bodily infirmity; suicide, attempted suicide or intentional self-inflicted Injury, whether sane or insane; dental care or treatment unless due to accidental Injury to natural teeth; war or any act of war (whether declared or undeclared) or participating in a riot or felony; alcoholism or drug addiction; 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; Injury originating prior to the effective date of the Policy; 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.); Voluntary inhalation of gas or fumes or taking of poison or asphyxiation; 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; 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.)

Injury incurred while engaging in an illegal occupation; Injury incurred while attempting to commit a felony or an assault; 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; driving in any race or speed test or while testing an automobile or any vehicle on any racetrack or speedway; hernia, carpal tunnel syndrome or any complication therefrom;

A3 Supplemental Limited Benefit Accident Expense Insurance 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.

Guaranteed Renewable You have the right to renew this Policy until the first premium due date on or after Your 69th birthday, if you pay the correct premium when due or within the Grace Period. When an Insured’s coverage terminates at age 70, coverage for other Insured Persons, if any, shall continue under this Policy. We have the right to change premium rates by class.

2305 Lakeland Drive | Flowood, MS 39232 ampublic.com | 800.256.8606

Accidental Dismemberment Benefit The total amount payable for all Losses resulting from the same accident will not exceed the Maximum Dismemberment Benefit of $5,000 cumulative per unit, per Accident. Loss must be within 90 days of the accident causing such Injury.

Underwritten by American Life Insurance Company. 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. | Policy Form A3 Series | Texas | Supplemental Limited Benefit Accident Expense Insurance Policy | (10/14) | ESC Region 1

48

APSB-22329(TX)-MGM/FBS ESC Region 1

APSB-22329(TX)-MGM/FBS ESC Region 1

A3 Supplemental Limited Benefit Accident Expense Insurance Limitations and Exclusions Eligibility This policy will be issued to only those persons who meet American Public Life Insurance Company’s insurability requirements. Persons not meeting APL’s insurability requirements will be excluded from coverage by an endorsement attached to the policy.

Base Policy and Optional Benefits

Exclusions 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) (2) (3)

No benefits are payable for a pre-existing condition. Preexisting condition means an Injury that pertains solely to an Accidental Bodily Injury which resulted from an accident sustained before the Effective Date of coverage. Pre-Existing Conditions specifically named or described as permanently excluded in any part of this contract are never covered.

(4)

A Hospital is not an institution which is primarily a place for alcoholics or drug addicts; the aged; a nursing, rest or convalescent nursing home; a mental institution or sanitarium; a facility contracted for or operated by the United States Government for treatment of members or ex-members of the armed forces (unless You are legally required to pay for services rendered in the absence of insurance); or, a long-term nursing unit or geriatrics ward.

(7)

(5) (6)

(8)

(9) (10)

Medical Expense Accidental Injury Benefit Expenses must commence within 60 days of the covered accident. The maximum benefit amount payable for any one accident for the Insured Person shall not exceed the Medical Expense Benefit.

Air and Ground Ambulance Benefit Emergency transportation must occur within 21 calendar days of the accident causing such Injury.

Daily Hospital Confinement Benefit

(11)

(12) (13) (14)

The maximum benefit period for this benefit is 30 days per covered accident.

(15)

Accidental Death

(16)

Accidental Death must result within 90 days of the covered accident causing the injury.

sickness, illness or bodily infirmity; suicide, attempted suicide or intentional self-inflicted Injury, whether sane or insane; dental care or treatment unless due to accidental Injury to natural teeth; war or any act of war (whether declared or undeclared) or participating in a riot or felony; alcoholism or drug addiction; 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; Injury originating prior to the effective date of the Policy; 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.); Voluntary inhalation of gas or fumes or taking of poison or asphyxiation; 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; 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.)

Injury incurred while engaging in an illegal occupation; Injury incurred while attempting to commit a felony or an assault; 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; driving in any race or speed test or while testing an automobile or any vehicle on any racetrack or speedway; hernia, carpal tunnel syndrome or any complication therefrom;

A3 Supplemental Limited Benefit Accident Expense Insurance 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.

Guaranteed Renewable You have the right to renew this Policy until the first premium due date on or after Your 69th birthday, if you pay the correct premium when due or within the Grace Period. When an Insured’s coverage terminates at age 70, coverage for other Insured Persons, if any, shall continue under this Policy. We have the right to change premium rates by class.

2305 Lakeland Drive | Flowood, MS 39232 ampublic.com | 800.256.8606

Accidental Dismemberment Benefit The total amount payable for all Losses resulting from the same accident will not exceed the Maximum Dismemberment Benefit of $5,000 cumulative per unit, per Accident. Loss must be within 90 days of the accident causing such Injury.

Underwritten by American Life Insurance Company. 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. | Policy Form A3 Series | Texas | Supplemental Limited Benefit Accident Expense Insurance Policy | (10/14) | ESC Region 1

49

APSB-22329(TX)-MGM/FBS ESC Region 1

APSB-22329(TX)-MGM/FBS ESC Region 1

THE HARTFORD

Critical Illness

YOUR BENEFITS PACKAGE

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About this Benefit Critical illness insurance is designed to supplement your medical and disability coverage easing the financial impacts by covering some of your additional expenses. It provides a benefit payable directly to the insured upon diagnosis of a covered condition or event, like a heart attack or stroke.

$16,500 Is the aggregate cost of a hospital stay for a heart attack.

This is a general overview of your plan benefits. If the terms of this outline differ from your policy, the policy will govern. Additional plan details on covered expenses, limitations and exclusions are included in the summary plan description located on the 50 ESC Region 1 Benefits Website: www.mybenefitshub.com/region1

Critical Illness Coverage Amounts

Description

EMPLOYEE COVERAGE AMOUNT(S)

$5,000 or $10,000 or $15,000 or $20,000

SPOUSE COVERAGE AMOUNT

Greater of $5,000 or 50% of Primary Insured

CHILD(REN) COVERAGE AMOUNT

$5,000

GUARANTEED ISSUE AMOUNT(S)1

Employee: $20,000 Spouse and/or Child(ren): All amounts 50% Reduction for each covered person when the employee reaches age 75

REDUCTION DUE TO AGE

Critical Illness Benefits The Hartfordâ&#x20AC;&#x2122;s Critical Illness plan will pay a lump sum benefit for a covered person diagnosed with any of the following covered illnesses while insurance is in effect, subject to any Pre-existing Condition Limitation. State specific variations may apply to the benefits shown below.

COVERED ILLNESS

BENEFIT

Vascular Heart Attack

100% of coverage amount

Heart Transplant

100% of coverage amount

Coronary Artery Bypass Graft

25% of coverage amount

Angioplasty/Stent

25% of coverage amount

Stroke

100% of coverage amount

Aneurysm

25% of coverage amount

Other Specified Major Organ Transplant

100% of coverage amount

End Stage Renal Failure

100% of coverage amount

Coma

100% of coverage amount

Paralysis

100% of coverage amount

Loss of Vision

100% of coverage amount

Loss of Hearing

100% of coverage amount

Loss of Speech

100% of coverage amount

Bone Marrow Transplant

25% of coverage amount

Additional Plan Features & Services BENEFIT SEPARATION PERIOD COVERAGE MAXIMUM (% of coverage amount)

Different (Non-related) Illness: None Related Illness: 30 days Employee/Spouse: 500%; Child(ren): 300%

RECURRENCE BENEFIT (% of coverage amount)

50%; 12 months separation period

PRE-EXISTING CONDITION LIMITATION

12 Months Lookback/ 12 Months Continuously Insured

POLICY AGE LIMIT

Coverage terminates when the employee reaches age 80

PORTABILITY

Included

CONTINUATION OF COVERAGE

Included

CONTINUITY OF COVERAGE

Included 51

Critical Illness

Age

Attained Age Non-Tobacco Monthly Premium Rates for $5,000 Coverage Amount Employee Employee Employee Family & Spouse & Child

Age

Attained Age Tobacco Monthly Premium Rates for $5,000 Coverage Amount Employee Employee Employee Employee & Spouse & Child & Family

18-24

$0.78

$1.61

$2.18

$3.25

18-24

$0.86

$1.80

$2.27

$3.44

25-29

$0.79

$1.66

$2.06

$3.13

25-29

$0.98

$2.07

$2.25

$3.54

30-34

$0.85

$1.78

$1.86

$2.96

30-34

$1.18

$2.51

$2.19

$3.69

35-39

$1.15

$2.43

$2.02

$3.44

35-39

$1.76

$3.75

$2.62

$4.76

40-44

$1.76

$3.72

$2.50

$4.58

40-44

$2.96

$6.38

$3.70

$7.24

45-49

$3.04

$6.46

$3.75

$7.29

45-49

$5.47

$11.82

$6.17

$12.64

50-54

$4.36

$9.26

$5.03

$10.04

50-54

$7.85

$16.97

$8.52

$17.75

55-59

$6.19

$13.15

$6.85

$13.92

55-59

$10.99

$23.70

$11.65

$24.47

60-64

$8.97

$19.05

$9.62

$19.81

60-64

$15.63

$33.63

$16.28

$34.39

65-69

$12.86

$26.94

$13.51

$27.69

65-69

$22.46

$47.77

$23.11

$48.53

70-74

$18.08

$37.54

$18.73

$38.30

70-74

$31.54

$66.60

$32.19

$67.36

75-79

$12.96

$26.67

$13.28

$27.05

75-79

$21.99

$46.05

$22.31

$46.43

Age

Attained Age Non-Tobacco Monthly Premium Rates for $10,000 Coverage Amount Employee Employee Employee Employee & Spouse & Child & Family

Age

Attained Age Tobacco Monthly Premium Rates for $10,000 Coverage Amount Employee Employee Employee Employee & Spouse & Child & Family

18-24

$1.55

$2.38

$2.96

$4.03

18-24

$1.73

$2.66

$3.13

$4.30

25-29

$1.59

$2.45

$2.85

$3.92

25-29

$1.96

$3.05

$3.23

$4.52

30-34

$1.69

$2.63

$2.71

$3.81

30-34

$2.36

$3.69

$3.37

$4.87

35-39

$2.30

$3.58

$3.17

$4.59

35-39

$3.51

$5.51

$4.38

$6.52

40-44

$3.52

$5.48

$4.25

$6.34

40-44

$5.93

$9.34

$6.67

$10.20

45-49

$6.08

$9.50

$6.79

$10.33

45-49

$10.93

$17.29

$11.64

$18.11

50-54

$8.71

$13.61

$9.38

$14.39

50-54

$15.71

$24.82

$16.38

$25.60

55-59

$12.38

$19.34

$13.04

$20.11

55-59

$21.98

$34.69

$22.64

$35.46

60-64

$17.93

$28.01

$18.58

$28.77

60-64

$31.25

$49.26

$31.90

$50.02

65-69

$25.71

$39.79

$26.36

$40.55

65-69

$44.91

$70.23

$45.56

$70.99

70-74

$36.16

$55.63

$36.81

$56.38

70-74

$63.09

$98.14

$63.74

$98.90

75-79

$25.92

$39.63

$26.24

$40.01

75-79

$43.97

$68.04

$44.30

$68.42

52

Critical Illness

Age

Attained Age Non-Tobacco Monthly Premium Rates for $15,000 Coverage Amount Employee Employee Employee Family & Spouse & Child

Age

Attained Age Tobacco Monthly Premium Rates for $15,000 Coverage Amount Employee Employee Employee Employee & Spouse & Child & Family

18-24

$2.33

$3.58

$3.74

$5.22

18-24

$2.59

$3.99

$4.00

$5.63

25-29

$2.38

$3.67

$3.64

$5.15

25-29

$2.95

$4.57

$4.21

$6.04

30-34

$2.54

$3.95

$3.55

$5.12

30-34

$3.54

$5.54

$4.55

$6.71

35-39

$3.46

$5.37

$4.32

$6.38

35-39

$5.27

$8.26

$6.14

$9.27

40-44

$5.28

$8.23

$6.01

$9.08

40-44

$8.89

$14.02

$9.63

$14.87

45-49

$9.12

$14.26

$9.83

$15.08

45-49

$16.40

$25.93

$17.11

$26.75

50-54

$13.07

$20.42

$13.74

$21.20

50-54

$23.56

$37.23

$24.23

$38.01

55-59

$18.57

$29.01

$19.23

$29.78

55-59

$32.97

$52.03

$33.63

$52.80

60-64

$26.90

$42.02

$27.55

$42.78

60-64

$46.88

$73.89

$47.53

$74.65

65-69

$38.57

$59.69

$39.22

$60.45

65-69

$67.37

$105.34

$68.02

$106.10

70-74

$54.25

$83.44

$54.90

$84.20

70-74

$94.63

$147.21

$95.28

$147.97

75-79

$38.87

$59.45

$39.20

$59.83

75-79

$65.96

$102.06

$66.29

$102.44

Age

Attained Age Non-Tobacco Monthly Premium Rates for $20,000 Coverage Amount Employee Employee Employee Employee & Spouse & Child & Family

Age

Attained Age Tobacco Monthly Premium Rates for $20,000 Coverage Amount Employee Employee Employee Employee & Spouse & Child & Family

18-24

$3.10

$4.77

$4.51

$6.41

18-24

$3.45

$5.32

$4.86

$6.96

25-29

$3.17

$4.90

$4.44

$6.37

25-29

$3.93

$6.10

$5.19

$7.57

30-34

$3.39

$5.26

$4.40

$6.44

30-34

$4.72

$7.38

$5.73

$8.56

35-39

$4.61

$7.17

$5.48

$8.18

35-39

$7.03

$11.02

$7.89

$12.03

40-44

$7.03

$10.97

$7.77

$11.83

40-44

$11.86

$18.69

$12.60

$19.55

45-49

$12.16

$19.01

$12.87

$19.83

45-49

$21.87

$34.57

$22.58

$35.40

50-54

$17.42

$27.22

$18.09

$28.00

50-54

$31.41

$49.64

$32.08

$50.43

55-59

$24.75

$38.67

$25.42

$39.45

55-59

$43.96

$69.37

$44.62

$70.15

60-64

$35.86

$56.03

$36.51

$56.79

60-64

$62.51

$98.52

$63.16

$99.28

65-69

$51.43

$79.59

$52.08

$80.34

65-69

$89.82

$140.46

$90.47

$141.22

70-74

$72.33

$111.25

$72.98

$112.01

70-74

$126.17

$196.29

$126.82

$197.04

75-79

$51.83

$79.27

$52.16

$79.64

75-79

$87.95

$136.08

$88.27

$136.46

53

BAY BRIDGE

Heart & Stroke

YOUR BENEFITS PACKAGE

About this Benefit Heart and Stroke insurance offers you and your family supplemental insurance protection in the event you or a covered family member is diagnosed with a heart attack or stroke. It pays a benefit directly to you to help with expenses associated with your treatment

61,800,000 Americans have one or more types of cardiovascular disease according to current estimates.

This is a general overview of your plan benefits. If the terms of this outline differ from your policy, the policy will govern. Additional plan details on covered expenses, limitations and exclusions are included in the summary plan description located on the 54 ESC Region 1 Benefits Website: www.mybenefitshub.com/region1

Heart & Stroke Individual Heart & Stroke Plan - Monthly Rates Base Policy: Rates Per Unit 30-44

45-59

Intensive Care Rider: Rates Per Unit 60+

Coverage Tier

0-30 30-44 45-59

60+

First Diagnosis: Rates Per Unit Coverage Tier

0-30

30-44

45-59

60+

Coverage Tier

0-30

Individual

$3.17 $10.26 $23.23 $46.14 Individual

$0.42 $0.73 $0.93 $1.01 Individual

$3.88 $8.04 $18.78 $32.07

Ind + Spouse

$6.34 $20.52 $46.46 $92.27 Ind + Spouse

$0.84 $1.46 $1.87 $2.03 Ind + Spouse

$7.76 $16.08 $37.56 $64.13

Ind + Child(ren) $4.14 $11.23 $24.19 $47.10 Ind + Child(ren) $0.87 $1.18 $1.38 $1.46 Ind + Child(ren)

$6.59 $10.75 $21.49 $34.77

Family

$10.47 $18.79 $40.27 $66.84

$7.31 $21.49 $47.42 $93.24 Family

$1.29 $1.91 $2.32 $2.48 Family

Benefit

Maximum Amount

Hospital Confinement: We will pay for each day a Covered Person is admitted to and confined as an Inpatient $200 per day for each period of in a Hospital due to Heart Attack, Heart Disease or Stroke.

Continuous Hospital Confinement Physicianâ&#x20AC;&#x2122;s Attendance: We will pay for each day a Covered Person requires services of a Physician while Hospital Confined due to Heart Attack, Heart Disease or Stroke. This benefit is payable only for the number of days the Hospital Confinement benefit in this Policy is payable.

Inpatient Drugs and Medicine: We will pay the amount, per day, for drugs or medicine required while Hospital Confined due to Heart Attack, Heart Disease or Stroke. This benefit is payable only for the number of days the Hospital Confinement benefit in this Policy is payable.

Private Duty Nursing: We will pay the amount, per day, for private nursing care and attendance by a Nurse while Hospital Confined due to Heart Attack, Heart Disease or Stroke. Nursing services must be required and authorized by the attending Physician. The maximum number of days this benefit is payable is 60 days for each period of continuous Hospital Confinement.

Physiotherapy: We will pay the amount, per day, for physiotherapy performed by a licensed physical therapist, as required while Hospital Confined due to Heart Attack, Heart Disease or Stroke. The maximum number of days this benefit is payable is 60 days for each period of continuous Hospital Confinement.

$25 per day

$25 per day

$100 per day

$50 per day

Oxygen: We will pay the amount for the use of oxygen equipment while Hospital Confined due to Heart Attack, Heart Disease or Stroke. This benefit is payable only once each period of continuous Hospital Confinement.

$200 per period of continuous Hospital Confinement

Cardiograms: We will pay the amount for an electrocardiogram, echocardiogram, phonocardiogram, or vectorcardiogram which requires Hospital Confinement due to Heart Attack, Heart Disease or Stroke. This benefit is payable only once for each period of continuous Hospital Confinement.

Cerebral or Cartoid Angiogram: We will pay the amount for a cerebral or cartoid angiogram required while Hospital Confined due to Heart Attack, Heart Disease or Stroke. This benefit is payable only once for each period of continuous Hospital Confinement.

$100 per period of continuous Hospital Confinement

Blood, Plasma and Platelets: We will pay the amount for the administration of blood, plasma or platelets while Hospital Confined due to Heart Attack, Heart Disease or Stroke. This benefit is payable only once for each period of continuous Hospital Confinement.

$200 per period of continuous Hospital Confinement

$150 per period of continuous Hospital Confinement

Cardiac Catheterization: We will pay the amount for a cardiac catheterization procedure required for the treatment of Heart Attack, Heart Disease or Stroke.

$500

Coronary Angioplasty: We will pay the amount for a Angioplasty procedure required for the treatment of Heart Attack, Heart Disease or Stroke. Only the amount shown is payable regardless of the number of blood vessels repaired during this procedure.

Pacemaker Insertion: We will pay the amount for the initial insertion of a permanent pacemaker required for the treatment of Heart Attack, Heart Disease or Stroke.

$750

Coronary Artery Bypass Graft Operation: We will pay for a coronary artery bypass graft operation required for the treatment of Heart Attack, Heart Disease or Stroke. Only the amount shown is payable regardless of the number of grafts performed during the operation.

$1,000 $2,500

55

Heart & Stroke Benefit

Maximum Amount

Thromboendarterectomy: We will pay for a thromboendarterectomy operation required for the treatment of Heart Attack, Heart Disease or Stroke.

Heart Transplant: We will pay for the implantation of a natural human heart required for the treatment of Heart Attack, Heart Disease or Stroke. This benefit is payable only once per Covered Person.

Surgery and Anesthesia: We will pay for the following benefits for Surgery performed in a Hospital or an Ambulatory Surgical Center, provided that the Surgery is required for the treatment of Heart Attack, Heart Disease or Stroke.

1. Surgery: See Surgical Schedule. If any surgical procedure for the treatment of Heart Attack, Heart Disease or Stroke other than those listed in the Surgical Schedule is performed, We will pay the unit value for a surgical procedure as set forth in the 1994 California Relative Value Schedule (C.R.V.S.) multiplied by $17 per unit of coverage, up to a maximum of $10,000 per unit of coverage. If the surgical procedure has no unit value or is not shown in the 1994 C.R.V.S., We will pay an amount we reasonably determine based upon relative difficulty and payment amounts for other procedures, up to a maximum of $5,000 per unit of coverage.

2. Anesthesia: We will pay an additional percentage of the amount paid for benefit “P.1. Surgery” for anesthesia received by a Covered Person during the course of covered Surgery.

3. Ambulatory Surgical Center: We pay an additional amount when benefit “P.1. Surgery “ is paid for an operation performed at an Ambulatory Surgical Center. This benefit does not pay for surgeries covered by other benefits in this Policy.

Second Surgical Opinion: We will pay the amount for a second opinion obtained after a positive diagnosis that results in a Physician recommending Surgery for the treatment of Heart Attack, Heart Disease or Stroke.

Ambulance: We will pay for transfer by a licensed ambulance service or a hospital owned ambulance to a Hospital or emergency room for the treatment of Heart Attack, Heart Disease or Stroke.

Non-Local Transportation: We will pay the amount when a Covered Person requires Hospital Confinement for the treatment of Heart Attack, Heart Disease or Stroke prescribed by your local attending Physician that cannot be obtained locally. This benefit is payable only once per continuous Hospital Confinement.

Family Member Lodging & Transportation: We will pay the following benefits for a member of the Covered Person’s family to be near the Covered Person when a Covered Person is confined in a NonLocal Hospital for the treatment of Heart Attack, Heart Disease or Stroke.

Lodging: We will pay the amount shown, per day, for a motel, hotel or other accommodations acceptable to us. This benefit is limited to 60 days for each period of continuous Hospital Confinement.

Transporation: We will pay the amount shown for each period of continuous Hospital Confinement when the Non-Local transportation benefit is paid and a family member travels more than 100 miles from his or her home to be near the Covered Person for a portion of his or her continuous Hospital Confinement.

56

$2,500 $100,000

See Surgical Schedule 25% of item P1

$250

$100 $200 (double for air ambulance)

$200 per period of continuous Hospital Confinement

$50 per day $200 per period of continuous Hospital Confinement

Heart & Stroke Exceptions and Other Limitations

Payment of Benefits

The policy provides benefits only for Heart Attack, Heart Disease or Stroke. The 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 was 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 the confinement attributable to the covered condition.

Benefits are payable for a Covered Person’s Heart Attack, Heart Disease or Stroke Positive Diagnosis that begins after the Policy Effective Date and while this Policy has remained in force.

Pre-Existing Condition Limitation

Covered Persons

Renewability The policy is guaranteed renewable for life, subject to change in premiums by class.

Premiums

We can change 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.

Effect of Simultaneous Surgical or Invasive Procedures: Two or Once the Policy has been issued, We cannot place any restrictive more surgical or invasive procedures done at the same time and riders on it or cancel or refuse to renew Your Policy if You through a common incision or entry point are considered one maintain it continuously in force. If We do change rates on all like operation. If benefits would otherwise be payable for two or policies in Your class, We will mail You a notice of this change. more surgical or invasive procedures which are considered one Notice will be mailed at least 31 days prior to such changes. It will operation, benefits for that operation are only payable for the be mailed to Your address as shown on Our records. No change one surgical or invasive procedure with the largest total benefits. in premiums is effective unless this notice is mailed.

Pre-Existing Condition means any injury or sickness, diagnosed or undiagnosed, for which medical care is received by a Covered Person within the 12 month period prior to the Covered Person’s effective date of insurance; or with respect to the limitation for increase in coverage, within the 12 month period prior to the effective date of the Covered Person’s increase in coverage.

We will consider medical care received when a Physician is consulted or medical advice is given; or treatmentis recommended or prescribed by, or received from a Physician.

We will consider treatment to include, but not be limited to, any: a. medical examination, test, treatment, or observation; b. medical services, supplies, or equipment, including their prescription or use; or c. prescribed drugs or medicines, including their prescription or use.

Covered Person means any of the following: a. the Named Insured; or b. any eligible Spouse or Child, as defined and as named on the Policy Schedule whose coverage has become effective; c. any eligible Spouse or Child, as defined and added to this Policy by endorsement after the Policy Effective Date whose coverage has become effective; or d. a Newborn Child (as described in the Eligibility Section).

Dependent means: a. your spouse, unless divorced or legally separated from you; b. your unmarried child(ren) who are less than age 25 and primarily dependent on you for support and maintenance; and c. your unmarried child(ren) who are at least age 25 but less than age 26 who: All manifestations, symptoms, or findings which result from the 1) regularly attend an institution of learning; and same or related accident or sickness, or from any aggravations of 2) are primarily dependent on You for support and accident or sickness, are considered to be the same accident or maintenance. sickness for the purpose of determining a Pre-Existing Condition.

During the first 12 months of a Covered Person’s insurance, A Child includes a stepchild residing with You, a child placed with losses incurred for Pre-Existing Conditions are not covered. you for adoption, a legally adopted child and a foster child. Child During the first 12 months following the date a Covered Person will also include a grandchild, if, at the time of his or her birth, makes a change in coverage that increases his or her benefits, one parent is Your dependent. If you give Us a Written Request, the increase will not be paid for Pre-Existing Conditions.

You may add Dependents to the Policy while it is in force.

30-Day Right to Examine Policy If You decide not to keep this Policy, send it to Us or Our agent within 30 days after You receive it. We will treat the Policy as though it had never been issued. We will refund any premiums paid.

57

GENWORTH FINANCIAL

Long Term Care

YOUR BENEFITS PACKAGE

PLAY VIDEO

About this Benefit Long Term Care insurance is designed to help create a safety net if you are no longer able to care for yourself. If you suffer from an eligible prolonged illness, disability or cognitive disorder, long term care insurance will provide financial support.

60% of Americans do not have a â&#x20AC;&#x153;rainy dayâ&#x20AC;? fund to cover three months of unanticipated financial emergencies.

This is a general overview of your plan benefits. If the terms of this outline differ from your policy, the policy will govern. Additional plan details on covered expenses, limitations and exclusions are included in the summary plan description located on the 58 ESC Region 1 Benefits Website: www.mybenefitshub.com/region1

Long Term Care The need Long term care insurance enhances Teacher Retirement System of Texas (TRS) benefit offerings by meeting a largely unrecognized need many of us may have. It pays for covered expenses for long term care services whether they are received at home, in the community or in a nursing facility. Here are a few points to consider:  Long term care coverage is not included in disability or health insurance.  Relying on government programs for long term care may not be a viable solution.  Without long term care insurance, the costs of these services may have to come out of your savings.

The cost

Step 2: Select Your Total Coverage Amount This is the total amount of money available to pay covered long term care expenses for the lifetime of your coverage. You have several choices available to you – depending on the monthly benefit you selected Monthly Benefit Choices $ 3,000 $ 108,000

Total Coverages Choices $ 180,000

$ 360,000

$ 4,500

$ 162,000

$ 270,000

$ 540,000

$ 6,000

$ 216,000

$ 360,000

$ 720,000

$ 7,500

$ 270,000

$ 450,000

$ 900,000

Now as an active TRS member, you and your spouse, plus other eligible family members, may be able to buy this important coverage at competitive group rates.  Employees in their fi rst TRS-covered position have 90 days beginning on their employment date to apply for this coverage with no medical underwriting or streamlined underwriting, depending on the plan they choose. Their spouses may apply with streamlined underwriting, depending on their age.  Current, active TRS members and their spouses may apply for this coverage subject to Genworth Life’s underwriting requirements.  Other eligible family members may also apply for this coverage, subject to Genworth Life’s underwriting requirements.

Step 3: Choose a Benefit Increase Option This program offers 3 Benefit Increase Options to help you protect against the rising cost of care:  Buy More Coverage Over Time Every three years, as long as you’re not in claim status, you’ll be offered the chance to buy more coverage without answering any medical questions. The premium for the increase will be based on your age at the time you increase your benefits. If you decline the increase two consecutive times, future offers will not be made.  Automatic 3% Increase for Life – Compound Your Monthly Benefit and Total Coverage will automatically increase by 3% compound every year, with no additional increase in your premium.  Automatic 5% Increase for Life – Compound Your Monthly Benefit and Total Coverage will automatically increase by 5% compound every year, with no additional increase in your premium.

A simple solution can fit your needs and budget It’s easy to apply for coverage – and it may be more affordable than you think. You can tailor a plan to meet your individual needs and your pocketbook.

What are your basic choices?

For example, with the new TRS Group Long Term Care Insurance Program, a 45 year old can purchase comprehensive coverage starting at $47.52 per month.3

Today, a private room in a Texas nursing facility averages $60,2251 a year and costs are rising. So, a long term care situation could potentially cost at least $180,675,* particularly if the cost of care continues to increase.

The opportunity

Step 1: Choose a Monthly Benefit This is the maximum amount you’ll be reimbursed each month for covered long term care expenses. You have 4 available choices: Will Reimburse Up to This Amount For Covered: Monthly Benefit Home Care Assisted Living Nursing Facility Choices Care Care $ 3,000 $ 2,250 $ 3,000 $ 3,000 $ 4,500

$ 3,375

$ 4,500

$ 4,500

$ 6,000

$ 4,500

$ 6,000

$ 6,000

$ 7,500

$ 5,625

$ 7,500

$ 7,500

Texas cost of care2

$ 3,422/month $ 3,210/month

$ 5,019/month

A sampling of additional available plans for a 45 year old.

Monthly Benefit $3,000

$4,500

$6,000

$7,500

Total Coverage

$ 162,000

$ 216,000

$ 270,000

$ 26.93

$ 35.92

$ 44.90

$ 108,000

Monthly Premium $ 17.95

1

Genworth 2011 Cost of Care Survey, conducted by CareScout®, April 2011 *Assumes 3 years of care 2 Genworth 2011 Cost of Care Survey, conducted by CareScout®, April 2011.

3 Assumes the “Buy more coverage over time” benefit increase option and does not include the optional non-forfeiture benefit.

59

NBS

FSA (Flexible Spending Account)

YOUR BENEFITS PACKAGE

PLAY VIDEO

About this Benefit A Cafeteria Plan is designed to take advantage of Section 125 of the Internal Revenue Code. It allows you to pay certain qualified expenses on a pre-tax basis, thereby reducing your taxable income. You can set aside a pre-established amount of money per plan year in a Healthcare Flexible Spending Account (FSA). Funds allocated to a healthcare FSA must be used during the plan year or are forfeited unless your plan contains a $500 rollover or grace period provision.

Unlimited FSA (Non HSA Compatible) The funds in the unlimited healthcare FSA can be used to pay for eligible medical expenses like deductibles, co-payments, orthodontics, glasses and contacts.

This is a general overview of your plan benefits. If the terms of this outline differ from your policy, the policy will govern. Additional plan details on covered expenses, limitations and exclusions are included in the summary plan description located on the 60 ESC Region 1 Benefits Website: www.mybenefitshub.com/region1

FSA (Flexible Spending Account) NBS Flexcard

When Will I Receive My Flex Card?

You may use the card to pay merchants or service providers who accept MasterCard® credit cards, so there is no need to pay cash up-front and then wait for reimbursement. If you are participating in the Dependent Care portion, the money isn’t loaded to the card. You must file web or paper claims or enroll in continual reimbursement.

NBS Prepaid MasterCard® Debit Card

Current plan participants: KEEP YOUR CARDS! NBS debit cards are good for 3 years. If you throw away your cards, there is a $5.00 fee to replace them.

Expect Flex Cards to be delivered to the address listed in THEbenefitsHUB mid-September.

Don’t forget, Flex Cards Are Good For 3 Years!

For a list of sample expenses, please refer to the ESC Region1 benefit website: www.mybenefitshub.com/region1

NBS Contact Information: 8523 South Redwood Road West Jordan, UT 84088 Phone (800) 274‐0503 Fax (800) 478‐1528 Email: claims@nbsbenefits.com

New Plan Participants NBS will mail out your new benefit cards to the address listed in THEbenefitsHUB. They will be sent in unmarked envelopes, so please watch for them, as they should arrive within 21 business days of the effective date. NBS debit cards are good for 3 years.

FSA Annual Contribution Max:

DID YOU KNOW? FSAs use tax-free funds to help pay for your Health Care Expenses?

$2,600

Dependent Care Annual Max: $5,000

Account Information: Participant Account Web Access: www.participant.nbsbenefits.com Participants may call NBS and talk to a representative during regular business hours, Monday-Friday, 8 am to 7 pm Central 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 (800) 274-0503. For immediate access to your account information at any time, log onto the NBS website: www.NBSbenefits.com    

Detailed claim history and processing status Health Care and Dependent Care Account balances Claim forms, direct deposit form, worksheets, etc.

Online claim FAQs 61

FSA Frequently Asked Questions What is a Flexible Spending Account?

A Flexible Spending Account allows you to save money by paying out-of-pocket health and/or dependent care related expenses with pre-tax dollars. Your contributions are deducted from your pay before taxes are withheld and your account is up fronted with an annual amount. Because you are taxed on a lower amount of pay, you pay less in taxes and you have more to spend.

How does a Flexible Spending Account Benefit Me? A Cafeteria plan enables you to save money on group insurance, health-related expenses and dependent care expenses. You may save as much as 35 percent on the cost of each benefit option!

Eligible expenses must be incurred within the plan year and contributions are use-it-or-lose-it. Remember to retain all your receipts.

Health Care Expense Account Example Expenses:          

Acupuncture Body scans Breast pumps Chiropractor Co-payments Deductible Diabetes Maintenance Eye Exam & Glasses Fertility treatment First aid

        

Hearing aids & batteries Lab fees Laser Surgery Orthodontia Expenses Physical exams Pregnancy tests Prescription drugs Vaccinations Vaporizers or humidifiers

Dependent Care Expense Account Example Expenses:    

Before and After School and/or Extended Day Programs The actual care of the dependent in your home Preschool tuition The base costs for day camps or similar programs used as care for a qualifying individual

What Can I Use My Flexible Spending Account On? For a full list of eligible expenses, please refer to www.mybenefitshub.com/region1

62

What Happens If I Don’t Use All of My Funds by The End of the Plan Year (August 31st)?

Eligible expenses must be incurred within the plan year +75 day grace period. Contributions are use-it-or-lose-it.

Remember to retain all your receipts (including receipts for card swipes).

How Do I File A Claim?

In most situations, you will be able to swipe your card.

However, in the event you lose your card or are waiting to receive one, you can visit www.mybenefitshub.com/region1 and complete the “Claim Form” to send to NBS or use the web or phone app to file online.

How To Receive Your Dependent Care Reimbursement Faster.

A Direct Deposit form is available on the Benefits Website, which will help you get reimbursed quicker!

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.

2.

3.

4.

Complete and sign a claim form (available on our website) or an online claim.

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

Fax or mail signed form and documentation to NBS. 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 who accept credit cards, so there is no need to pay cash up-front and then wait for reimbursement.

Account Information 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 (800) 274-0503. For immediate access to your account information at any time, log on to our website: www.NBSbenefits.com Information includes:  Detailed claim history and processing status  Health Care and Dependent Care account balances  Claim forms, worksheets, etc.  Online Claim Submission

Enrollment Considerations After 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, in order for you to submit qualified claims for any unused funds.

63

NATIONWIDE - INFO ARMOR

Identity Theft

YOUR BENEFITS PACKAGE

About this Benefit Identity theft protection monitors and alerts you to identity threats. Resolution services are included should your identity ever be compromised while you are covered.

An identity is stolen every 2 seconds, and takes over

300 hours

to resolve, causing an average loss of $9,650.

This is a general overview of your plan benefits. If the terms of this outline differ from your policy, the policy will govern. Additional plan details on covered expenses, limitations and exclusions are included in the summary plan description located on the 64 ESC Region 1 Benefits Website: www.mybenefitshub.com/region1

Identity Theft The LegalShield® Membership Includes: PrivacyArmor offers consumers a comprehensive and proactive defense against identity theft. Features include:

Legal Guard



The LegalGUARD Plan is only $16.91 monthly, via payroll deduction. The LegalGUARD Plan + Family Coverage is only $18.88 monthly, via payroll deduction.

LegalGUARD is a legal benefits plan presented by Nationwide® that provides support and protection for unexpected personal SNAPD® Identity Monitoring legal issues. What you get with a LegalGUARD Plan: We create a SNAPD identity blueprint (an acronym for Social  An attorney with expertise specific to your personal legal Security number, Name, matter Address, Phone and Date of birth) to monitor over 700 billion  Access to a national network of attorneys with exceptional data elements (and growing by 45 million more daily) from experience that are matched to meet your needs sources such as new credit cards, wireless accounts, retail  In and out-of-network coverage credit accounts, automobile loans, mortgage loans, payday  Concierge help navigating common individual or family loans, check and check reorders, utility accounts and change of legal issues address requests.

The value of a LegalGUARD Plan.

InfoArmor is capable of identifying anomalies indicative of Being a LegalGUARD member also saves you time and costly fraudulent activity up to 90 days sooner than credit monitoring. legal fees. But most importantly, it gives you confidence and This patented technology makes InfoArmor’s identity provides coverage* for: protection more than enough to stand up to 21st century  Home and residential (Buying, selling, refinancing, and crime. tenant disputes)  Financial (Debts, credit, collections, and bankruptcy) • Privacy Advocate® Remediation Auto and traffic (Moving violations and accidents) Our Privacy Advocates are CITRMS® Certified and ITRC Trained  Family (Divorce, adoption, name change, guardianship) to be experts in identity restoration. If we detect suspicious  Estate planning and wills (Will, living will, power of activity a Privacy Advocate will: attorney)

 

Initiate a live phone call to discuss any fraudulent activity associated with the account Act as a dedicated case manager to act on behalf of the victim and resolve the issue from start to case completion Implement preventative steps to proactively prevent fraud

Additional PrivacyArmor features include: IdentityMD Whether it is learning about ID theft, protecting a wallet’s contents, or even restoring an identity following fraudulent events, IdentityMD is designed to offer interactive, step-by-step assistance.

Out of Pocket Expense Coverage Protect consumers from the financial damages of identity theft with our $25,000 identity fraud reimbursement policy that is underwritten by Travelers Insurance.

To learn more about your legal benefits plan visit legaleaseplan.com/region1 or call 1(800) 248-9000. Be prepared and fully confident with LegalGUARD. *Visit https:// www.legaleaseplan.com/region1 for more information.

Plan Cost InfoArmor: $12.00 per month LegalGUARD and InfoArmor: $28.16 per month. A $2.50 savings.

Solicitation Reduction We help reduce the root cause of up to 20% of identity theft by reducing junk mail, stopping pre-approved credit offers, and ending telemarketing calls.

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NOTES

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NOTES

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WWW.MYBENEFITSHUB.COM/ REGION1 68