Eliada Homes 2021 Booklet 21-22PY (10.27.21) by Pierce Group Benefits

EMPLOYEE BENEFITS PLAN ELIADA HOMES PLAN YEAR: DECEMBER 1, 2021 - NOVEMBER 30, 2022

ARRANGED BY PIERCE GROUP BENEFITS WWW.PIERCEGROUPBENEFITS.COM

EMPLOYEE BENEFITS GUIDE

TABLE OF CONTENTS Welcome to the Eliada Homes comprehensive benefits program. This booklet highlights the benefits offered to all eligible employees for the plan year listed below. Benefits described in this booklet are voluntary, employee-paid benefits unless otherwise noted.

ENROLLMENT PERIOD: NOVEMBER 1, 2021 - NOVEMBER 12, 2021 EFFECTIVE DATES: DECEMBER 1, 2021 - NOVEMBER 30, 2022

EAP

Benefits Plan Overview

page

Disability Benefits

page

Online Enrollment Instructions

page

Accident Benefits

page

Health Benefits

page

Medical Bridge Benefits

page

Health Reimbursement Arrangment

page

Life Insurance

page

Employee Assistance Program

page

Additional Benefits Available

page

Dental Benefits

page

Authorization Form

page

Notice Of Insurance Information Practices

page

Continuation Of Coverage for Benefits Form

page

Vision Benefits

page

Group Term Life Insurance

page

Flexible Spending Accounts

page

Cancer Benefits

page

Critical Illness Benefits

page

41 Rev. 10/28/2021

PRE-TAX & POST-TAX BENEFITS

ELIADA HOMES

ENROLLMENT PERIOD: NOVEMBER 1, 2021 - NOVEMBER 12, 2021 EFFECTIVE DATES: DECEMBER 1, 2021 - NOVEMBER 30, 2022

PRE-TAX BENEFITS Health Insurance

Dental Insurance

BlueCross BlueShield

Ameritas

Vision Insurance* EyeMed

Flexible Spending Accounts**

Ameriflex • Medical Reimbursement FSA Maximum: $2,750/year | Minimum $100/year • Dependent Care Reimbursement FSA Maximum: $5,000/year **You will need to re-sign for the Flexible Spending Accounts if you want them to continue next year.

Cancer Benefits

Colonial Life

Accident Benefits

Colonial Life

Medical Bridge Benefits

Colonial Life

POST-TAX BENEFITS Short-Term Disability Benefits Colonial Life

Long-Term Disability Benefits

The Hartford

Critical Illness Benefits Colonial Life

Employer-Paid Benefit

Life Insurance

Colonial Life • Term Life Insurance • Whole Life Insurance

Group Term Life Insurance The Hartford

• Basic GTL - Employer-Paid Benefit • Voluntary GTL - Employee-Paid Benefit

*EMPLOYEES WILL NEED TO RE-ENROLL IN VISION BENEFITS IN ORDER TO CONTINUE COVERAGE FOR THE NEW PLAN YEAR BEGINNING DECEMBER 1, 2021. 2

QUALIFICATIONS & IMPORTANT INFO

THINGS YOU NEED TO KNOW QUALIFICATIONS: • You must work 30 hours or more per week.

IMPORTANT FACTS: • The plan year for BlueCross BlueShield Health, Ameritas Dental, EyeMed Vision, Colonial Insurance products, Spending Accounts, The Hartford Long-Term Disability and The Hartford Group Term Life lasts from December 1, 2021 through November 30, 2022. Please Note: Dental benefits are based on the Calendar Year, running from January 1st through December 31st. Dental benefits and deductibles will reset every January 1st. • Deductions for BlueCross BlueShield Health, Ameritas Dental, EyeMed Vision, Colonial Insurance products, Spending Accounts and The Hartford Voluntary Group Term Life will begin December 2021. The Hartford Basic Group Term Life and Long-Term Disability plans are benefits provided by your employer. • If signing up for any coverage on your spouse and/or children, please have their dates of birth and social security numbers available when speaking with the Benefits Representative. • If you will be receiving a new debit card, please be aware that it may take up to 30 days following your plan effective date for your card to arrive. Your card will be delivered by mail in a plain white envelope. During this time you may use manual claim forms for eligible expenses. Please note that your debit card is good through the expiration date printed on the card. • Elections made during this enrollment period CANNOT BE CHANGED AFTER THE ENROLLMENT PERIOD unless there is a family status change as defined by the Internal Revenue Code. Examples of a family status change are: marriage, divorce, death of a spouse or child, birth or adoption of a child, termination or commencement of a spouse's employment, or the transition of spouse's employment from full-time to part-time, or vice-versa . Once a family status change has occurred, an employee has 30 days to notify the North Carolina Service Center at 1-888-662-7500 to request a change in elections. • Flexible Spending Account expenses must be incurred during the Plan Year in order to be eligible for reimbursement. • An employee has 90 days after the plan year ends to submit claims for spending account expenses that were incurred during the plan year. Please note that if employment terminates during the plan year, that employee's plan year ends the day employment ends. The employee has 90 days after the termination date to submit claims. • With Dependent Care Flexible Spending Accounts, the maximum reimbursement you can request is equal to the current account balance in your Dependent Care account. You cannot be reimbursed more than has actually been deducted from your pay. • As a married couple, one spouse cannot be enrolled in a Medical Reimbursement FSA at the same time the other opens or contributes to an HSA. • The Colonial Cancer plan and the Health Screening Rider on the Colonial Accident and Colonial Medical Bridge plan have a 30-day waiting period for new enrollees. Coverage, therefore, will not begin until December 31, 2021. • Additionally, some policies may include a pre-existing condition clause. Please read your policy carefully for full details. • Please be aware there are certain coverages that may be subject to federal and state tax when premium is paid by pretax deduction or employee contribution. • An employee taking a leave of absence, other than under the Family & Medical Leave Act, may not be eligible to re-enter the Flexible Benefits Program until the next plan year. Please contact your Benefit Administrator for more information.

EMPLOYEE BENEFITS GUIDE

ELIADA HOMES

IN PERSON

During your open enrollment period, a Pierce Group Benefits representative will be available by appointment to answer any questions you may have and to assist you in the enrollment process.

ONLINE You may enroll or make changes online to

your benefits plan. To enroll online, please visit https://access.paylocity.com/ (Company #99708) and see the information below and on the following pages.

ENROLLMENT PERIOD: NOVEMBER 1, 2021 - NOVEMBER 12, 2021 YOU CAN MAKE THE FOLLOWING BENEFIT ELECTIONS ONLINE DURING THE ENROLLMENT PERIOD: • Enroll in Health Insurance. • Enroll in Dental Insurance. • Enroll in Vision Insurance*. • Enroll in Group Term Life Insurance. • Enroll in Long-Term Disability Insurance. • Enroll in Flexible Spending Accounts⁺ (Medical Reimbursement and Dependent Care). • Enroll in Colonial coverage (see below for enrollments that can be completed online). ⁺You will need to re-sign for the spending accounts if you want them to continue each year.

*EMPLOYEES WILL NEED TO RE-ENROLL IN VISION BENEFITS IN ORDER TO CONTINUE COVERAGE FOR THE NEW PLAN YEAR BEGINNING DECEMBER 1, 2021. • CANCER ASSIST - You may enroll online in Cancer Assist coverage. • DISABILITY - NCK1000 - You may enroll online in NCK1000 coverage. • ACCIDENT 1.0 - You may enroll online in Accident 1.0; however persons over age 64 applying for coverage and employees wishing to purchase an individual policy for their spouse should speak with the Benefits Representative. • MEDICAL BRIDGE - You may enroll online in Medical Bridge coverage. • CRITICAL ILLNESS 6000 - You may enroll online in Critical Illness 6000 coverage. • TERM LIFE 5000 - You may enroll online in Term Life 5000; however, employees wishing to purchase an individual policy for their spouse should speak with the Benefits Representative. • WHOLE LIFE 5000 Plus - You may enroll online in Whole Life 5000 Plus; however, employees wishing to purchase an individual policy for their spouse should speak with the Benefits Representative.

ACCESS YOUR BENEFITS ONLINE WHENEVER, WHEREVER. Benefits Details | Educational Videos | Download Forms | Online Chat with Service Center To view your personalized benefits website, go to:

www.piercegroupbenefits.com/EliadaHomes

or piercegroupbenefits.com and click “Find Your Benefits”.

IMPORTANT NOTE & DISCLAIMER

This is neither an insurance contract nor a Summary Plan Description and only the actual policy provisions will prevail. All information in this booklet including premiums quoted is subject to change. All policy descriptions are for information purposes only. Your actual policies may be different than those in this booklet.

1.Overview You will be able to use the Benefits Enterprise site to make your New Hire and/or Open Enrollment elections, view your current elections, make life event changes, update family and/or beneficiary information, access benefit materials (i.e. plan summary documents or forms), etc.

2. Accessing Benefits Enterprise You will be able to access the Benefits Enterprise site directly from the Web Pay Employee Self Service Portal, by hovering over the Web Pay tab and selecting Enterprise Web Benefits from the dropdown options. You will not need a separate user ID or password when accessing the site via the Employee Self Service Portal.

For successful navigation of the site, do not use the back button in your internet browser, as this will automatically log you out of the site. To navigate through the site, use the navigation bar located at the top of the screen.

3. Making Your Benefit Elections From the homepage, click on Start Your Enrollment. If you do not see the Start Your Enrollment button, please contact your HR department.

The enrollment process consists of the following four steps. You will be taken through each step to make changes or confirm your information on file and choose your benefits for the new plan year. 1. 2. 3. 4.

Employee (Personal Information) Family (Family Information) Enroll Confirm

VERIFY YOUR PERSONAL INFORMATION Before beginning your enrollment, please verify the accuracy of all of your personal information (e.g., address, DOB, etc.). If you need to make any changes, please do so in your Employee Self-Service Portal. All updates will reflect on this page within 24 hours. You can still move on with your enrollment. Verify that all information is accurate. When done, check I Agree at the bottom of the page and click Continue. Any field that has an asterisk next to it is required.

VERIFY YOUR FAMILY INFORMATION Please add all dependents that may be missing from the Family Information section before proceeding to the next section. To do this, click Add Dependents. When all of your family information is accurate, check I Agree and click Continue.

MAKING BENEFIT ELECTIONS Below is a sample of what the Benefit Election screen will look like. To review all available plan options, click the View Plan Options link.

Before you are able to select a plan, select all dependents you wish to cover (the system will generate your coverage tier based on this) and click Continue. If you wish to add a new dependent at this time, click Add Dependents to the family tab and add the dependent.

From here, you can use the View All Plans Side-by-Side section to compare all available plans. Once you have chosen the plan you wish to enroll in, click Select to the corresponding plan.

After each election that you make, you will see a summary of your election.

Basic Employee Life This is a benefit provided to you by your employer at no cost to you. You do not need to make an election here. You can use the View Information button to review any applicable plan information.

If you enrolled in a plan that requires beneficiary designation, you will be asked to do that now. Any dependents on file will be listed automatically as beneficiaries. Enter your designations. Your percentages must equal 100 percent. When complete, click Continue. If you would like to add another beneficiary, click Add Beneficiary.

Almost Finished! You will now be on the final review page. Review all of your benefit elections and covered dependents. If you wish to make any changes, simply click on any one of the Edit Selection buttons. It will return you to the enrollment page.

Once you have completed your review, check “I agree, and I’m finished with my enrollment” and “Complete Enrollment.” If you stop at any point before this step, your progress will be saved, but your enrollment is not complete.

CONFIRMATION

You can send yourself an email confirmation of your elections or print it for your records. Click the printer icon on the right-hand side of the screen. Note: Although the online benefits enrollment site is a secure site and your information is encrypted during transit, it is important that you log off when you have completed your session. Click the Log Off icon in the upper right-hand corner of the enrollment site to do so. For security purposes, the system will automatically log you out if you leave your system idle for more than 30 minutes.

Blue Options with HRA Fund Benefit Highlights (PPO) The coinsurance amounts that appear on this benefit highlight represent Plan responsibility. The coinsurance amounts that display in the benefit booklet represent member responsibility.

Deductibles, Out-of-Pocket Limits & Benefit Maximums

Out-of-network 1

In-network

The following Deductibles, Out-of-Pocket Limits, and Benefit Maximums apply to all services. All copays are before deductible.

Embedded Deductibles Individual (per Benefit Period) Family (per Benefit Period)

$5,000 $10,000

$10,000 $20,000

$8,550 $17,100

$17,100 $34,200

Unlimited

Embedded Out-of-Pocket Limits Individual (per Benefit Period) Family (per Benefit Period)

Benefit Maximums: Lifetime Total Dollar Maximum Lifetime Infertility Benefit Maximum Ovulation Induction Cycles

3 Cycle Limits

(with insemination, per Member, in all places of service)

Annual Benefit Maximums: Maximums apply to Home, Office and Outpatient Settings only, unless otherwise indicated. Maximums include both Habilitative and Rehabilitative services unless otherwise indicated. All maximums are on a combined In- and Out-of-Network basis per Member, per Benefit Period.

Physical, Occupational and Chiropractic Therapies (combined) Speech Therapy Adaptive Behavior Treatment is covered for members, up to age 19. Skilled Nursing Facility Stay Provider Office visits for the evaluation and treatment of obesity

30 visits 30 visits $40,000 60 days 4 visits

(maximum does not apply to dietician/nutritional visits)

Physician Office Services (See "Outpatient Services" for "outpatient clinic" or "hospital-based" services.)

Office Visit Includes all Office Visits regardless of specialty or diagnosis (including medical, mental health, substance use disorder, infertility, therapies and pre-natal/postdelivery care unable to be included in the global delivery fee). Includes Office Surgery, Consultation, X-rays and Labs.

Primary Care Provider $25 50% after deductible Log in to Blue Connect to select your Primary Care Provider (PCP). Your copay is waived for your first 3 visits to your selected PCP. Specialist Mental Health and Substance Use Disorder

Vendor Telehealth

$50 $10

50% after deductible 50% after deductible

$10

Benefits not available

Includes Telehealth services for medical/acute care/behavioral health

Preventive Care (Primary Preventive Diagnosis Only) For the most updated list of general preventive/screenings, immunizations, wellbaby/well-child care, women’s preventive care services, nutritional counseling and other services mandated under Federal law, see our website at bluecrossnc.com/preventive. State mandated services include colorectal screening, bone mass measurement, newborn hearing screening, prostate specific antigen tests (PSAs), gynecological exams, cervical cancer screening, ovarian cancer screening and screening mammograms.

Primary Care Provider Specialist

ELIADA HOMES, INC.

100% no deductible 100% no deductible

70% after deductible 70% after deductible

Blue Options with HRA Fund Benefit Highlights (PPO) Urgent and Emergency Care Ambulance Emergency Room Visit* Urgent Care Centers

In-network 70% after deductible $500 $50

Out-of-network 1 70% after deductible $500 $50

70% after deductible 70% after deductible

50% after deductible 50% after deductible

70% after deductible

50% after deductible

70% after deductible 100% no deductible 70% after deductible

50% after deductible 70% after deductible 50% after deductible

70% after deductible 70% after deductible 70% after deductible 70% after deductible

50% after deductible 50% after deductible 50% after deductible 50% after deductible

*If admitted from the ER, any applicable ER member responsibility does not apply; instead, Inpatient Hospital benefits apply. If held for observation, Outpatient benefits apply. See "Inpatient Hospital Services" and "Outpatient Services". Out-of -Network Emergency Room services are payable at the In-Network level and applied to the In-Network Out- of-Pocket Limit regardless of where they are obtained.

Inpatient Hospital Services Includes all Inpatient Hospital Services regardless of diagnosis (including, but not limited to, medical, mental health, substance use disorder, infertility, therapies, transplants, deliveries, and surgeries.)You may receive a better benefit if you receive care at a Blue Distinction Center (BDC). Visit bluecrossnc.com/bdc to find a BDC.

Inpatient Hospital Facility Services Inpatient Hospital Professional Services

Outpatient Services Hospital Based or Free-standing Facility Services (other than preventive services above)

Outpatient Diagnostic Services Outpatient lab tests Outpatient Mammography Outpatient X-rays, ultrasounds, and other diagnostic tests such as EEGs and EKGs Other Services Skilled Nursing Facility Home Health Care and Hospice Durable Medical Equipment, Prosthetics and Orthotics CT scans, MRIs, MRAs and PET scans in any location, including a physician's office

ELIADA HOMES, INC.

Blue Options with HRA Fund Benefit Highlights (PPO) Prescription Drugs

In-network 100% no deductible

Out-of-network 1 100% no deductible

Preventive OTC Medications and Contraceptive Drugs and Devices as listed at bluecrossnc.com/preventive Up to 30 day supply. 31-60 day supply is two copayments and 61-90 day supply is three copayments. Prescription Drug copayments*, coinsurance* and deductibles* (*if applicable) apply to the Out-of-Pocket limit. MAC B Pricing (Brand Penalty when Generic Equivalent is available and Provider does not require Brand to be dispensed). Penalty does not count toward OOP Limit. Essential 5 Tier Commercial, Limited NC Network Formulary. Prior Plan approval, step therapy and quantity limits may apply. Tier 1 Drugs $10 $10 Tier 2 Drugs $25 $25 Tier 3 Drugs $40 $40 Tier 4 Drugs $80 $80 Tier 5 Drugs 75% 75% There is a $100 per Prescription Minimum and a $200 per Prescription Maximum for each 30-day supply of Tier 5 drugs. You are responsible for charges over the allowed amount received from an Out-of-Network pharmacy. Limits apply to Infertility drugs, refer to your benefit booklet. 1NOTICE:

Your actual expenses for covered services may exceed the stated coinsurance percentage or co-payment amount because actual provider charges may not be used to determine the payment obligations for Blue Cross NC and its members.

Employee Portion Employee Only $161.74 Employee + Spouse $568.22 Employee + Child(ren) $522.02 Employee + Family $739.64

ELIADA HOMES, INC.

Employer Portion $287.00 $287.00 $287.00 $287.00

Total $448.74 $855.22 $809.02 $1,026.64

ADDITIONAL INFORMATION ABOUT BLUE OPTIONS with HRA Fund Benefit Period The period of time, usually 12 months as stated in the group contract, during which charges for covered services provided to a member must be incurred in order to be eligible for payment by Blue Cross NC. A charge shall be considered incurred on the date the service or supply was provided to a member. Allowed Amount The maximum amount that Blue Cross NC determines is to be paid for covered services provided to a member. Out-of-Pocket Limit The dollar amount you pay for covered services in a benefit period before Blue Cross NC pays 100% of covered services. It includes deductible, coinsurance and copayments. It does not include charges over the allowed amount, premiums, and charges for non-covered services. Utilization Management To make sure you have access to high quality, cost-effective health care, we manage utilization through a variety of programs including certification, transplant management, concurrent and retrospective review. If you have a concern regarding the final determination of your care, you have the right to appeal the decision. For further information about our Utilization Management programs, please refer to your benefit booklet. Certification Certification is a program designed to make sure that your care is given in a cost effective setting and efficient manner. If you need to be hospitalized, you must obtain certification. Nonemergency and non-maternity hospital admissions must be certified prior to the hospitalization. If the admission is not certified, the claim will be denied. For maternity admissions, your provider is not required to obtain certification from Blue Cross NC for prescribing a length of stay up to 48 hours for a normal vaginal delivery, or up to 96 hours for delivery by cesarean section. You or your provider must request certification for coverage for additional days, which will be given by Blue Cross NC, if medically necessary. All inpatient and certain outpatient Mental Health and Substance Use Disorder services and all Adaptive Behavior Treatment must be certified in advance by Blue Cross NC or services will not be covered. Call Blue Cross NC at 1-800-359-2422. Mental Health and Substance Use Disorder office visits do not require certification. In-network providers in North Carolina are responsible for obtaining certifications. The member will bear no financial penalties if the innetwork provider in North Carolina fails to obtain the appropriate authorization. The member is responsible for obtaining certification for services rendered by an out-of-network provider in North Carolina or by any provider outside of North Carolina.

What is Not Covered? The following are summaries of some of the coverage restrictions. A full explanation and listing of restrictions will be found in your benefit booklet. Your health benefit plan does not cover services, supplies, drugs or charges that are:

· · · · · · · · · · · · · ·

Not medically necessary For injury or illness resulting from an act of war For personal hygiene and convenience items For inpatient admissions that are primarily for diagnostic studies For palliative or cosmetic foot care For investigative or experimental purposes For hearing aids or tinnitus maskers, except as specifically covered by the benefit plan For cosmetic services or cosmetic surgery For custodial care, domiciliary care or rest cures For treatment of obesity, except for surgical treatment of morbid obesity, or as specifically covered by your health benefit plan For reversal of sterilization For treatment of sexual dysfunction not related to organic disease For assisted reproductive technologies as defined by the Centers for Disease Control and Prevention For self-injectable drugs in the provider's office

Embedded Deductible Definition Members must meet their individual deductible before benefits are payable under the health benefit plan. However, once the family deductible is met, all covered family members will be in benefit. Any member who meets their individual Out-Of-Pocket Limit will have the benefit levels apply to them only and not the entire family. However, once the family Out-Of-Pocket Limit is met, the benefit levels will apply to the entire family.

Health and Wellness Program Because we want to help you stay healthy, we offer a variety of wellness benefits and services. You can take advantage of the Health Line Blue, our 24-hour free nurse support line, a health topics library, chronic condition management and a prenatal program. You will also have access to online health and wellness tools and trackers at BlueConnectNC.com. With our program you can get health advice anytime you need it, so you can learn how to take charge of your health. SM

®, Registration and Service marks of the Blue Cross and Blue Shield Association Plan codes: PB90302 R041941 MP90016 SP90016 C003300 V000100 D000100 Facets codes: MED-FS003300 (base) DRU-BR002192 (base) Blue Cross NC is an Independent licensee of the Blue Cross and Blue Shield Association Billing arrangement: ee, ee+spouse, ee+children, fam

ELIADA HOMES, INC.

Blue Options 1-2-3 with HRA Fund Benefit Highlights (PPO) The coinsurance amounts that appear on this benefit highlight represent Plan responsibility. The coinsurance amounts that display in the benefit booklet represent member responsibility.

Deductibles, Out-of-Pocket Limits & Benefit Maximums

Out-of-network 1

In-network

The following Deductibles, Out-of-Pocket Limits, and Benefit Maximums apply to all services. All copays are before deductible.

Embedded Deductibles Individual (per Benefit Period) Family (per Benefit Period)

$5,000 $10,000

$10,000 $20,000

$8,550 $17,100

$17,100 $34,200

Unlimited

Embedded Out-of-Pocket Limits Individual (per Benefit Period) Family (per Benefit Period)

Benefit Maximums: Lifetime Total Dollar Maximum Lifetime Infertility Benefit Maximum Ovulation Induction Cycles

3 Cycle Limits

(with insemination, per Member, in all places of service)

30 visits 30 visits $40,000 60 days 4 visits

(maximum does not apply to dietician/nutritional visits)

Level 1

In-network

Out-of-network 1

Preventive Care (See hospital based clinics-Level 3) (Primary Preventive Diagnosis Only) For the most updated list of general preventive/screenings, immunizations, well-baby/well-child care, women's preventive care services, nutritional counseling and other services mandated under Federal law, see our website at bluecrossnc.com/preventive. State mandated services include colorectal screening, bone mass measurement, newborn hearing screening, prostate specific antigen tests (PSAs), gynecological exams, cervical cancer screening, ovarian cancer screening and screening mammograms.

Primary Care Provider Specialist Primary Care Office-based Services

100% no deductible 100% no deductible

Includes all Office Visits regardless of diagnosis (including medical, mental health, substance use disorder, infertility, therapies and pre-natal/post-delivery care unable to be included in the global delivery fee). Includes Office Surgery, Consultation, X-rays and Labs. For these services provided by a specialist, see Level 3 Benefits.

Primary Care Provider

$25

70% after deductible 70% after deductible

40% after deductible

Log in to Blue Connect to select your Primary Care Provider (PCP). Your copay is waived for your first 3 visits to your selected PCP. Vendor Telehealth $10 Benefits not available Includes Telehealth services for medical/acute care/behavioral health

ELIADA HOMES, INC.

Blue Options 1-2-3 with HRA Fund Benefit Highlights (PPO) Level 2

Out-of-network 1

In-network

Inpatient Hospital Services Includes all Inpatient Hospital Services regardless of diagnosis (including, but not limited to, medical, mental health, substance use disorder, infertility, therapies, transplants, deliveries, and surgeries.) You may receive a better benefit if you receive care at a Blue Distinction Center (BDC). Visit bluecrossnc.com/bdc to find a BDC.

Hospital and Hospital Based Services

Inpatient Professional Services Professional Services Skilled Nursing Facility Inpatient Home Health Care and Hospice Care

Level 3

$250 per admission, then 70% after deductible

$500 per admission, then 40% after deductible

70% after deductible 70% after deductible 70% after deductible

40% after deductible 40% after deductible 40% after deductible

Out-of-network 1

In-network

Specialist Office-Based Services Professional Services Specialist Outpatient Facility-Based Service Professional Services Urgent Care Center Services Emergency Room Visit*

50% after deductible

40% after deductible

50% after deductible

40% after deductible $100 50% after deductible

*If admitted from the ER, any applicable ER member responsibility does not apply; instead, Inpatient Hospital (Level 2) benefits apply. If held for observation, Outpatient (Level 3) benefits apply. Out-of-Network Emergency Room services are payable at the In-Network level and applied to the In-Network Out-of-Pocket Limit regardless of where they are obtained.

50% after deductible

Outpatient Hospital Services

40% after deductible

Includes hospital and hospital-based services, hospital based clinics, surgery, and outpatient diagnostic services such as lab tests, X-rays, ultrasounds, and other diagnostic tests, such as EEGs, EKGs, pulmonary function tests, rehabilitative, habilitative and other therapies.

Outpatient Diagnostic Services Outpatient lab tests 50% after deductible CT scans, MRIs, MRAs and PET scans in any location, including physician’s office, Durable Medical Equipment, Home Infusion Therapy, Medical Supplies, Orthotic Devices and Prosthetic Appliances 50% after deductible Ambulance 50% after deductible

ELIADA HOMES, INC.

40% after deductible

40% after deductible 50% after deductible

Blue Options 1-2-3 with HRA Fund Benefit Highlights (PPO) Prescription Drugs

In-network 100% no deductible

Out-of-network 1 100% no deductible

Employee Portion Employee Only $105.48 Employee + Spouse $461.05 Employee + Child(ren) $420.64 Employee + Family $610.97

ELIADA HOMES, INC.

Employer Portion $287.00 $287.00 $287.00 $287.00

Total $392.48 $748.05 $707.64 $897.97

ADDITIONAL INFORMATION ABOUT BLUE OPTIONS 1-2-3 with HRA Fund Benefit Period The period of time, usually 12 months as stated in the group contract, during which charges for covered services provided to a member must be incurred in order to be eligible for payment by Blue Cross NC. A charge shall be considered incurred on the date the service or supply was provided to a member. Allowed Amount The maximum amount that Blue Cross NC determines is to be paid for covered services provided to a member. Out-of-Pocket Limit The dollar amount you pay for covered services in a benefit period before Blue Cross NC pays 100% of covered services. It includes deductible, coinsurance and copayments. It does not include charges over the allowed amount, premiums, and charges for non-covered services. Utilization Management To make sure you have access to high quality, cost-effective health care, we manage utilization through a variety of programs including certification, transplant management, concurrent and retrospective review. If you have a concern regarding the final determination of your care, you have the right to appeal the decision. For further information about our Utilization Management programs, please refer to your benefit booklet. Certification Certification is a program designed to make sure that your care is given in a cost effective setting and efficient manner. If you need to be hospitalized, you must obtain certification. Nonemergency and non-maternity hospital admissions must be certified prior to the hospitalization. If the admission is not certified, the claim will be denied. For maternity admissions, your provider is not required to obtain certification from Blue Cross NC for prescribing a length of stay up to 48 hours for a normal vaginal delivery, or up to 96 hours for delivery by cesarean section. You or your provider must request certification for coverage for additional days, which will be given by Blue Cross NC, if medically necessary. All inpatient and certain outpatient Mental Health and Substance Use Disorder services and all Adaptive Behavior Treatment must be certified in advance by Blue Cross NC or services will not be covered. Call Blue Cross NC at 1-800-359-2422. Mental Health and Substance Use Disorder office visits do not require certification. In-network providers in North Carolina are responsible for obtaining certifications. The member will bear no financial penalties if the innetwork provider in North Carolina fails to obtain the appropriate authorization. The member is responsible for obtaining certification for services rendered by an out-of-network provider in North Carolina or by any provider outside of North Carolina.

· · · · · · · · · · · · · ·

®, Registration and Service marks of the Blue Cross and Blue Shield Association Blue Cross NC is an Independent licensee of the Blue Cross and Blue Shield Association

ELIADA HOMES, INC.

Plan codes: PT70132 R041941 MTI1900 STI1900 C000100 V000100 D000100 Facets codes: MED-FS003472 (base) DRU-BR002192 (base) Billing arrangement: ee, ee+spouse, ee+children, fam

Health Reimbursement Arrangement (“HRA") Your HRA is integrated with your BCBSNC Health Plan and is provided by Health Equity. Health Equity Customer Service: 1-866-346-5800 Website: www.myhealthequity.com

I. Eligibility What are the eligibility requirements for this HRA? You will be automatically enrolled in the HRA when you enroll in the Employer’s group medical plan, unless you have opted out of the HRA. When is my Entry Date? Your entry date is the date you satisfy the eligibility requirements of and enroll in the Employer’s group medical plan. II. Benefits How are payments made from the HRA? The group Health Plan Carrier will submit requests for reimbursement of expenses you have incurred during the course of a Coverage Period for Qualified Medical Expenses as described in Appendix A. All claims need to be submitted for reimbursements no later than 90 days after the end of the Coverage Period (that is, no later than 02/28). If the request qualifies as a benefit or expense that the HRA has agreed to pay, the claims processor will pay your Provider direct. You are responsible to pay your Provider for any expenses not covered by this HRA. Remember, reimbursements made from the HRA are generally not subject to federal income tax or withholding, nor are they subject to Social Security taxes. What happens if I terminate employment? If your employment is terminated during the Plan Year for any reason, your participation in the HRA will cease on the date of your termination, and you will not be eligible to be reimbursed for any expenses incurred past that date. You must submit claims for any expenses incurred prior to your termination of employment within 90 days after you terminate employment. Any unused amounts will be forfeited.

Health Reimbursement Arrangement (“HRA")

HRA Plan Benefit

Employee Class • Individual Qualified benefits • Deductible- Medical Plan Coverage • Medical Reimbursement Schedule • First, the Employee will pay $2,500.00 of qualifying expenses. • Last, the HRA will pay $2,500.00 of qualifying expenses up to the max benefit limit of $2,500.00. Unused HRA Funds • Unused benefits at the end of the coverage period shall be forfeited.

HRA Plan Benefit

Employee Class • Employee Plus One and Family Qualified benefits • Deductible- Medical Plan Coverage • Medical Reimbursement Schedule • First, the Employee will pay $5,000.00 of qualifying expenses. • Last, the HRA will pay $5,000.00 of qualifying expenses up to the max benefit limit of $5,000.00. Unused HRA Funds • Unused benefits at the end of the coverage period shall be forfeited.

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Help is a one call or click away! Use company code: ELIADA

NCE

ELIADA HOMES, INC. Policy #: 010-52340

Dental Plan Benefits - LOW PLAN Type 1 Preventive

100%

No Waiting Period

· · ·

Routine Exam (2 per Benefit Period) Bitewing X-rays (1 per Benefit Period) Cleaning (4 per Benefit Period)

Type 2 Basic

80%

No Waiting Period

· · ·

Restorative Amalgams Restorative Composites Simple Extractions

Deductible

Type 1 Type 2 Family Maximum

$0 $50 per person, per calendar year $150 per Calendar Year

Benefit Year Maximum Type 1 and 2 (per person, per calendar year)

$1,000

Claims Allowance

Type 1, 2 In network allowance is discounted fee

75th U&C

Monthly Rates

Employee only Employee & Spouse Employee & Child(ren) Employee & Spouse & Child(ren)

$21.52 $41.60 $52.20 $76.08

Rates are effective from 12/1/2021 to 12/1/2022.

Open Enrollment

If you do not elect to participate when initially eligible, you may elect to participate at the policyholder’s next enrollment period, which normally coincides with the policy anniversary date.

Dental Rewards

Your dental plan includes Dental Rewards as a way to grow your annual maximum benefit. Simply by visiting a dental provider each year and submitting a claim, you can increase your annual maximum benefit over time. After your initial benefit is used, accumulated rewards are there to help pay for more expensive procedures, such as root canals or crowns. Here's how it works. For each year, you submit at least one dental claim and your total dental benefits paid for the year are at or under $500 you qualify to carry over $250 in rewards to the following year. When your dental visit is to an Ameritas network provider, you earn an extra $100 PPO Bonus. You may accumulate rewards up to the maximum amount of $1000. Please note, if you do not submit a dental claim during the year, no rewards are earned and accumulated rewards are reset to zero. However, you can start qualifying for rewards again the very next year.

Created 10/11/2021

1 of 2

Class 1

ELIADA HOMES, INC. Policy #: 010-52340

Provider Flexibility and Network Savings

Members aren’t limited to one particular dentist, or a small group of providers, who may or may not be taking new patients. Each plan member is free to visit any provider they choose, including your current dentist, regardless if they are in- or out-of-network. And family members do not have to see the same dentist. When you visit an in-network dentist there are no claim forms to complete. For a list of network dentists in your area, go to Find A Provider at ameritas.com.

Late Entrant

We strongly encourage you and/or your dependents to sign up for coverage when you are initially eligible. If you choose to enroll after initially declined, you and/or your eligible dependents will be considered a Late Entrant. Covered expenses will not include and benefits will not be payable in the first 12 months that a person is insured if the person is a Late Entrant; except for evaluations, prophylaxis (cleanings), and fluoride application. After 12 months, you will have access to all of the plan's benefits.

Member Savings

Customer Service

Customer Connections 800-487-5553 www.Ameritas.com Monday - Thursday 7am-12am CST, Friday 7am-6:30pm CST

This document is a highlight of plan benefits provided by Ameritas Life Insurance Corp. as selected by your employer. It is not a certificate of insurance and does not include exclusions and limitations. For exclusions and limitations, or a complete list of covered procedures, contact your benefits administrator.

2 of 2

ELIADA HOMES, INC. Policy #: 010-52340

Dental Plan Benefits - HIGH PLAN Type 1 Preventive

100%

No Waiting Period

· · ·

Routine Exam (2 per Benefit Period) Bitewing X-rays (1 per Benefit Period) Cleaning (4 per Benefit Period)

Type 2 Basic

80%

No Waiting Period

· · ·

Restorative Amalgams Restorative Composites Simple Extractions

Type 3 Major

50%

No Waiting Period

· · · · · · ·

Surgical Extractions Endodontics (nonsurgical) Periodontics (nonsurgical) Crowns (1 in 10 years per tooth) Endodontics (surgical) Periodontics (surgical) Prosthodontics (Bridges, Dentures) (1 in 10 years)

Deductible

Type 1 Type 2 and 3 Family Maximum

$0 $50 per person, per calendar year $150 per Calendar Year

Benefit Year Maximum Type 1, 2, and 3 (per person, per calendar year)

$2,000

Claims Allowance

Type 1, 2 and 3 In network allowance is discounted fee

75th U&C

Monthly Rates

Employee only Employee & Spouse Employee & Child(ren) Employee & Spouse & Child(ren)

$37.48 $69.84 $82.08 $119.68

Rates are effective from 12/1/2021 to 12/1/2022.

Open Enrollment

If you do not elect to participate when initially eligible, you may elect to participate at the policyholder’s next enrollment period, which normally coincides with the policy anniversary date.

Dental Rewards

Created 10/11/2021

1 of 2

Class 2

ELIADA HOMES, INC. Policy #: 010-52340

Here's how it works. For each year, you submit at least one dental claim and your total dental benefits paid for the year are at or under $750 you qualify to carry over $400 in rewards to the following year. When your dental visit is to an Ameritas network provider, you earn an extra $200 PPO Bonus. You may accumulate rewards up to the maximum amount of $1200. Please note, if you do not submit a dental claim during the year, no rewards are earned and accumulated rewards are reset to zero. However, you can start qualifying for rewards again the very next year.

Provider Flexibility and Network Savings

Late Entrant

Member Savings

Customer Service

Customer Connections 800-487-5553 www.Ameritas.com Monday - Thursday 7am-12am CST, Friday 7am-6:30pm CST

2 of 2

Eliada Homes SUMMARY OF BENEFITS VISION CARE SERVICES EXAM SERVICES Exam Retinal Imaging

40%

OFF

CONTACT LENS FIT AND FOLLOW-UP Fit & Follow-up - Standard

additional complete pair of prescription eyeglasses

Fit & Follow-up - Premium

STANDARD PLASTIC LENSES Single Vision Bifocal Trifocal Lenticular Progressive - Standard Progressive - Premium Tier 1 - 4

%OFF

non-covered items, including nonprescription sunglasses

Find an eye doctor (Insight Network)

• eyemed.com • EyeMed Members App • For LASIK, call 1.800.988.4221

Heads up

IN-NETWORK MEMBER COST

You may have additional benefits. Log into eyemed.com/member to see all plans included with your benefits.

FRAME Frame

LENS OPTIONS Anti Reflective Coating - Standard Anti Reflective Coating - Premium Tier 1 - 3

OUT-OF-NETWORK MEMBER REIMBURSEMENT

$10 copay Up to $39

Up to $40 Not covered

Up to $40; contact lens fit and two follow-up visits 10% off retail price

Not covered Not covered

$0 copay; 20% off balance over $150 allowance

Up to $105

$25 copay $25 copay $25 copay $25 copay $80 copay $110 - 200 copay

Up to $30 Up to $50 Up to $70 Up to $70 Up to $50 Up to $50

$45 copay $57 - 85 copay

Up to $23 Up to $23

Photochromic - Non-Glass

$75

Not covered

Polycarbonate - Standard

$40

Not covered

Scratch Coating - Standard Plastic Tint - Solid and Gradient UV Treatment

$15 $15 $15

Not covered Not covered Not covered

All Other Lens Options

20% off retail price

Not covered

$0 copay; 15% off balance over $150 allowance $0 copay; 100% of balance over $150 allowance $0 copay; paid-in-full

Up to $105

CONTACT LENSES Contacts - Conventional Contacts - Disposable Contacts - Medically Necessary OTHER Hearing Care from Amplifon Network Lasik or PRK from U.S. Laser Network FREQUENCY

Up to $300

Discounts on hearing exam and aids; call 1.877.203.0675 15% off retail or 5% off promo price; call 1.800.988.4221

Not covered

ALLOWED FREQUENCY – ADULTS

ALLOWED FREQUENCY – KIDS

Exam Once every plan year Frame Once every plan year Lenses Once every plan year Contacts Lenses Once every plan year (Plan allows member to receive either contacts and frame, or frame and lens services)

MONTHLY RATES Subscriber Subscriber + Spouse Subscriber + Child(ren) Subscriber + Family

Up to $105

Not covered

Once every plan year Once every plan year Once every plan year Once every plan year

$7.10 $12.36 $13.96 $19.01 QL-0000053706

EyeMed reserves the right to make changes to the products available on each tier. All providers are not required to carry all brands on all tiers. For current listing of brands by tier, call 866-939-3633. No benefits will be paid for services or materials connected with or charges arising from: medical or surgical treatment, services or supplies for the treatment of the eye, eyes or supporting structures; Refraction, when not provided as part of a Comprehensive Eye Examination; services provided as a result of any Workers’ Compensation law, or similar legislation, or required by any governmental agency or program whether federal, state or subdivisions thereof; orthoptic or vision training, subnormal vision aids and any associated supplemental testing; Aniseikonic lenses; any Vision Examination or any corrective Vision Materials required by a Policyholder as a condition of employment; safety eyewear; solutions, cleaning products or frame cases; non-prescription sunglasses; plano (non-prescription) lenses; plano (nonprescription) contact lenses; two pair of glasses in lieu of bifocals; electronic vision devices; services rendered after the date an Insured Person ceases to be covered under the Policy, except when Vision Materials ordered before coverage ended are delivered, and the services rendered to the Insured Person are within 31 days from the date of such order; or lost or broken lenses, frames, glasses, or contact lenses that are replaced before the next Benefit Frequency when Vision Materials would next become available. Fees charged by a Provider for services other than a covered benefit and any local, state or Federal taxes must be paid in full by the Insured Person to the Provider. Such fees, taxes or materials are not covered under the Policy. Allowances provide no remaining balance for future use within the same Benefit Frequency. Some provisions, benefits, exclusions or limitations listed herein may vary by state.. Plan discounts cannot be combined with any other discounts or promotional offers. In certain states members may be required to pay the full retail rate and not the negotiated discount rate with certain participating providers. Please see online provider locator to determine which participating providers have agreed to the discounted rate.

FREEDOM PAS S

Feeling free is so you YOUR ST YLE. YOUR PERSONALIT Y. YOUR CHOICE OF FR AMES You have a style all your own. Now you can get the frames to match — with a special offer from Target Optical®. For $0 out-of-pocket expense get any available frame, any brand — no matter the original retail price point. You’re free to choose any frame in the store at no additional cost to you. For example, if you purchase a pair of frames that retails for $180, your out-of-pocket cost is still $0 — even if you have a $130 frame allowance. That’s up to a $50 value! Plus, you get extra savings on lenses through your EyeMed vision benefits to complete your look.

Any frame, any price for $0 out-of-pocket at Target Optical®

PLUS ENJOY SAVINGS ON LENSES

H OW TO RE DE E M Take this flyer to any Target Optical®. They’ll handle the rest. OFFER CODE: 755288

S H O P THES E TO P B R ANDS AND M O RE

WANT M O RE? YO U G OT IT

Visit eyemed.com to get special offers from other in-network providers

A special offer from Target Optical. $130 or higher frame allowance required. Valid for each year of the initial contract term and in-store only at Target Optical. Complete pair purchase required — member is still responsible for lenses, which are covered based on benefits outlined in the vision benefits and may include an additional copay. Discounts are not insured benefits. Proof of offer is required at time of purchase. Store associates enter code: 755288. PDF-2002-M-74

BASIC GROUP TERM LIFE and ACCIDENTAL DEATH & DISMEMBERMENT INSURANCE BENEFIT HIGHLIGHTS Eliada Homes, Inc.

The group term Life and Accidental Death and Dismemberment (AD&D) insurance available through your employer gives extra protection that you and your family may need. Life and AD&D insurance offers financial protection by providing you coverage in case of an untimely death or an accident that destroys your income-earning ability. Life benefits are disbursed to your beneficiaries in a lump sum in the event of your death.

More than half of Americans (53%) expressed a heightened need for life

To learn more about Life and AD&D insurance, visit thehartford.com/employee-beneﬁts/employees

insurance because of COVID-19.1

COVERAGE INFORMATION APPLICANT Employee

LIFE COVERAGE

AD&D COVERAGE

Beneﬁt : $25,000

AD&D: Included

p y [

AD&D BENEFITS – PERCENT OF COVERAGE AMOUNT PER ACCIDENT Covered accidents or death can occur up to 365 days after the accident. The total beneﬁt for all losses due to the same accident will not exceed 100% of your coverage amount.

LOSS FROM ACCIDENT

COVERAGE

Life %RWK +DQGV RU %RWK )HHW RU 6LJKW RI %RWK (\HV 2QH +DQG DQG 2QH )RRW Speech and Hearing in Both Ears (LWKHU +DQG RU )RRW DQG 6LJKW RI 2QH (\H Movement of Both Upper and Lower Limbs (Quadriplegia) Movement of Both Lower Limbs (Paraplegia) Movement of Three Limbs (Triplegia) Movement of the Upper and Lower Limbs of One Side of the Body (Hemiplegia) (LWKHU +DQG RU )RRW Sight of One Eye Speech or Hearing in Both Ears Movement of One Limb (Uniplegia) 7KXPE DQG ,QGH[ )LQJHU RI (LWKHU +DQG

100% 100% 100% 100% 100% 100% 75% 75% 50% 50% 50% 50% 25% 25%

PREMIUMS

Your employer pays 100% of the premium for your coverage.3

ASKED & ANSWERED

WHO IS ELIGIBLE? You are eligible if you are an active full time employee who works at least 30 hours per week on a regularly scheduled basis.

235%

@ 65, 50% @ 70, 65% @ 75

AM I GUARANTEED COVERAGE? This insurance is guaranteed issue coverage - it is available without having to provide information about your health. AD&D is available without having to provide information about your health. HOW MUCH DOES IT COST AND HOW DO I PAY FOR THIS INSURANCE? Your employer pays 100% of the premium for your (employee) coverage. WHEN CAN I ENROLL? Your employer will automatically enroll you for this coverage. If you have not already done so, you must designate a beneficiary. WHEN DOES THIS INSURANCE BEGIN? This insurance will become effective for you on the date you become eligible. You must be actively at work with your employer on the day your coverage takes effect. WHEN DOES THIS INSURANCE END? This insurance will end when you no longer satisfy the applicable eligibility conditions, premium is unpaid, you are no longer actively working, you leave your employer, or the coverage is no longer offered. CAN I KEEP THIS INSURANCE IF I LEAVE MY EMPLOYER OR AM NO LONGER A MEMBER OF THIS GROUP? Yes, you can take this life coverage with you. Coverage may be continued for you under a group portability certificate or an individual conversion life certificate. The specific terms and qualifying events for conversion and portability are described in the certificate. Conversion and portability are not available for AD&D coverage. 1LIMRA, Facts About Life 2020: https://www.limra.com/globalassets/limra/newsroom/fact-tank/fact-sheets/liam-facts-2020-final.pdf, 3Rates and/or benefits may be changed on a class basis.

as viewed on October 14, 2020.

The Buck’s Got Your Back.© The Hartford® is The Hartford Financial Services Group, Inc. and its subsidiaries, including underwriting company Hartford Life and Accident Insurance Company. Home Office is Hartford, CT. All benefits are subject to the terms and conditions of the policy. Policies underwritten by the underwriting company listed above detail exclusions, limitations, reduction of benefits and terms under which the policies may be continued in force or discontinued. This Benefit Highlights document explains the general purpose of the insurance described, but in no way changes or affects the policy as actually issued. In the event of a discrepancy between this document and the policy, the terms of the policy apply. Complete details are in the Certificate of Insurance issued to each insured individual and the Master Policy as issued to the policyholder. Benefits are subject to state availability. © 2020 The Hartford. The Hartford compensates both internal and external producers, as well as others, for the sale and service of our products. For additional information regarding The Hartford’s compensation practices, please review our website http://thehartford.com/group-benefits-producer-compensation. Life Form Series includes GBD-1000, GBD-1100, or state equivalent. 5962a and 5962b NS 07/21

VOLUNTARY GROUP TERM LIFE and ACCIDENTAL DEATH & DISMEMBERMENT INSURANCE BENEFIT HIGHLIGHTS

Eliada Homes, Inc.

The group term Life and Accidental Death and Dismemberment (AD&D) insurance available through your employer is a smart, affordable way to purchase the extra protection that you and your family may need. Life and AD&D insurance offers financial protection by providing you coverage in case of an untimely death or an accident that destroys your income-earning ability. Life benefits are disbursed to your beneficiaries in a lump sum in the event of your death.

More than half of Americans (53%) expressed a

To learn more about Life and AD&D insurance, visit thehartford.com/employee-beneﬁts/employees

heightened need for life insurance because of COVID-19.1

COVERAGE INFORMATION APPLICANT

LIFE COVERAGE

AD&D COVERAGE

Employee

Beneﬁt : Increments of $10,000 Maximum: the lesser of 4x earnings or $500,000

AD&D: Included

Spouse

Beneﬁt2: Increments of $5,000. Maximum: the lesser of 50% of your supplemental coverage or $250,000

AD&D: Included

Child(ren)

Beneﬁt: $10,000

AD&D: Included

p y [

LOSS FROM ACCIDENT

COVERAGE

beneﬁt will be reduced by 35% at age 65 and 50% at age 70. Reductions will be applied to the original amount.

100% 100% 100% 100% 100% 100% 75% 75% 50% 50% 50% 50% 25% 25%

PREMIUMS

See the Life Premium Worksheet.3

ASKED & ANSWERED

WHO IS ELIGIBLE? You are eligible if you are an active full time employee who works at least 30 hours per week on a regularly scheduled basis. Your spouse and child(ren) are also eligible for coverage. Any child(ren) must be under age 26. CAN I INSURE MY DOMESTIC OR CIVIL UNION PARTNER? Yes. Any reference to “spouse” in this document includes your domestic partner, civil union partner or equivalent, as recognized and allowed by applicable law. AM I GUARANTEED COVERAGE? If you are newly eligible and elect an amount that exceeds the guaranteed issue amount of $100,000, you will need to provide evidence of insurability that is satisfactory to The Hartford before the excess can become effective. If you were previously eligible and are electing coverage for the first time or electing to increase your current coverage, you will need to provide evidence of insurability that is satisfactory to The Hartford before coverage can become effective. If you are newly eligible and elect an amount that exceeds the guaranteed issue amount of $30,000, your spouse will need to provide evidence of insurability that is satisfactory to The Hartford before the excess can become effective. If you were previously eligible and are electing coverage for the first time or electing to increase your spouse's current coverage, your spouse will need to provide evidence of insurability that is satisfactory to The Hartford before coverage can become effective. This insurance is guaranteed issue coverage – it is available without having to provide information about your child(ren)’s health. AD&D is available without having to provide information about your or your family’s health. HOW MUCH DOES IT COST AND HOW DO I PAY FOR THIS INSURANCE? Premiums are provided on the Life Premium Worksheet. You have a choice of coverage amounts. You may elect insurance for you only, or for you and your dependent(s). Premiums will be automatically paid through payroll deduction, as authorized by you during the enrollment process. This ensures you don’t have to worry about writing a check or missing a payment. WHEN CAN I ENROLL? You may enroll during any scheduled enrollment period within 31 days of the date you have a change in family status, or within 31 days of the completion of any eligibility waiting period established by your employer. WHEN DOES THIS INSURANCE BEGIN? Subject to any eligibility waiting period established by your employer, insurance will become effective in accordance with the terms of the certificate (usually the first day of the month following the date you elect coverage). You must be actively at work with your employer on the day your coverage takes effect. Your spouse and child(ren) must be performing normal activities and not be confined (at home or in a hospital/care facility), unless already insured with the prior carrier. WHEN DOES THIS INSURANCE END? This insurance will end when you (or your dependent(s)) no longer satisfy the applicable eligibility conditions, premium is unpaid, or the coverage is no longer offered. CAN I KEEP THIS INSURANCE IF I LEAVE MY EMPLOYER OR AM NO LONGER A MEMBER OF THIS GROUP? Yes, you can take this life coverage with you. Coverage may be continued for you and your dependent(s) under a group portability certificate or an individual conversion life certificate. Your spouse may also continue insurance in certain circumstances. The specific terms and qualifying events for conversion and portability are described in the certificate.Conversion and portability are not available for AD&D coverage.

1LIMRA, Facts About Life 2020: https://www.limra.com/globalassets/limra/newsroom/fact-tank/fact-sheets/liam-facts-2020-ﬁnal.pdf, as viewed on October 14, 2020. 3Rates and/or beneﬁts may be changed on a class basis. Rates are based on the age of the insured person and increase on the policy anniversary date on or following

you enter each new age category.

your birthday as

The Buck’s Got Your Back.® ®

The Hartford® is The Hartford Financial Services Group, Inc. and its subsidiaries, including underwriting company Hartford Life and Accident Insurance Company. Home Office is Hartford, CT. All benefits are subject to the terms and conditions of the policy. Policies underwritten by the underwriting company listed above detail exclusions, limitations, reduction of benefits and terms under which the policies may be continued in force or discontinued. This Benefit Highlights document explains the general purpose of the insurance described, but in no way changes or affects the policy as actually issued. In the event of a discrepancy between this document and the policy, the terms of the policy apply. Complete details are in the Certificate of Insurance issued to each insured individual and the Master Policy as issued to the policyholder. Benefits are subject to state availability. © 2020 The Hartford. The Hartford compensates both internal and external producers, as well as others, for the sale and service of our products. For additional information regarding The Hartford’s compensation practices, please review our website http://thehartford.com/group-benefits-producer-compensation. Life Form Series includes GBD-1000, GBD-1100, or state equivalent. 5962a and 5962b NS 07/21

GROUP ACCIDENTAL DEATH & DISMEMBERMENT INSURANCE GENERAL LIMITATIONS AND EXCLUSIONS • 35% @ 65, 50% @ 70, 65% @ 75 • Your supplemental/voluntary AD&D benefit will be reduced by 35% at age 65 and 50% at age 70. Reductions will be applied to the original amount. •

This insurance does not cover losses caused by: • Sickness; disease; or any treatment for either • Any infection, except certain ones caused by an accidental cut or wound • Intentionally self-inﬂicted injury, suicide or suicide attempt • War or act of war, whether declared or not • Injury sustained while in the armed forces of any country or international authority • Taking prescription or illegal drugs unless prescribed by or administered by a licensed physician • Injury sustained while committing or attempting to commit a felony • Injury sustained while driving while intoxicated

• You and your dependent(s) must be citizens or legal residents of the United States, its territories and protectorates. DEPENDENT LIMITATIONS AND EXCLUSIONS • Coverage may only be elected for dependents when you elect and are approved for coverage for yourself. • Coverage may not be elected for a dependent who has employee coverage under this certificate. • Child(ren) may only be covered as a dependent of one employee. DEFINITIONS • Loss means, with regard to hands and feet, actual severance through or above wrist or ankle joints; with regard to sight, speech or hearing, entire and irrecoverable loss thereof; with regard to thumb and index finger, actual severance through or above the metacarpophalangeal joints; with regard to movement, complete and irreversible paralysis of such limbs. • Injury means bodily injury resulting directly from an accident, independent of all other causes, which occurs while you or your dependent(s) have coverage.

5962c NS 05/21 Accident Form Series includes GBD-1000, GBD-1300, or state equivalent.

The Buck’s Got Your Back!®

The Hartford® is The Hartford Financial Services Group, Inc. and its subsidiaries, including underwriting company Hartford Life and Accident Insurance Company. Home Office is Hartford, CT. All benefits are subject to the terms and conditions of the policy. Policies underwritten by the underwriting company listed above detail exclusions, limitations, reduction of benefits and terms under which the policies may be continued in force or discontinued. This Benefit Highlights document explains the general purpose of the insurance described, but in no way changes or affects the policy as actually issued. In the event of a discrepancy between this document and the policy, the terms of the policy apply. Complete details are in the Certificate of Insurance issued to each insured individual and the Master Policy as issued to the policyholder. Benefits are subject to state availability. © 2020 The Hartford.

This this text box here. A post process uses the text above to do a "Find/Re-

ADDITIONAL place" of variable texSERVICES t and the header. Template: Additional_Services

Eliada Homes, Inc.

If you are enrolled in insurance coverage with The Hartford, you may also be eligible to receive additional services. These services help with challenges that come before and after a claim. Be sure to read the information provided below; The Hartford wants to be there when you need us.

SERVICES AVAILABLE COVERAGE ENROLLED IN Life

ADDITIONAL SERVICES AVAILABLE Beneficiary Assist Counseling Services EstateGuidance Will Services Funeral Concierge Services Travel Assistance and ID Theft Protection Services

ASKED & ANSWERED WHAT IS BENEFICIARY ASSIST COUNSELING SERVICES? Beneficiary Assist®2 Counseling Services offers compassionate expertise to help you, your beneficiaries (those you name in your policy) and immediate family members cope with emotional, financial and legal issues that arise after a loss. Includes unlimited phone contact with professionals, as well as five face-to-face sessions* available for up to one year. For more information on Beneficiary Assist® Counseling Services, call 1-800-411-7239. *California residents are limited to three prepaid behavioral health counseling sessions in any six-month period. Except for acute emergencies and other special circumstances, additional sessions for California employees are available on a fee-for-service basis. WHAT IS ESTATEGUIDANCE WILL SERVICES? EstateGuidance®3 Will Services helps you protect your family’s future by creating a customized and legally binding online will. Online support is also available from licensed attorneys, if needed. For more information on EstateGuidance® Will Services: www.estateguidance.com Use Code: WILLHLF WHAT IS FUNERAL CONCIERGE SERVICES? Funeral Concierge Services4 provides a suite of online tools to guide you through key decisions before a loss, including help comparing funeral-related costs. After a loss, this service includes family advocacy and professional negotiation of funeral prices with local providers— often resulting in significant financial savings. In addition, Express Pay is a service that delivers proceeds in as little as 48 hours, allowing beneficiaries to use proceeds immediately for funeral expenses. For more information on Funeral Concierge Services: Call 1-866-854-5429 or visit www.everestfuneral.com/hartford Use Code: HFEVLC WHAT IS TRAVEL ASSISTANCE AND ID THEFT PROTECTION SERVICES? Travel Assistance Services and ID Theft Protection Services6 includes pre-trip information to help you feel more secure while traveling. It can also help you access medical professionals across the globe for medical assistance when traveling 100+ miles away from home for 90 days or less when unexpected detours arise. The ID theft protection services are available to you and your family at home or when you travel. Protection is provided two ways: educational materials to help prevent identity theft and access to caseworkers to help resolve problems that result from identity theft. For more information on Travel Assistance Services or ID Theft Services: Call from United States: 1-800-243-6108 Call collect from other locations: 202-828-5885 Fax: 202-331-1528 Travel Assistance Identification Number: GLD-09012 You’ll be asked to provide your employer’s name, a phone number where you can be reached, nature of the problem, Travel Assistance Identification Number, and your company policy number which can be obtained through your Human Resources/Personnel department. If you have a serious medical emergency, please obtain emergency medical services first, and then contact Generali Global Assistance for follow-up.

2BeneficiaryAssist®

services are offered through The Hartford by ComPsych®. ComPsych is not affiliated with The Hartford and is not a provider of insurance services. The Hartford is not responsible and assumes no liability for the goods and services provided by ComPsych and reserves the right to discontinue any of these services at any time. Services may not be available in all states. Visit https://www.thehartford.com/employee-benefits/value-added-services for more information. 3Estate Guidance® services are provided through The Hartford by ComPsych®. A simple will does not cover printing or certain other features. These features are available at an additional cost to you. ComPsych is not affiliated with The Hartford and is not a provider of insurance services. The Hartford is not responsible and assumes no liability for the goods and services provided by ComPsych and reserves the right to discontinue any of these services at any time. Estate Guidance is a registered trademark of ComPsych. Services may not be available in all states. Visit https://www.thehartford.com/employee-benefits/value-added-services for more information. 4Funeral Concierge services is offered through Everest Funeral Package, LLC (Everest). Everest and the Everest logo are service marks of Everest Funeral Package, LLC. Everest is not affiliated with The Hartford and is not a provider of insurance services. Everest and its affiliates have no affiliation with Everest ReGroup, Ltd., Everest Reinsurance Company or any of their affiliates. The Hartford is not responsible and assumes no liability for the services provided by Everest Funeral Package, LLC as described in these materials and reserves the right to discontinue any of these services at any time. Services may not be available in all states. Visit https://www.thehartford.com/employee-benefits/value-added-services for more information. 6Travel Assistance and Identity Theft Protection Services are provided by Generali Global Assistance, Inc. Generali Global Assistance, Inc. is not affiliated with The Hartford and is not a provider of insurance services. Generali Global Assistance, Inc. may modify or terminate all or any part of the service at any time without prior notice. None of the benefits provided to you by Generali Global Assistance, Inc. as a part of the Travel Assistance and Identity Theft service are insurance. The flyer, the Travel Assistance and Identity Theft service Terms and Conditions of Use, and the Identity Theft Resolution Kit constitute your benefit materials and contain the terms, conditions, and limitations relating to your benefits. These services may not be used for business or commercial purposes or by any person other than the individual insured under The Hartford’s group insurance policy. The Hartford is not responsible and assumes no liability for the goods and services described in these materials and reserves the right to discontinue any of these services at any time. Services may not be available in all states. Visit https://www.thehartford.com/employee-benefits/value-added-services for more information. The Buck's Got Your Back.®

The Hartford® is The Hartford Financial Services Group, Inc. and its subsidiaries, including underwriting company Hartford Life and Accident Insurance Company. Home Office is Hartford, CT. © 2020 The Hartford. This Benefit Highlights Sheet is an overview of the non-insurance services being offered and is provided for illustrative purposes only and is not a contract. It in no way changes or affects the services as actually provided. Only the Service Provider can fully describe all of the provisions, terms, conditions, limitations and exclusions of your non-insurance service coverage. 5962a NS 05/21

Flexible Spending Account An account for setting aside tax-free money for healthcare expenses Use the below information to determine if a Flexible Spending Account (FSA) is right for you and how to best take advantage of an FSA account.

How It Works When you enroll in a Flexible Spending Account (FSA) you get to experience tax savings on qualified expenses such as copays, deductibles, prescriptions, over-the-counter drugs and medications, and thousands of other everyday items. Can I have an FSA and an HSA? You can’t contribute to an FSA and HSA within the same plan year. However, you can contribute to an HSA and a limited purpose FSA, which only covers dental and vision expenses. As per IRS Publication 969, an employee covered by an HDHP and a health FSA or an HRA that pays or reimburses qualified medical expenses generally can’t make contributions to an HSA. An employee is also not HSA-eligible during an FSA Grace Period. An employee enrolled in a Limited Purpose FSA is HSA-eligible. As a married couple, one spouse cannot be enrolled in an FSA at the same time the other is contributing to an HSA. FSA coverage extends tax benefits to family members allowing the FSA holder to be reimbursed for medical expenses for themselves, their spouse, and their dependents.

The Value & Perks • Election Accessibility: You will have access to your entire election on the ﬁrst day of the plan year. • Save On Eligible Expenses: You can save up to 40% on thousands of eligible everyday expenses such as prescriptions, doctor’s visits, dental services, glasses, over-the-counter medicines, and copays.

• Keep More Money: The funds are taken out of your paycheck "pre-tax" (meaning they are subtracted from your gross earnings before taxes) throughout the course of the year. Let’s say you earn $40,000 a year and contribute $1,500 to an FSA; so, only $38,500 of your income gets taxed. That means you are increasing your take-home pay simply by participating!

• Easy Spending and Account Management: You will receive an Ameriﬂex Debit Mastercard linked to your FSA. You can use your card for eligible purchases everywhere Mastercard is accepted. Account information can be securely accessed 24/7 online and through the mobile app.

Learn more at myameriﬂex.com | 844.423.4636 | info@myameriﬂex.com

Eligible FSA Expenses The IRS determines what expenses are eligible under an FSA. Below are some examples of common eligible expenses.

Copays, deductibles, and other payments you are responsible for under your health plan.

Routine exams, dental care, prescription drugs, eye care, hearing aids, etc.

Prescription glasses and sunglasses, contact lenses and solution, LASIK, and eye exams.

Certain OTC expenses such as Band-aids, medicine, First Aid supplies, etc. (prescription required).

Diabetic equipment and supplies, durable medical equipment, and qualiﬁed medical products or services.

For a full list of eligible expenses, go to myameriﬂex.com/eligibleexpenses.

The “Use-or-Lose” Rule If you contribute dollars to a reimbursement account and do not use all the money you deposit, you will lose any remaining balance in the account at the end of the eligible claims period. This rule, established by the IRS as a component of tax-advantaged plans, is referred to as the “use-or-lose” rule. To avoid losing any of the funds you contribute to your FSA, it’s important to plan ahead as much as possible to estimate what your expenditures will be in a given plan year.

Learn more at myameriﬂex.com | 844.423.4636 | info@myameriﬂex.com

Dependent Care Account Set aside tax-free money for daycare and dependent care services Use the below information to determine if a Dependent Care Account (DCA) is right for you and how to best take advantage of an DCA account.

How It Works When you enroll in a Dependent Care Account (DCA) you get to experience tax savings on expenses like daycare, elderly care, summer day camp, preschool, and other services that allow you to work full time.

The Value & Perks • Save On Eligible Expenses: You can use a DCA to pay for qualifying expenses such as daycare, summer day care, elder care, before and after school programs, and pre-school.

• Keep More Money:

The funds are taken out of your paycheck "pre-tax" (meaning they are subtracted from your gross earnings before taxes) throughout the course of the year. Let’s say you earn $40,000 a year and contribute $1,500 to an DCA; so, only $38,500 of your income gets taxed. That means you are increasing your take-home pay simply by participating!

• Easy Spending and Account Management: You will receive an Ameriﬂex Debit Mastercard linked to your DCA. You can use your card for eligible purchases everywhere Mastercard is accepted. Account information can be securely accessed 24/7 online and through the mobile app.

Eligible DCA Expenses The IRS determines what expenses are eligible under a DCA. Below are some examples of common eligible expenses:

Private sitter

Daycare and elder care

Summer day camp

Before- and after-school care

Nanny service

Nursery school & Pre-school

For a full list of eligible expenses, go to myameriﬂex.com/eligibleexpenses.

Learn more at myameriﬂex.com | 844.423.4636 | info@myameriﬂex.com

www.myameriflex.com

Online Account Instructions How to Access Your Ameriflex Account: Go to MyAmeriflex.com and click “Login” from the upper right hand corner. When prompted, select “Participant.”

How to Register Online For Your Ameriflex Spending Account: Click the register button atop the right corner of the home screen. 1. As the primary account holder, enter your personal information. • Choose a unique User ID and create a password (if you are told that your username is invalid or already taken, you must select another). • Enter your first and last name. • Enter your email address. • Enter your Employee ID, which in most cases, will be the account holder’s Social Security Number(no dashes or spaces needed). 2. Check the box if you accept the terms of use. 3. Click 'register'. This process may take a few seconds. Do not click your browser’s back button or refresh the page. 4. Last, you must complete your Secure Authentication setup. Implemented to protect your privacy and help us prevent fraudulent activity, setup is quick and easy. After the registration form is successfully completed, you will be prompted to complete the secure authentication setup process: Step 1: Select a Security Question option, and type in a corresponding answer. Step 2: Repeat for the following three Security Questions, then click next. Step 3: Verify your email address, and then click next. Step 4: Verify and submit setup information, 5. The registration process is complete! Should you receive an information error message that does not easily guide you through the information correction process, please feel free to contact our dedicated Member Services Team at 888.868.FLEX (3539).

Want to Manage Your Account on the go? Download the MyAmeriflex mobile app, available through the App Store or Google Play. Your credentials for the MyAmeriflex Portal and the MyAmeriflex Mobile App are the same; there is no need for separate login information!

Cancer Insurance Our Cancer Assist plan helps employees protect themselves and their loved ones through their diagnosis, treatment and recovery journey. This individual voluntary policy pays benefits that can be used for both medical and/or out-of-pocket, non-medical expenses traditional health insurance may not cover. Available exclusively at the workplace, Cancer Assist is an attractive addition to any competitive benefits package that won’t add costs to a company’s bottom line.

Competitive advantages n

Composite rates.

n Four distinct plan levels, each featuring the same benefits with premiums and benefit

amounts designed to meet a variety of budgets and coverage needs (benefits overview on reverse).

Indemnity-based benefits pay exactly what’s listed for the selected plan level.

n The plan’s Family Care Benefit provides a daily benefit when a covered dependent child

receives inpatient or outpatient cancer treatment.

Employer-optional cancer wellness/health screening benefits available:

n Part One covers 24 tests. If selected, the employer chooses one of four benefit amounts for employees: $25, $50, $75 or $100. This benefit is payable once per covered person per calendar year. n Part Two covers an invasive diagnostic test or surgical procedure if an abnormal result from a Part One test requires additional testing. This benefit is payable once per calendar year per covered person and matches the Part One benefit.

Flexible family coverage options n

Individual, Individual/Spouse, One-parent and Two-parent family policies.

n Family coverage includes eligible dependent children (to age 26) for the same rate,

regardless of the number of children covered.

Attractive features n

Available for businesses with 3+ eligible employees.

Broad range of policy issue ages, 17-75.

n Each plan level features full schedule of 30+ benefits and three optional riders

(benefit amounts may vary based on plan level selected).

Benefits don’t coordinate with any other coverage from any other insurer.

HSA compliant.

Guaranteed renewable.

n Portable. n Waiver of premium if named insured is disabled due to cancer for longer than 90

consecutive days and the date of diagnosis is after the waiting period and while the policy is in force.

n Form 1099s may not be issued in most states because all benefits require that a

charge is incurred. Discuss details with your benefits representative, or consult your tax adviser if you have questions.

Talk to your benefits representative today to learn more about this product and how it helps provide extra financial protection to employees who may be impacted by cancer.

Optional riders (available at an additional cost/payable once per covered person) n Initial Diagnosis of Cancer Rider pays a one-time benefit for the initial diagnosis of cancer.

A benefit amount in $1,000 increments from $1,000-$10,000 may be chosen. The benefit for covered dependent children is two and a half times ($2,500-25,000) the chosen benefit amount.

n Initial Diagnosis of Cancer Progressive Payment Rider pays a $50 lump-sum payment

for each month the rider has been in force, after the waiting period, once cancer is first diagnosed. The issue ages for this rider are 17-64.

n Specified Disease Hospital Confinement Rider pays $300 per day for confinement to a

hospital for treatment of one of 34 specified diseases covered under the rider.

INDIVIDUAL CANCER INSURANCE

Cancer Assist Benefits Overview This overview shows benefits available for all four plan levels and the range of benefit amounts payable for most common cancer treatments. Each benefit is payable for each covered person under the policy. Actual benefits vary based on the plan level selected.

Radiation/Chemotherapy

n Injected chemotherapy by medical personnel: $250-$1,000 once per calendar week n Radiation delivered by medical personnel: $250-$1,000 once per calendar week n Self-injected chemotherapy: $150-$400 once per calendar month n Topical chemotherapy: $150-$400 once per calendar month n Chemotherapy by pump: $150-$400 once per calendar month n Oral hormonal chemotherapy (1-24 months): $150-$400 once per calendar month n Oral hormonal chemotherapy (25+ months): $75-$200 once per calendar month n Oral non-hormonal chemotherapy: $150-$400 once per calendar month

Anti-nausea Medication

$25-$60 per day, up to $100-$240 per calendar month

Medical Imaging Studies

$75-$225 per study, up to $150-$450 per calendar year

Outpatient Surgical Center

$100-$400 per day, up to $300-$1,200 per calendar year

Skin Cancer Initial Diagnosis

$300-$600 payable once per lifetime

Surgical Procedures

Inpatient and Outpatient Surgeries: $40-$70 per surgical unit, up to $2,500-$6,000 per procedure

Reconstructive Surgery

$40-$60 per surgical unit, up to $2,500-$3,000 per procedure including 25% for general anesthesia

Anesthesia

General: 25% of Surgical Procedures Benefit Local: $25-$50 per procedure

Hospital Confinement Each benefit requires that charges are incurred for treatment. All benefits and riders are subject to a 30-day waiting period. Waiting period means the first 30 days following the policy’s coverage effective date during which no benefits are payable. States without a waiting period will have a pre-existing condition limitation. Product has exclusions and limitations that may affect benefits payable. Benefits vary by state and may not be available in all states. See your Colonial Life benefits representative for complete details.

30 days or less: $100-$350 per day 31 days or more: $200-$700 per day

Family Care

Inpatient and outpatient treatment for a covered dependent child: $30-$60 per day, up to $1,500-$3,000 per calendar year

Second Medical Opinion on Surgery or Treatment $150-$300 once per lifetime

Home Health Care Services

Examples include physical therapy, speech therapy, occupational therapy, prosthesis and orthopedic appliances, durable medical equipment: $50-$150 per day, up to the greater of 30 days per calendar year or twice the number of days hospitalized per calendar year

Hospice Care

Initial: $1,000 once per lifetime Daily: $50 per day $15,000 maximum for initial and daily hospice care per lifetime

Transportation and Lodging

n Transportation for treatment more than 50 miles from covered person’s home:

$0.50 per mile, up to $1,000-$1,500 per round trip Companion Transportation (for any companion, not just a family member) for commercial travel when treatment is more than 50 miles from covered person’s home: $0.50 per mile, up to $1,000-$1,500 per round trip n Lodging for the covered person or any one adult companion or family member when treatment is more than 50 miles from the covered person’s home: $50-$80 per day, up to 70 days per calendar year

ColonialLife.com © 2014 Colonial Life & Accident Insurance Company Colonial Life products are underwritten by Colonial Life & Accident Insurance Company, for which Colonial Life is the marketing brand. 1-14 | 101478

Benefits also included in each plan

Air Ambulance, Ambulance, Blood/Plasma/Platelets/Immunoglobulins, Bone Marrow or Peripheral Stem Cell Donation, Bone Marrow Donor Screening, Bone Marrow or Peripheral Stem Cell Transplant, Cancer Vaccine, Egg(s) Extraction or Harvesting/Sperm Collection and Storage (Cryopreservation), Experimental Treatment, Hair/External Breast/Voice Box Prosthesis, Private Full-time Nursing Services, Prosthetic Device/Artificial Limb, Skilled Nursing Facility, Supportive or Protective Care Drugs and Colony Stimulating Factors

INDIVIDUAL CANCER INSURANCE

Cancer Insurance Wellness Benefits

To encourage early detection, our cancer insurance offers benefits for wellness and health screening tests.

For more information, talk with your benefits counselor.

Part One: Cancer Wellness/Health Screening Provided when one of the tests listed below is performed after the waiting period and while the policy is in force. Payable once per calendar year, per covered person.

Cancer Wellness Tests

Health Screening Tests

■

Bone marrow testing

■

Blood test for triglycerides

■

Breast ultrasound

■

Carotid Doppler

■

CA 15-3 [blood test for breast cancer]

■

Echocardiogram [ECHO]

■

CA 125 [blood test for ovarian cancer]

■

Electrocardiogram [EKG, ECG]

■

CEA [blood test for colon cancer]

■

Fasting blood glucose test

■

Chest X-ray

■

Colonoscopy

erum cholesterol test for HDL S and LDL levels

■

Flexible sigmoidoscopy

■

Stress test on a bicycle or treadmill

■

Hemoccult stool analysis

■

Mammography

■

Pap smear

■

PSA [blood test for prostate cancer]

■

erum protein electrophoresis S [blood test for myeloma]

■

Skin biopsy

■

Thermography

■

ThinPrep pap test

■

Virtual colonoscopy

Part Two: Cancer Wellness — Additional Invasive Diagnostic Test or Surgical Procedure Provided when a doctor performs a diagnostic test or surgical procedure after the waiting period as the result of an abnormal result from one of the covered cancer wellness tests in Part One. We will pay the benefit regardless of the test results. Payable once per calendar year, per covered person.

Waiting period means the first 30 days following the policy’s coverage effective date during which no benefits are payable. The policy has exclusions and limitations. For cost and complete details of the coverage, see your Colonial Life benefits counselor. Coverage may vary by state and may not be available in all states. Applicable to policy form CanAssist (and state abbreviations where applicable – for example: CanAssist-TX).

CANCER ASSIST WELLNESS – 101486

Group Critical Illness Insurance Plan 1

When life takes an unexpected turn due to a critical illness diagnosis, your focus should be on recovery — not finances. Colonial Life’s group critical illness insurance helps provide financial support by providing a lump-sum benefit payable directly to you for your greatest needs.

An unexpected moment changes life forever

Coverage amount: ____________________________

Chris was mowing the lawn when he suffered a stroke. His recovery will be challenging and he's worried, since his family relies on his income.

Critical illness benefit

HOW CHRIS’S COVERAGE HELPED

The lump-sum payment from his critical illness insurance helped pay for: Co-payments and hospital bills not covered by his medical insurance Physical therapy to get back to doing what he loves Household expenses while he was unable to work

For illustrative purposes only.

COVERED CONDITION¹

PERCENTAGE OF APPLICABLE COVERAGE AMOUNT

Benign brain tumor

100%

Coma

100%

End stage renal (kidney) failure

100%

Heart attack (myocardial infarction)

100%

Loss of hearing

100%

Loss of sight

100%

Loss of speech

100%

Major organ failure requiring transplant

100%

Occupational infectious HIV or occupational infectious hepatitis B, C, or D

100%

Permanent paralysis due to a covered accident

100%

Stroke

100%

Sudden cardiac arrest

100%

Coronary artery disease

25%

GCI6000 – PLAN 1 – CRITICAL ILLNESS

KEY BENEFITS

Available coverage for spouse and eligible dependent children at 50% of your coverage amount Cover your eligible dependent children at no additional cost Receive coverage regardless of medical history, within specified limits Works alongside your health savings account (HSA) Benefits payable regardless of other insurance

For more information, talk with your benefits counselor.

Subsequent diagnosis of a different critical illness2 If you receive a benefit for a critical illness, and are later diagnosed with a different critical illness, 100% of the coverage amount may be payable for that particular critical illness.

Subsequent diagnosis of the same critical illness2 If you receive a benefit for a critical illness, and are later diagnosed with the same critical illness,3 25% of the coverage amount may be payable for that critical illness.

Additional covered conditions for dependent children COVERED CONDITION¹

PERCENTAGE OF APPLICABLE COVERAGE AMOUNT

Cerebral palsy

100%

Cleft lip or palate

100%

Cystic fibrosis

100%

Down syndrome

100%

Spina bifida

100%

Preparing for the unexpected is simpler than you think. With Colonial Life, youʼll have the support you need to face lifeʼs toughest challenges.

1. R efer to the certificate for complete definitions of covered conditions. 2. Dates of diagnoses of a covered critical illness must be separated by more than 180 days. 3. Critical illnesses that do not qualify include: coronary artery disease, loss of hearing, loss of sight, loss of speech, and occupational infectious HIV or occupational infectious hepatitis B,C,or D. THIS INSURANCE PROVIDES LIMITED BENEFITS Insureds in MA must be covered by comprehensive health insurance before applying for this coverage.

EXCLUSIONS AND LIMITATIONS FOR CRITICAL ILLNESS

We will not pay the Critical Illness Benefit, Benefits Payable Upon Subsequent Diagnosis of a Critical Illness or Additional Critical Illness Benefit for Dependent Children that occurs as a result of a covered person’s: alcoholism or drug addiction; felonies or illegal occupations; intoxicants and narcotics; suicide or injuring oneself intentionally, whether sane or not; war or armed conflict; or pre-existing condition, unless the covered person has satisfied the pre-existing condition limitation period shown on the Certificate Schedule on the date the covered person is diagnosed with a critical illness.

ColonialLife.com

PRE-EXISTING CONDITION LIMITATION

We will not pay a benefit for a pre-existing condition that occurs during the 12-month period after the coverage effective date. Pre-existing condition means a sickness or physical condition for which a covered person was treated, had medical testing, received medical advice or had taken medication within 12 months before the coverage effective date. This information is not intended to be a complete description of the insurance coverage available. The insurance or its provisions may vary or be unavailable in some states. The insurance has exclusions and limitations which may affect any benefits payable. Applicable to policy form GCI6000-P and certificate form GCI6000-C (including state abbreviations where used, for example: GCI6000-C-TX). For cost and complete details of coverage, call or write your Colonial Life benefits counselor or the company. Underwritten by Colonial Life & Accident Insurance Company, Columbia, SC. ©2020 Colonial Life & Accident Insurance Company. All rights reserved. Colonial Life is a registered trademark and marketing brand of Colonial Life & Accident Insurance Company.

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Group Critical Illness Insurance Plan 2

When life takes an unexpected turn, your focus should be on recovery — not finances. Colonial Life’s group critical illness insurance helps relieve financial worries by providing a lump-sum benefit payable directly to you to use as needed.

Preparing for a lifelong journey Rebecca was born with Down syndrome. Her parents’ critical illness coverage provided a benefit that can help cover expenses related to Rebecca’s care and her changing needs. HOW THEIR COVERAGE HELPED

The lump-sum amount from the family coverage benefit helped pay for:

A hospital stay and treatment for corrective heart surgery Physical therapy to build muscle strength

Special needs daycare

Coverage amount: ____________________________

Critical illness and cancer benefits COVERED CRITICAL ILLNESS CONDITION¹

Benign brain tumor

100%

Coma

100%

End stage renal (kidney) failure

100%

Heart attack (myocardial infarction)

100%

Loss of hearing

100%

Loss of sight

100%

Loss of speech

100%

Major organ failure requiring transplant

100%

Occupational infectious HIV or occupational infectious hepatitis B, C, or D

100%

Permanent paralysis due to a covered accident

100%

Stroke

100%

Sudden cardiac arrest

100%

Coronary artery disease

25%

COVERED CANCER CONDITION¹ For illustrative purposes only.

PERCENTAGE OF APPLICABLE COVERAGE AMOUNT

Invasive cancer (including all breast cancer)

100%

Non-invasive cancer

25%

Skin cancer initial diagnosis............................................................. $400 per lifetime

GCI6000 – PLAN 2 – CRITICAL ILLNESS AND CANCER

KEY BENEFITS

Reoccurrence of invasive cancer (including all breast cancer) If you receive a benefit for invasive cancer and are later diagnosed with a reoccurrence of invasive cancer, 25% of the coverage amount is payable if treatment-free for at least 12 months and in complete remission prior to the date of reoccurrence; excludes non-invasive or skin cancer.

Additional covered conditions for dependent children COVERED CONDITION¹

PERCENTAGE OF APPLICABLE COVERAGE AMOUNT

Cerebral palsy

100%

Cleft lip or palate

100%

Cystic fibrosis

100%

Down syndrome

100%

Spina bifida

100%

Preparing for the unexpected is simpler than you think. With Colonial Life, youʼll have the support you need to face lifeʼs toughest challenges. 1. R efer to the certificate for complete definitions of covered conditions. 2. Dates of diagnoses of a covered critical illness must be separated by more than 180 days. 3. Critical illnesses that do not qualify include: coronary artery disease, loss of hearing, loss of sight, loss of speech, and occupational infectious HIV or occupational infectious hepatitis B,C,or D.

For more information, talk with your benefits counselor.

THIS INSURANCE PROVIDES LIMITED BENEFITS Insureds in MA must be covered by comprehensive health insurance before applying for this coverage.

EXCLUSIONS AND LIMITATIONS FOR CRITICAL ILLNESS

EXCLUSIONS AND LIMITATIONS FOR CANCER

We will not pay the Invasive Cancer (including all Breast Cancer) Benefit, Non-Invasive Cancer Benefit, Benefit Payable Upon Reoccurrence of Invasive Cancer (including all Breast Cancer) or Skin Cancer Initial Diagnosis Benefit for a covered person’s invasive cancer or non-invasive cancer that: is diagnosed or treated outside the territorial limits of the United States, its possessions, or the countries of Canada and Mexico; is a pre-existing condition, unless the covered person has satisfied the pre-existing condition limitation period shown on the Certificate Schedule on the date the covered person is initially diagnosed as having invasive or non-invasive cancer. No pre-existing condition limitation will be applied for dependent children who are born or adopted while the named insured is covered under the certificate, and who are continuously covered from the date of birth or adoption.

PRE-EXISTING CONDITION LIMITATION

ColonialLife.com

This information is not intended to be a complete description of the insurance coverage available. The insurance or its provisions may vary or be unavailable in some states. The insurance has exclusions and limitations which may affect any benefits payable. Applicable to policy form GCI6000-P and certificate form GCI6000-C (including state abbreviations where used, for example: GCI6000-C-TX). For cost and complete details of coverage, call or write your Colonial Life benefits counselor or the company. Underwritten by Colonial Life & Accident Insurance Company, Columbia, SC ©2020 Colonial Life & Accident Insurance Company. All rights reserved. Colonial Life is a registered trademark and marketing brand of Colonial Life & Accident Insurance Company.

5-20 | 387100

Group Critical Illness Insurance First Diagnosis Building Benefit Rider

The first diagnosis building benefit rider provides a lump-sum payment in addition to the coverage amount when you are diagnosed with a covered critical illness or invasive cancer (including all breast cancer). This benefit is for you and all your covered family members.

First diagnosis building benefit Payable once per covered person per lifetime

¾ Named insured............................................................. Accumulates $1,000 each year ¾ Covered spouse/dependent children................................ Accumulates $500 each year The benefit amount accumulates each rider year the rider is in force before a diagnosis is made, up to a maximum of 10 years.

For more information, talk with your benefits counselor.

If diagnosed with a covered critical illness or invasive cancer (including all breast cancer) before the end of the first rider year, the rider will provide one-half of the annual building benefit amount. Coronary artery disease is not a covered critical illness. Non-invasive and skin cancer are not covered cancer conditions.

ColonialLife.com

THIS INSURANCE PROVIDES LIMITED BENEFITS. This information is not intended to be a complete description of the insurance coverage available. The insurance or its provisions may vary or be unavailable in some states. The insurance has exclusions and limitations which may affect any benefits payable. Applicable to policy form GCI6000-P and certificate form GCI6000-C (including state abbreviations where used, for example: GCI6000-C-TX) and rider form R-GCI6000-BB. For cost and complete details of coverage, call or write your Colonial Life benefits counselor or the company. Underwritten by Colonial Life & Accident Insurance Company, Columbia, SC. ©2020 Colonial Life & Accident Insurance Company. All rights reserved. Colonial Life is a registered trademark and marketing brand of Colonial Life & Accident Insurance Company.

GCI6000 – FIRST DIAGNOSIS BUILDING BENEFIT RIDER | 5-20 | 387381

Group Critical Illness Insurance Infectious Diseases Rider

The sudden onset of an infectious or contagious disease can create unexpected circumstances for you or your family. The infectious diseases rider provides a lump sum which can be used toward health care expenses or meeting day-today needs. These benefits are for you as well as your covered family members.

Payable for each covered infectious disease once per covered person per lifetime COVERED INFECTIOUS DISEASE¹

PERCENTAGE OF APPLICABLE COVERAGE AMOUNT

Hospital confinement for seven or more consecutive days for treatment of the disease

For more information, talk with your benefits counselor.

ColonialLife.com

Antibiotic resistant bacteria (including MRSA)

50%

Cerebrospinal meningitis (bacterial)

50%

Diphtheria

50%

Encephalitis

50%

Legionnaires’ disease

50%

Lyme disease

50%

Malaria

50%

Necrotizing fasciitis

50%

Osteomyelitis

50%

Poliomyelitis

50%

Rabies

50%

Sepsis

50%

Tetanus

50%

Tuberculosis

50%

Hospital confinement for 14 or more consecutive days for treatment of the disease Coronavirus disease 2019 (COVID-19)

25%

GCI6000 – INFECTIOUS DISEASES RIDER

1. R efer to the certificate for complete definitions of covered diseases. THIS INSURANCE PROVIDES LIMITED BENEFITS.

EXCLUSIONS AND LIMITATIONS FOR INFECTIOUS DISEASES RIDER

ColonialLife.com

We will not pay benefits for a covered infectious disease that occurs as a result of a covered person’s: alcoholism or drug addiction; felonies or illegal occupations; intoxicants and narcotics; suicide or injuring oneself intentionally, whether sane or not; war or armed conflict; or pre-existing condition, unless the covered person has satisfied the pre-existing condition limitation period shown on the Certificate Schedule on the date the covered person is diagnosed with a covered infectious disease.

PRE-EXISTING CONDITION LIMITATION

We will not pay a benefit for a pre-existing condition that occurs during the 12-month period after the coverage effective date. Pre-existing condition means a sickness or physical condition for which a covered person was treated, had medical testing, received medical advice or had taken medication within 12 months before the coverage effective date. This information is not intended to be a complete description of the insurance coverage available. The insurance or its provisions may vary or be unavailable in some states. The insurance has exclusions and limitations which may affect any benefits payable. Applicable to policy form GCI6000-P and certificate form GCI6000-C (including state abbreviations where used, for example: GCI6000-C-TX) and rider form R-GCI6000-INF. For cost and complete details of coverage, call or write your Colonial Life benefits counselor or the company. Underwritten by Colonial Life & Accident Insurance Company, Columbia, SC. ©2020 Colonial Life & Accident Insurance Company. All rights reserved. Colonial Life is a registered trademark and marketing brand of Colonial Life & Accident Insurance Company.

5-20 | 387523

Group Critical Illness Insurance Progressive Diseases Rider

The debilitating effects of a progressive disease not only impact you physically, but financially as well. Changes in lifestyle may require home modification, additional medical treatment and other expenses. These benefits are for you as well as your covered family members. Payable for each covered progressive disease once per covered person per lifetime PERCENTAGE OF APPLICABLE COVERAGE AMOUNT

COVERED PROGRESSIVE DISEASE¹

This benefit is payable if the covered person is unable to perform two or more activities of daily living2 and the 90-day elimination period has been met.

For more information, talk with your benefits counselor.

ColonialLife.com

Amyotrophic Lateral Sclerosis (ALS)

25%

Dementia (including Alzheimer’s disease)

25%

Huntington’s disease

25%

Lupus

25%

Multiple sclerosis (MS)

25%

Muscular dystrophy

25%

Myasthenia gravis (MG)

25%

Parkinson’s disease

25%

Systemic sclerosis (scleroderma)

25%

1. R efer to the certificate for complete definitions of covered diseases. 2. Activities of daily living include bathing, continence, dressing, eating, toileting and transferring. THIS INSURANCE PROVIDES LIMITED BENEFITS.

EXCLUSIONS AND LIMITATIONS FOR PROGRESSIVE DISEASES RIDER

We will not pay benefits for a covered progressive disease that occurs as a result of a covered person’s: alcoholism or drug addiction; felonies or illegal occupations; intoxicants and narcotics; suicide or injuring oneself intentionally, whether sane or not; war or armed conflict; or pre-existing condition, unless the covered person has satisfied the preexisting condition limitation period shown on the Certificate Schedule on the date the covered person is diagnosed with a covered progressive disease.

PRE-EXISTING CONDITION LIMITATION We will not pay a benefit for a pre-existing condition that occurs during the 12-month period after the coverage effective date. Pre-existing condition means a sickness or physical condition for which a covered person was treated, had medical testing, received medical advice or had taken medication within 12 months before the coverage effective date. This information is not intended to be a complete description of the insurance coverage available. The insurance or its provisions may vary or be unavailable in some states. The insurance has exclusions and limitations which may affect any benefits payable. Applicable to policy form GCI6000-P and certificate form GCI6000-C (including state abbreviations where used, for example: GCI6000-C-TX) and rider form R-GCI6000-PD. For cost and complete details of coverage, call or write your Colonial Life benefits counselor or the company. Underwritten by Colonial Life & Accident Insurance Company, Columbia, SC. ©2020 Colonial Life & Accident Insurance Company. All rights reserved. Colonial Life is a registered trademark and marketing brand of Colonial Life & Accident Insurance Company.

GCI6000 – PROGRESSIVE DISEASES RIDER | 5-20 | 387594

Group Critical Illness Insurance Exclusions and Limitations STATE-SPECIFIC EXCLUSIONS

STATE-SPECIFIC PRE-EXISTING CONDITION LIMITATIONS

AK: Alcoholism or Drug Addiction Exclusion does not apply CO: Suicide exclusion: whether sane or not replaced with while sane CT: Alcoholism or Drug Addiction Exclusion replaced with Intoxication or Drug Addiction; Felonies or Illegal Occupations Exclusion replaced with Felonies; Intoxicants and Narcotics Exclusion does not apply DE: Alcoholism or Drug Addiction Exclusion does not apply IA: Exclusions and Limitations headers renamed to Exclusions and Limitations for Critical Illness Covered Conditions and Critical Illness Cancer Covered Conditions ID: War or Armed Conflict Exclusion replaced with War; Felonies and Illegal Occupations Exclusion replaced with Felonies; Intoxicants and Narcotics Exclusion does not apply; Domestic Partner added to Spouse IL: Alcoholism or Drug Addiction Exclusion replaced with Alcoholism or Substance Abuse Disorder KS: Alcoholism or Drug Addiction Exclusion does not apply KY: Alcoholism or Drug Addiction Exclusion does not apply; Intoxicants and Narcotics Exclusion replaced with Intoxicants, Narcotics and Hallucinogenics. LA: Alcoholism or Drug Addiction Exclusion does not apply; Domestic Partner added to Spouse MA: Exclusions and Limitations headers renamed to Limitations and Exclusions for critical illness and cancer MI: Intoxicants and Narcotics Exclusion does not apply; Suicide Exclusion does not apply MN: Alcoholism or Drug Addiction Exclusion does not apply; Suicide Exclusion does not apply; Felonies and Illegal Occupations Exclusion replaced with Felonies or Illegal Jobs; Intoxicants and Narcotics Exclusion replaced with Narcotic Addiction MS: Alcoholism or Drug Addiction Exclusion does not apply ND: Alcoholism or Drug Addiction Exclusion does not apply NV: Intoxicants and Narcotics Exclusion does not apply; Domestic Partner added to Spouse PA: Alcoholism or Drug Addiction Exclusion does not apply; Suicide Exclusion: whether sane or not removed SD: Alcoholism or Drug Addiction Exclusion does not apply; Intoxicants and Narcotics Exclusion does not apply TX: Alcoholism or Drug Addiction Exclusion does not apply; Doctor or Physician Relationship added as an additional exclusion UT: Alcoholism or Drug Addiction Exclusion replaced with Alcoholism VT: Alcoholism or Drug Addiction Exclusion does not apply; Intoxicants and Narcotics Exclusion does not apply; Suicide Exclusion: whether sane or not removed

FL: Pre-existing is 6/12; Pre-existing Condition means a sickness or physical condition for which a covered person was treated, had medical testing, received medical advice or had taken medication within six months before the coverage effective date shown on the Certificate Schedule. Genetic information is not a pre-existing condition in the absence of a diagnosis of the condition related to such information. GA: Pre-existing Condition means the existence of symptoms which would cause an ordinarily prudent person to seek diagnosis, care, or treatment, or a condition for which medical advice or treatment was recommended by or received within 12 months preceding the coverage effective date. ID: Pre-existing is 6 months/12 months; Pre-existing Condition means a sickness or physical condition which caused a covered person to seek medical advice, diagnosis, care or treatment during the six months immediately preceding the coverage effective date shown on the Certificate Schedule. IL: Pre-existing Condition means a sickness or physical condition for which a covered person was diagnosed, treated, had medical testing by a legally qualified physician, received medical advice, produced symptoms or had taken medication within 12 months before the coverage effective date shown on the Schedule of Benefits. IN: Pre-existing is 6 months/12 months MA: Pre-existing is 6 months/12 months; Pre-existing Condition means a sickness or physical condition for which a covered person was treated, had medical testing, or received medical advice within six months before the coverage effective date shown on the Certificate Schedule. ME: Pre-existing is 6 months/6 months; Pre-existing Condition means a sickness or physical condition for which a covered person was treated, had medical testing, or received medical advice within six months before the coverage effective date shown on the Certificate Schedule. MI: Pre-existing is 6 months/6 months NC: Pre-existing Condition means those conditions for which medical advice, diagnosis, care, or treatment was received or recommended within the one-year period immediately preceding the effective date of a covered person. If a covered person is 65 or older when this certificate is issued, pre-existing conditions for that covered person will include only conditions specifically eliminated. NV: Pre-existing is 6 months/12 months; Pre-existing Condition means a sickness or physical condition for which a covered person was treated, had medical testing, received medical advice or had taken medication within six months before the coverage effective date. Pre-existing Condition does not include genetic information in the absence of a diagnosis of the condition related to such information. PA: Pre-existing is 90 days/12 months; Pre-existing Condition means a disease or physical condition for which you received medical advice or treatment within 90 days before the coverage effective date shown on the Certificate Schedule. SD: Pre-existing is 6 months/12 months TX: Pre-existing condition means a sickness or physical condition for which a covered person received medical advice or treatment within 12 months before the coverage effective date shown on the Certificate Schedule. UT: Pre-existing is 6 months/6 months

This information is not intended to be a complete description of the insurance coverage available. The insurance, its name or its provisions may vary or be unavailable in some states. The insurance has exclusions and limitations which may affect any benefits payable. Applicable to policy form GCI6000-P and certificate form GCI6000-C (including state abbreviations where used, for example: GCI6000-C-TX). For cost and complete details of coverage, call or write your Colonial Life benefits counselor or the company. This form is not complete without base form 385403, 387100, 387169, 402383, 402558 or 387238, and rider form 387307, 387381, 387452, 387523, 387594, 387665, 402605 or 402671. Underwritten by Colonial Life & Accident Insurance Company, Columbia, SC. ©2020 Colonial Life & Accident Insurance Company. All rights reserved. Colonial Life is a registered trademark and marketing brand of Colonial Life & Accident Insurance Company.

GCI6000 – EXCLUSIONS AND LIMITATIONS | 8-20 | 388113-1

GROUP LONG-TERM DISABILITY INSURANCE BENEFIT HIGHLIGHTS Eliada Homes, Inc.

A disability can happen to anyone. Long-term disability insurance helps protect your paycheck if you’re unable to work for a long period of time after a serious condition, injury or sickness.

More than 1 in 4 adults in the U.S. has some type of disability.1

To learn more about Long-Term Disability insurance, visit thehartford.com/employee-beneﬁts/employees

COVERAGE INFORMATION BENEFIT PERCENTAGE (PERCENT OF YOUR EARNINGS)

60%

MINIMUM MAXIMUM

$6,382

(BASED ON MONTHLY INCOME LOSS BEFORE THE DEDUCTION OF OTHER INCOME BENEFITS)

$100

BENEFIT STARTS

BENEFIT DURATION

After 90 days disabled

Disabled before: Age 61 Beneﬁt duration: As long as you are disabled Beneﬁt duration maximum: 5 years

(ELIMINATION PERIOD)

PREMIUMS

Your employer pays 100% of the premium for your coverage.2

ASKED & ANSWERED WHO IS ELIGIBLE? You are eligible if you are an active full time director, executive officers, managers or employee with 10 years of service who works at least 30 hours per week on a regularly scheduled basis. AM I GUARANTEED COVERAGE? This insurance is guaranteed issue coverage – it is available without having to provide information about your health. This coverage is subject to a pre-existing condition exclusion. Please refer to the Limitations & Exclusions sheet provided with this benefit highlights sheet for more information on limitations and exclusions, such as pre-existing conditions. WHEN CAN I ENROLL? Your employer will automatically enroll you for this coverage. WHEN DOES THIS INSURANCE BEGIN? This insurance will become effective on the date you become eligible. You must be actively at work with your employer on the day your coverage takes effect. WHEN DOES THIS INSURANCE END? This insurance will end when you no longer satisfy the applicable eligibility conditions, premium is unpaid, you leave your employer, or the coverage is no longer offered. WHAT DOES IT MEAN TO BE DISABLED? Disability is defined in The Hartford’s certificate with your employer. Typically, disability means that you cannot perform one or more of the essential duties of your occupation due to injury, sickness, pregnancy or other medical condition covered by the insurance, and as a result, your current monthly earnings are less than 80% (standard) of your pre-disability earnings. Pre-disability earnings are defined in your policy. 1Center

for Disease Control and Prevention “Disability Impacts All of Us,” September 2020: https://www.cdc.gov/ncbddd/disabilityandhealth/infographic-disability-impacts-all.html, as viewed on 10/14/2020. 2Rates and/or beneﬁts may be changed on a class basis. The Buck’s Got Your Back.®

The Hartford® is The Hartford Financial Services Group, Inc. and its subsidiaries, including underwriting company Hartford Life and Accident Insurance Company. Home Office is Hartford, CT. All benefits are subject to the terms and conditions of the policy. Policies underwritten by the underwriting company listed above detail exclusions, limitations, reduction of benefits and terms under which the policies may be continued in force or discontinued. This Benefit Highlights document explains the general purpose of the insurance described, but in no way changes or affects the policy as actually issued. In the event of a discrepancy between this document and the policy, the terms of the policy apply. Complete details are in the Certificate of Insurance issued to each insured individual and the Master Policy as issued to the policyholder. Benefits are subject to state availability. © 2020 The Hartford. The Hartford compensates both internal and external producers, as well as others, for the sale and service of our products. For additional information regarding Hartford’s compensation practices, please review our website http://thehartford.com/group-benefits-producer-compensation. Disability Form Series includes GBD-1000, GBD-1200, or state equivalent.

LIMITATIONS & EXCLUSIONS This insurance coverage includes certain limitations and exclusions. The certiﬁcate details all provisions, limitations, and exclusions for this insurance coverage. A copy of the certiﬁcate can be obtained from your employer. GROUP LONG TERM DISABILITY INSURANCE LIMITATIONS AND EXCLUSIONS GENERAL EXCLUSIONS • You must be under the regular care of a physician to receive benefits. • You cannot receive disability insurance benefit payments for disabilities that are caused or contributed to by: • War or act of war (declared or not) • The commission of, or attempt to commit a felony • An intentionally self-inflicted injury • Your being engaged in an illegal occupation PRE-EXISTING CONDITIONS • Your insurance excludes the benefits you can receive for pre-existing conditions. In general, if you were diagnosed or received care for a condition before the effective date of your certificate, you will be covered for a disability due to that condition only if: • You have not received treatment for your condition for 3 months before the effective date of your insurance, or • You have been insured under this coverage for 12 months prior to your disability commencing, so you can receive benefits even if you're receiving treatment, or • You have already satisfied the pre-existing condition requirement of your previous insurer LIMITATIONS • Mental Illness and Substance Abuse Limitation. If you are disabled because of Mental Illness or because of alcoholism or the use of narcotics, sedatives, stimulants, hallucinogens or other similar substance, benefits will be payable for a maximum of 24 months in your lifetime, unless at the end of that 24 months, you are confined to a hospital or other place licensed to provide medical care for your disability. OFFSETS • Your benefit payments will be reduced by other income you receive or are eligible to receive due to your disability, such as: • Social Security disability insurance (please see next section for exceptions) • Workers’ compensation • Other employer-based insurance coverage you may have • Unemployment benefits • Settlements or judgments for income loss • Retirement benefits that your employer fully or partially pays for (such as a pension plan) • Your benefit payments will not be reduced by certain kinds of other income, such as: • Retirement benefits if you were already receiving them before you became disabled • Retirement benefits that are funded by your after-tax contributions your personal savings, investments, IRAs or Keoghs profit-sharing • Most personal disability policies • Social Security cost-of-living increases This example is for purposes of illustrating the effect of the benefit reductions and is not intended to reflect the situation of a particular claimant under the Policy: Insured’s monthly [Pre-Disability Earnings/Basic Monthly Pay] $3,000 Long term disability benefits percentage x 60% Unreduced maximum benefit $1,800 Less Social Security disability benefit per month - $900 Less state disability income benefit per month - $300 Total amount of long term disability benefit per month $600 THIS POLICY PROVIDES LIMITED BENEFITS. This limited benefit plan (1) does not constitute major medical coverage, and (2) does not satisfy the individual mandate of the Affordable Care Act (ACA) because the coverage does not meet the requirements of minimum essential coverage. In New York: This Disability policy provides disability income insurance only. It does NOT provide basic hospital, basic medical or major medical insurance as defined by the New York State Department of Financial Services. 5962d NS 05/21 Disability Form Series includes GBD-1000, GBD-1200, or state equivalent.

The Buck’s Got Your Back!®

Educator Income Protection Insurance

How long could you afford to go without a paycheck? Monthly Expenses:

$_________________

Mortgage/rent Groceries Car

$_________________ $_________________ $_________________ Medical bills Utilities Other

Total $_________________ Colonial Life’s Income Protection for School Personnel in North Carolina was designed especially to supplement existing state plans in North Carolina and help protect your paycheck.

My Coverage Worksheet (For use with your Colonial Life Benefits Counselor) Employee Coverage (includes both on- and off-job benefits) How much coverage do I need? On-Job Accident/On-Job Sickness

= Total Disability

$_____________ Off-Job Accident/Off-Job Sickness $_____________

On-Job

Off-Job

First 3 months

$_____________/month

Next 9 months

$_____________/month

$____________/month

$_____________/month

= Partial Disability

Up to 3 months

When will my benefits start? After an Accident: ___________ days

After a Sickness: ___________ day

NCK 1000

What additional features are available? l

Normal pregnancy is covered the same as any other covered sickness.

Waiver of Premium.

You’re eligible for most benefits from the first day of your covered accident – including weekends, holidays and summer vacation – with no waiting period. Disability benefits may have an elimination period.

How much will it cost? Your cost will vary based on the level of coverage you select.

Employee Coverage In addition to disability coverage, this plan also provides employees with benefits for medical fees related to accidents, hospital confinement, accidental death and dismemberment, as well as fractures and dislocations. Even if you’re not disabled, the following benefits are payable for covered accidental injuries: Even if you’re not disabled, the following benefits are payable for covered accidental injuries:

Medical Fees for Accidents Only Medical Fees are for doctor office visits, X-rays, and hospital emergency room expenses, including supplies used. Up to.................................................................................................................................................................................................. $350

Hospital Confinement Benefit for Accident or Sickness Pays in addition to disability benefit. l

Benefits begin on the first day of confinement in a hospital for a covered accident or covered sickness.

Up to 3 months..................................................................................................................... $1,200/month ($40/day)

The Hospital Confinement benefit increases to $6,200/month when the Total Disability benefit ends at age 70.

Accidental Death and Dismemberment Benefits Benefits payable for death or dismemberment occurring within 90 days from date of accident. l l

Accidental Death............................................................................................................................................................... $10,000 Loss of a Finger or Toe Single Dismemberment.................................................................................................................................................. $750 Double Dismemberment.............................................................................................................................................$1,500

Loss of a Hand, Foot or Sight of an Eye Single Dismemberment...............................................................................................................................................$5,000 Double Dismemberment.......................................................................................................................................... $10,000

Common Carrier Death (includes school bus for school activities) ............................................................... $20,000

Complete Fractures Complete Fractures requiring closed reduction Hip, Thigh .....................................................................................................................................................................................$1,500 Vertebrae ........................................................................................................................................................................................ 1,350 Pelvis ................................................................................................................................................................................................ 1,200 Skull (depressed) ......................................................................................................................................................................... 1,125 Leg ........................................................................................................................................................................................................900 Foot, Ankle, Kneecap ......................................................................................................................................................................750 Forearm, Hand, Wrist ......................................................................................................................................................................750 Lower Jaw ...........................................................................................................................................................................................600 Shoulder Blade, Collarbone .........................................................................................................................................................600 Skull (simple) .....................................................................................................................................................................................525 Upper Arm, Upper Jaw ..................................................................................................................................................................525 Facial Bones .......................................................................................................................................................................................450 Vertebral Processes .........................................................................................................................................................................300 Coccyx, Rib, Finger, Toe .................................................................................................................................................................120

Complete Dislocations .Complete Dislocations requiring closed reduction with anesthesia Hip ...................................................................................................................................................................................................$1,350 Knee .....................................................................................................................................................................................................975 Shoulder .............................................................................................................................................................................................750 Collarbone ..........................................................................................................................................................................................675 Ankle, Foot .........................................................................................................................................................................................600 Hand .....................................................................................................................................................................................................525 Lower Jaw ...........................................................................................................................................................................................450 Wrist .....................................................................................................................................................................................................375 Elbow ...................................................................................................................................................................................................300 One Finger, Toe .................................................................................................................................................................................120 l

For a fracture or dislocation requiring an open operation, your benefit would be 1½ times the amount shown.

For a chip fracture, your benefit would be 25% of the amount shown. Chip fractures are those in which a fragment of bone is broken off near a joint at a point where a ligament is attached.

For multiple fractures or dislocations, you would receive each amount, up to a total of 1½ times the highest amount.

For your first dislocation, you would receive the amount shown; however, recurrent dislocations of the same joint are not covered.

Optional Spouse and Dependent Coverage You may cover one or all of the eligible dependent members of your family for an additional premium. Eligible dependents include your spouse and ALL dependent children who are younger than age 26.

Medical Fees for Accidents Only Medical Fees are for doctor office visits, X-rays, and hospital emergency room expenses, including supplies used. Up to ................................................................................................................................................................................................... $350

Hospital Confinement Benefit for Accident or Sickness

Up to 3 months........................................................................................................................ $1,200/month ($40/day)

Accidental Death and Dismemberment Benefits

Accidental Death.........................................................................................................................................................$1,000

Loss of a Finger or Toe

Single Dismemberment............................................................................................................................................$75

Double Dismemberment...................................................................................................................................... $150

Loss of a Hand, Foot or Sight of an Eye

Single Dismemberment......................................................................................................................................... $500

Double Dismemberment...................................................................................................................................$1,000

Common Carrier Death (includes school bus for school activities) ........................................................ $2,000

Here are some

frequently asked questions about Colonial Life’s Educator Income Protection insurance:

Will my disability income payment be reduced if I have other insurance?

How do I file a claim Visit coloniallife.com or call our Policyholder Service Center at 1.800.325.4368 for additional information.

You’re paid regardless of workers’ compensation or any other insurance you may have with other insurance companies. Benefits are paid directly to you (unless you specify otherwise).

What is a pre-existing condition? A pre-existing condition means a sickness or physical condition for which any covered person was treated, received medical advice, or had taken medication within 12 months before the effective date of the policy. If you are age 65 or older when the policy is issued, pre-existing conditions include only conditions specifically excluded from coverage by the rider.

When am I considered totally disabled? Totally disabled means you are: l Unable to perform the material and substantial duties of your job; l Not, in fact, working at any job; and l Under the regular and appropriate care of a doctor.

If you become disabled due to a pre-existing condition, we will not pay for any disability period if it begins during the first 12 months the policy is in force.

What if I want to return to work part-time after I am totally disabled? You may be able to return to work part-time and still receive benefits. We call this “Partial Disability.” This means you may be eligible for coverage if: l You are unable to perform the material and substantial duties of your job for 20 hours or more per week, l You are able to work at your job or your place of employment for less than 20 hours per week, l Your employer will allow you to return to your job or place of employment for less than 20 hours per week; and l You are under the regular and appropriate care of a doctor. The total disability benefit must have been paid for at least one full month immediately prior to your being partially disabled.

When do disability benefits end? The Total Disability Benefit will end on the policy anniversary date on or next following your 70th birthday. The Hospital Confinement benefit increases when the Total Disability Benefit ends.

What if I change employers or retire?

What is a covered accident or a covered sickness? A covered accident is an accident. A covered sickness means an illness, infection, disease or any other abnormal physical condition. A covered accident or covered sickness: Occurs after the effective date of the policy; l Occurs while the policy is in force; and l Is of a type listed on the Policy Schedule; and l Is not excluded by name or specific description in the policy. l

EXCLUSIONS We will not pay benefits for losses that are caused by or are the result of: alcoholism or drug addiction; flying; hazardous avocations; felonies or illegal occupations; having a pre-existing condition as defined and limited by the policy; psychiatric or psychological condition; racing; semi-professional or professional sports; suicide or self-inflicted injury, war or armed conflict. For cost and complete details, see your Colonial Life benefits counselor. Applicable to policy form NCK1000-NC. This is not an insurance contract and only the actual policy provisions will control. NCK 1000

If you change jobs or retire, you can take your coverage with you at no additional cost. Your coverage is guaranteed renewable for life as long as you pay your premiums when they are due or within the grace period.

Colonial Life 1200 Colonial Life Boulevard Columbia, South Carolina 29210 coloniallife.com

© 2013 Colonial Life & Accident Insurance Company Colonial Life are underwritten byLife Colonial Life & Accident Colonial Life products are products underwritten by Colonial & Accident Insurance Insurance Company, for which Colonial Life is the marketing brand. Company, for which Colonial Life is the marketing brand. 71381-1 7/13 62617-4

Accident Insurance

Accidents happen in places where you and your family spend the most time – at work, in the home and on the playground – and they’re unexpected. How you care for them shouldn’t be. In your lifetime, which of these accidental injuries have happened to you or someone you know? l

Sports-related accidental injury Broken bone Burn Concussion Laceration

Back or knee injuries

l l l

Car accidents l Falls & spills l Dislocation l Accidental injuries that send you to the Emergency Room, Urgent Care or doctor’s office

Accident 1.0-Preferred with Health Screening Benefit

Colonial Life’s Accident Insurance is designed to help you fill some of the gaps caused by increasing deductibles, co-payments and out-of-pocket costs related to an accidental injury. The benefit to you is that you may not need to use your savings or secure a loan to pay expenses. Plus you’ll feel better knowing you can have greater financial security.

What additional features are included? l

Worldwide coverage

Portable

Compliant with Healthcare Spending Account (HSA) guidelines

What if I change employers? If you change jobs or leave your employer, you can take your coverage with you at no additional cost. Your coverage is guaranteed renewable as long as you pay your premiums when they are due or within the grace period.

Can my premium change?

Will my accident claim payment be reduced if I have other insurance?

Colonial Life can change your premium only if we change it on all policies of this kind in the state where your policy was issued.

You’re paid regardless of any other insurance you may have with other insurance companies, and the benefits are paid directly to you (unless you specify otherwise).

How do I file a claim? Visit coloniallife.com or call our Customer Service Department at 1.800.325.4368 for additional information.

Benefits listed are for each covered person per covered accident unless otherwise specified.

Initial Care l

Accident Emergency Treatment........... $150

Ambulance........................................$400

X-ray Benefit....................................................$50

l Air

Ambulance.............................. $2,000

Common Accidental Injuries Dislocations (Separated Joint) Hip Knee (except patella) Ankle – Bone or Bones of the Foot (other than Toes) Collarbone (Sternoclavicular) Lower Jaw, Shoulder, Elbow, Wrist Bone or Bones of the Hand Collarbone (Acromioclavicular and Separation) One Toe or Finger Fractures Depressed Skull Non-Depressed Skull Hip, Thigh Body of Vertebrae, Pelvis, Leg Bones of Face or Nose (except mandible or maxilla) Upper Jaw, Maxilla Upper Arm between Elbow and Shoulder Lower Jaw, Mandible, Kneecap, Ankle, Foot Shoulder Blade, Collarbone, Vertebral Process Forearm, Wrist, Hand Rib Coccyx Finger, Toe

Non-Surgical

Surgical

$6,600 $3,300 $2,640 $1,650 $990 $990 $330 $330

$13,200 $6,600 $5,280 $3,300 $1,980 $1,980 $660 $660

Non-Surgical

Surgical

$5,500 $2,200 $3,300 $1,650 $770 $770 $770 $660 $660 $660 $550 $440 $220

$11,000 $4,400 $6,600 $3,300 $1,540 $1,540 $1,540 $1,320 $1,320 $1,320 $1,100 $880 $440

Your Colonial Life policy also provides benefits for the following injuries received as a result of a covered accident. l

Burn (based on size and degree).....................................................................................$1,000 to $12,000

Coma..............................................................................................................................................................$10,000

Concussion........................................................................................................................................................$150

Emergency Dental Work........................................$75 Extraction, $300 Crown, Implant, or Denture l Lacerations (based on size)............................................................................................................$50 to $800 l

Requires Surgery l

Eye Injury............................................................................................................................................................$300

Tendon/Ligament/Rotator Cuff...........................................................$500 - one, $1,000 - two or more

Ruptured Disc...................................................................................................................................................$500

Torn Knee Cartilage........................................................................................................................................$500

Surgical Care Surgery (cranial, open abdominal or thoracic)................................................................................. $1,500

l l

Surgery (hernia)...............................................................................................................................................$150

Surgery (arthroscopic or exploratory).....................................................................................................$250

Blood/Plasma/Platelets.................................................................................................................................$300

Transportation/Lodging Assistance If injured, covered person must travel more than 50 miles from residence to receive special treatment and confinement in a hospital. Transportation..............................................................................$500 per round trip up to 3 round trips

Lodging (family member or companion)................................................$125 per night up to 30 days for a hotel/motel lodging costs

Accident Hospital Care Hospital Admission*......................................................................................................... $1,500 per accident

Hospital ICU Admission*................................................................................................. $3,000 per accident * We will pay either the Hospital Admission or Hospital Intensive Care Unit (ICU) Admission, but not both. l

Hospital Confinement.......................................................... $250 per day up to 365 days per accident

Hospital ICU Confinement ....................................................$500 per day up to 15 days per accident

Accident Follow-Up Care l

Accident Follow-Up Doctor Visit........................................................... $50 (up to 3 visits per accident)

Medical Imaging Study.......................................................................................................$250 per accident (limit 1 per covered accident and 1 per calendar year)

Occupational or Physical Therapy...................................................... $35 per treatment up to 10 days

Appliances ........................................................................................... $125 (such as wheelchair, crutches)

Prosthetic Devices/Artificial Limb .....................................................$500 - one, $1,000 - more than 1

Rehabilitation Unit..................................................$100 per day up to 15 days per covered accident, and 30 days per calendar year. Maximum of 30 days per calendar year

Accidental Dismemberment l

Loss of Finger/Toe..................................................................................$750 – one, $1,500 – two or more

Loss or Loss of Use of Hand/Foot/Sight of Eye......................$7,500 – one, $15,000 – two or more

Catastrophic Accident For severe injuries that result in the total and irrecoverable: l

Loss of one hand and one foot

Loss of the sight of both eyes

Loss of both hands or both feet

Loss of the hearing of both ears

Loss or loss of use of one arm and one leg or

Loss of the ability to speak

Loss or loss of use of both arms or both legs

Named Insured................. $25,000 Spouse...............$25,000 Child(ren)..........$12,500 365-day elimination period. Amounts reduced for covered persons age 65 and over. Payable once per lifetime for each covered person.

Accidental Death Accidental Death

Common Carrier

Named Insured

$25,000

$100,000

Spouse

$25,000

$100,000

Child(ren)

$5,000

$20,000

Health Screening Benefit

$50 per covered person per calendar year

Provides a benefit if the covered person has one of the health screening tests performed. This benefit is payable once per calendar year per person and is subject to a 30-day waiting period.

Tests include: l.

Blood test for triglycerides

Hemoccult stool analysis

Bone marrow testing

Mammography

Breast ultrasound

Pap smear

CA 15-3 (blood test for breast cancer)

PSA (blood test for prostate cancer)

CA125 (blood test for ovarian cancer)

Carotid doppler

Serum cholesterol test to determine level of HDL and LDL

CEA (blood test for colon cancer)

Chest x-ray

Serum protein electrophoresis (blood test for myeloma)

Colonoscopy

Stress test on a bicycle or treadmill

Echocardiogram (ECHO)

Skin cancer biopsy

Electrocardiogram (EKG, ECG)

Thermography

Fasting blood glucose test

ThinPrep pap test

Flexible sigmoidoscopy

Virtual colonoscopy

My Coverage Worksheet (For use with your Colonial Life benefits counselor) Who will be covered? (check one) Employee Only

Spouse Only

One-Parent Family, with Employee

One Child Only

One-Parent Family, with Spouse

Employee & Spouse Two-Parent Family

On and Off -Job Benefits

Off -Job Only Benefits

EXCLUSIONS We will not pay benefits for losses that are caused by or are the result of: hazardous avocations; felonies or illegal occupations; racing; semi-professional or professional sports; sickness; suicide or self-inflicted injuries; war or armed conflict; in addition to the exclusions listed above, we also will not pay the Catastrophic Accident benefit for injuries that are caused by or are the result of: birth; intoxication. For cost and complete details, see your Colonial Life benefits counselor. Applicable to policy form Accident 1.0-HS-NC. This is not an insurance contract and only the actual policy provisions will control.

Colonial Life 1200 Colonial Life Boulevard Columbia, South Carolina 29210 coloniallife.com

71740-NC

Accident 1.0-Preferred with Health Screening Benefit

When are covered accident benefits available? (check one)

Hospital Confinement Indemnity Insurance Plan 2

Our Individual Medical BridgeSM insurance can help with medical costs that your health insurance may not cover. These benefits are available for you, your spouse and eligible dependent children. Hospital confinement. ......................................................................... $_______________ Maximum of one benefit per covered person per calendar year

Observation room................................................................................... $100 per visit Maximum of two visits per covered person per calendar year

Rehabilitation unit confinement.................................................................. $100 per day Maximum of 15 days per confinement with a 30-day maximum per covered person per calendar year

Waiver of premium Available after 30 continuous days of a covered hospital confinement of the named insured

Outpatient surgical procedure Tier 1.. . . . . .......................................................................................... .. $_______________ Tier 2.. . . . . .......................................................................................... .. $_______________ Maximum of $________________ per covered person per calendar year for all covered outpatient surgical procedures combined

For more information, talk with your benefits counselor.

The surgeries listed below are only a sampling of the surgeries that may be covered. Surgeries must be performed by a doctor in a hospital or ambulatory surgical center. For complete details and definitions, please refer to your policy.

Tier 1 outpatient surgical procedures Breast

Gynecological

– Axillary node dissection – Breast capsulotomy – Lumpectomy

– Dilation and curettage (D&C) – Endometrial ablation – Lysis of adhesions

Cardiac

Liver

– Pacemaker insertion

– Paracentesis

Digestive

Musculoskeletal system

– Colonoscopy – Fistulotomy – Hemorrhoidectomy – Lysis of adhesions

– Carpal/cubital repair or release – Foot surgery (bunionectomy, exostectomy, arthroplasty, hammertoe repair) – Removal of orthopedic hardware – Removal of tendon lesion

Skin – Laparoscopic hernia repair – Skin grafting

Ear, nose, throat, mouth – Adenoidectomy – Removal of oral lesions – Myringotomy – Tonsillectomy – Tracheostomy – Tympanotomy

IMB7000 – PLAN 2

Tier 2 outpatient surgical procedures Breast

Gynecological

– Breast reconstruction – Breast reduction

– Hysterectomy – Myomectomy

Cardiac

Musculoskeletal system

– Angioplasty – Cardiac catheterization

Digestive – Exploratory laparoscopy – Laparoscopic appendectomy – Laparoscopic cholecystectomy

Ear, nose, throat, mouth – Ethmoidectomy – Mastoidectomy – Septoplasty – Stapedectomy – Tympanoplasty

– Arthroscopic knee surgery with meniscectomy (knee cartilage repair) – Arthroscopic shoulder surgery – Clavicle resection – Dislocations (open reduction with internal fixation) – Fracture (open reduction with internal fixation) – Removal or implantation of cartilage – Tendon/ligament repair

Thyroid – Excision of a mass

Urologic

Eye – Cataract surgery – Corneal surgery (penetrating keratoplasty) – Glaucoma surgery (trabeculectomy) – Vitrectomy

– Lithotripsy

ColonialLife.com THIS POLICY PROVIDES LIMITED BENEFITS. EXCLUSIONS We will not pay benefits for losses which are caused by: alcoholism or drug addiction, dental procedures, elective procedures and cosmetic surgery, felonies or illegal occupations, pregnancy of a dependent child, psychiatric or psychological conditions, suicide or injuries which any covered person intentionally does to himself or herself, or war. We will not pay benefits for hospital confinement of a newborn who is neither injured nor sick. We will not pay benefits for loss during the first 12 months after the effective date due to a pre-existing condition. Pre-exisiting conditions are those conditions whether diagnosed or not, for which a covered person received medical advice, diagnosis or care, or treatment was received or recommended within the one-year period immediately preceding the effective date of the policy. If a covered person is 65 or older when the policy is issued, pre-existing conditions will include only conditions specifically eliminated by rider. For cost and complete details, see your Colonial Life benefits counselor. Applicable to policy number IMB7000-NC. This is not an insurance contract and only the actual policy provisions will control. Underwritten by Colonial Life & Accident Insurance Company, Columbia, SC ©2018 Colonial Life & Accident Insurance Company. All rights reserved. Colonial Life is a registered trademark and marketing brand of Colonial Life & Accident Insurance Company.

5-18 | 101578-1-NC

Hospital Confinement Indemnity Insurance Plan 3 Our Individual Medical BridgeSM insurance can help with medical costs that your health insurance may not cover. These benefits are available for you, your spouse and eligible dependent children. Hospital confinement. ......................................................................... $_______________ Maximum of one benefit per covered person per calendar year

Observation room................................................................................... $100 per visit Maximum of two visits per covered person per calendar year

Rehabilitation unit confinement. ................................................................. $100 per day Maximum of 15 days per confinement with a 30-day maximum per covered person per calendar year

Waiver of premium

Available after 30 continuous days of a covered hospital confinement of the named insured

Diagnostic procedure Tier 1. . . . . .......................................................................................... ................. $250 Tier 2. . . . . .......................................................................................... ................. $500 Maximum of $500 per covered person per calendar year for all covered diagnostic procedures combined

Outpatient surgical procedure Tier 1. . . . . .......................................................................................... . $_______________ Tier 2. . . . . ............................................................................................ $_______________

For more information, talk with your benefits counselor.

Maximum of $___________ per covered person per calendar year for all covered outpatient surgical procedures combined

The following is a list of common diagnostic procedures that may be covered.

Tier 1 diagnostic procedures Breast – Biopsy (incisional, needle, stereotactic) Diagnostic radiology – Nuclear medicine test Digestive – Barium enema/lower GI series – Barium swallow/upper GI series – Esophagogastroduodenoscopy (EGD) Ear, nose, throat, mouth – Laryngoscopy Gynecological – Hysteroscopy – Amniocentesis – Loop electrosurgical – Cervical biopsy excisional procedure – Cone biopsy (LEEP) – Endometrial biopsy

Liver – biopsy Lymphatic – biopsy Miscellaneous – Bone marrow aspiration/biopsy Renal – biopsy Respiratory – Biopsy – Bronchoscopy – Pulmonary function test (PFT) Skin – Biopsy – Excision of lesion Thyroid – biopsy Urologic – Cystoscopy

Tier 2 diagnostic procedures Cardiac – Angiogram – Arteriogram – Thallium stress test – Transesophageal echocardiogram (TEE)

Diagnostic radiology – Computerized tomography scan (CT scan) – Electroencephalogram (EEG) – Magnetic resonance imaging (MRI) – Myelogram – Positron emission tomography scan (PET scan) IMB7000 – PLAN 3

Tier 1 outpatient surgical procedures Breast

Gynecological

Cardiac

Liver

Digestive

Musculoskeletal system

– Axillary node dissection – Breast capsulotomy – Lumpectomy

– Dilation and curettage (D&C) – Endometrial ablation – Lysis of adhesions

– Pacemaker insertion

– Paracentesis

– Colonoscopy – Fistulotomy – Hemorrhoidectomy – Lysis of adhesions

– Carpal/cubital repair or release – Foot surgery (bunionectomy, exostectomy, arthroplasty, hammertoe repair) – Removal of orthopedic hardware – Removal of tendon lesion

Skin

– Laparoscopic hernia repair – Skin grafting

Ear, nose, throat, mouth – Adenoidectomy – Removal of oral lesions – Myringotomy – Tonsillectomy – Tracheostomy – Tympanotomy

Tier 2 outpatient surgical procedures Breast

Gynecological

Cardiac

Musculoskeletal system

– Breast reconstruction – Breast reduction

– Hysterectomy – Myomectomy

– Angioplasty – Cardiac catheterization

Digestive

– Exploratory laparoscopy – Laparoscopic appendectomy – Laparoscopic cholecystectomy

Ear, nose, throat, mouth – Ethmoidectomy – Mastoidectomy – Septoplasty – Stapedectomy – Tympanoplasty

Thyroid

– Excision of a mass

Eye

ColonialLife.com

– Cataract surgery – Corneal surgery (penetrating keratoplasty) – Glaucoma surgery (trabeculectomy) – Vitrectomy

Urologic

– Lithotripsy

EXCLUSIONS We will not pay benefits for losses which are caused by: alcoholism or drug addiction, dental procedures, elective procedures and cosmetic surgery, felonies or illegal occupations, pregnancy of a dependent child, psychiatric or psychological conditions, suicide or injuries which any covered person intentionally does to himself or herself, or war. We will not pay benefits for hospital confinement of a newborn who is neither injured nor sick. We will not pay benefits for loss during the first 12 months after the effective date due to a pre-existing condition. Pre-exisiting conditions are those conditions whether diagnosed or not, for which a covered person received medical advice, diagnosis or care, or treatment was received or recommended within the one-year period immediately preceding the effective date of the policy. If a covered person is 65 or older when the policy is issued, pre-existing conditions will include only conditions specifically eliminated by rider. For cost and complete details, see your Colonial Life benefits counselor. Applicable to policy number IMB7000-NC. This is not an insurance contract and only the actual policy provisions will control. ©2015 Colonial Life & Accident Insurance Company, Columbia, SC | Colonial Life insurance products are underwritten by Colonial Life & Accident Insurance Company, for which Colonial Life is the marketing brand.

7-15 | 101581-NC

Hospital Confinement Indemnity Insurance Health Screening Individual Medical BridgeSM insurance’s health screening benefit can help pay for health and wellness tests you have each year.

Health screening. .............................................................................. $_____________ Maximum of one health screening test per covered person per calendar year; subject to a 30-day waiting period

Blood test for triglycerides Bone marrow testing Breast ultrasound CA 15-3 (blood test for breast cancer) CA 125 (blood test for ovarian cancer) CEA (blood test for colon cancer) Carotid Doppler

Serum protein electrophoresis (blood test for myeloma) Skin cancer biopsy Stress test on a bicycle or treadmill Thermography ThinPrep pap test Virtual colonoscopy

Chest X-ray Colonoscopy Echocardiogram (ECHO) Electrocardiogram (EKG, ECG) Fasting blood glucose test Flexible sigmoidoscopy

For more information, talk with your benefits counselor.

Hemoccult stool analysis Mammography Pap smear PSA (blood test for prostate cancer) Serum cholesterol test for HDL and LDL levels

ColonialLife.com

Waiting period means the first 30 days following any covered person’s policy coverage effective date, during which no benefits are payable. For cost and complete details, see your Colonial Life benefits counselor. Applicable to policy number IMB7000 (including state abbreviations where used, for example: IMB7000-TX). Coverage may vary by state and may not be available in all states. This is not an insurance contract and only the actual policy provisions will control. ©2015 Colonial Life & Accident Insurance Company, Columbia, SC | Colonial Life insurance products are underwritten by Colonial Life & Accident Insurance Company, for which Colonial Life is the marketing brand.

IMB7000 – HEALTH SCREENING BENEFIT | 2-15 | 101579

Hospital Confinement Indemnity Insurance Medical Treatment Package The medical treatment package for Individual Medical BridgeSM coverage can help pay for deductibles, co-payments and other out-of-pocket expenses related to a covered accident or covered sickness.

The medical treatment package paired with Plan 2 or Plan 3 provides the following benefits: Air ambulance.............................................................................................. $1,000 Maximum of one benefit per covered person per calendar year

Ambulance. .................................................................................................... $100 Maximum of one benefit per covered person per calendar year

Appliance. ...................................................................................................... $100 Maximum of one benefit per covered person per calendar year

Doctor’s office visit. ................................................................................... $25 per visit Maximum of three visits per calendar year for named insured coverage or maximum of five visits per calendar year for all covered persons combined

Emergency room visit. ............................................................................. $100 per visit

For more information, talk with your benefits counselor.

Maximum of two visits per covered person per calendar year

X-ray. ................................................................................................ $25 per benefit Maximum of two benefits per covered person per calendar year

THIS POLICY PROVIDES LIMITED BENEFITS. EXCLUSIONS

ColonialLife.com

We will not pay benefits for losses which are caused by: alcoholism or drug addiction, dental procedures, elective procedures and cosmetic surgery, felonies or illegal occupations, pregnancy of a dependent child, psychiatric or psychological conditions, suicide or injuries which any covered person intentionally does to himself or herself, or war. This information is not intended to be a complete description of the insurance coverage available. The insurance has exclusions and limitations which may affect any benefits payable. Applicable to policy form IMB7000-NC. For cost and complete details of coverage, call or write your Colonial Life benefits counselor or the company. Underwritten by Colonial Life & Accident Insurance Company, Columbia, SC. © 2021 Colonial Life & Accident Insurance Company. All rights reserved Colonial Life is a registered trademark and marketing brand of Colonial Life & Accident Insurance Company. IMB7000-MEDICAL TREATMENT PACKAGE NORTH CAROLINA EDUCATORS | 3-21 | NS-15014-1-NC

Hospital Confinement Indemnity Insurance Optional Riders Individual Medical BridgeSM offers two optional benefit riders – the daily hospital confinement rider and the enhanced intensive care unit confinement rider. For an additional cost, these riders can help provide extra financial protection to help with out-of-pocket medical expenses.

Daily hospital confinement rider. ................................................................. $100 per day Per covered person per day of hospital confinement Maximum of 365 days per covered person per confinement

Enhanced intensive care unit confinement rider............................................... $500 per day Per covered person per day of intensive care unit confinement Maximum of 30 days per covered person per confinement

Re-confinement for the same or related condition within 90 days of discharge is considered a continuation of a previous confinement.

For more information, talk with your benefits counselor.

EXCLUSIONS

ColonialLife.com

We will not pay benefits for losses which are caused by: alcoholism or drug addiction, dental procedures, elective procedures and cosmetic surgery, felonies or illegal occupations, pregnancy of a dependent child, psychiatric or psychological conditions, suicide or injuries which any covered person intentionally does to himself or herself, or war. We will not pay benefits for hospital confinement of a newborn who is neither injured nor sick. We will not pay benefits for loss during the first 12 months after the effective date due to a pre-existing condition. Pre-exisiting conditions are those conditions whether diagnosed or not, for which a covered person received medical advice, diagnosis or care, or treatment was received or recommended within the one-year period immediately preceding the effective date of the policy. If a covered person is 65 or older when the policy is issued, pre-existing conditions will include only conditions specifically eliminated by rider. For cost and complete details, see your Colonial Life benefits counselor. Applicable to rider numbers R-DHC7000-NC and R-EIC7000-NC. This is not an insurance contract and only the actual policy or rider provisions will control. ©2015 Colonial Life & Accident Insurance Company, Columbia, SC | Colonial Life insurance products are underwritten by Colonial Life & Accident Insurance Company, for which Colonial Life is the marketing brand.

IMB7000 – DAILY HOSPITAL CONFINEMENT AND ENHANCED INTENSIVE CARE UNIT CONFINEMENT RIDERS | 7-15 | 101582-NC

Term Life Insurance Life insurance protection when you need it most Life insurance needs change as life circumstances change. You may need different coverage if you’re getting married, buying a home or having a child. Term life insurance from Colonial Life provides protection for a specified period of time, typically offering the greatest amount of coverage for the lowest initial premium. This fact makes term life insurance a good choice for supplementing cash value coverage during life stages when obligations are higher, such as while children are younger. It’s also a good option for families on a tight budget — especially since you can convert it to a permanent cash value plan later.

With this coverage: n A beneficiary can receive a benefit that is typically free from income tax. n The policy’s accelerated death benefit can pay a percentage of the death benefit if the covered person is diagnosed with a terminal illness. n You can convert it to a Colonial Life cash value insurance plan, with no proof of good health, to age 75. n Coverage is guaranteed renewable up to age 95 as long as premiums are paid when due. n Portability allows you to take it with you if you change jobs or retire.

Talk with your Colonial Life benefits counselor to learn more.

ColonialLife.com

Spouse coverage options

Dependent coverage options

Two options are available for spouse coverage at an additional cost:

You may add a Children’s Term Life Rider to cover all of your eligible dependent children with up to $20,000 in coverage each for one premium.

1. Spouse Term Life Policy: Offers guaranteed premiums and level death benefits equivalent to those available to you –whether or not you buy a policy for yourself. 2. Spouse Term Life Rider: Add a term rider for your spouse to your policy, up to a maximum death benefit of $50,000; 10-year and 20-year are available (20-year rider only available with a 20- or 30-year term policy).

The Children’s Term Life Rider may be added to either the primary or spouse policy, not both.

If the insured dies by suicide, whether sane or insane, within two years (one year in ND) from the coverage effective date or the date of reinstatement, we will not pay the death benefit. We will terminate this policy and return the premiums paid, without interest. Product may vary by state. For cost and complete details of the coverage, call or write your Colonial Life benefits counselor or the company. Colonial Life insurance products are underwritten by Colonial Life & Accident Insurance Company, Columbia, SC. ©2019 Colonial Life & Accident Insurance Company. All rights reserved. Colonial Life is a registered trademark and marketing brand of Colonial Life & Accident Insurance Company. 7-19 | NS-16570-1

Whole Life Plus Insurance

You can’t predict your family’s future, but you can be prepared for it.

ADVANTAGES OF WHOLE LIFE PLUS INSURANCE

Give your family peace of mind and coverage for final expenses with Whole Life Plus insurance from Colonial Life.

• P ermanent coverage that stays the same through the life of the policy

BENEFITS AND FEATURES Choose the age when your premium payments end — Paid-Up at Age 70 or Paid-Up at Age 100 Stand-alone spouse policy available even without buying a policy for yourself Ability to keep the policy if you change jobs or retire Built-in terminal illness accelerated death benefit that provides up to 75% of the policy’s death benefit (up to $150,000) if you’re diagnosed with a terminal illness2 Immediate $3,000 claim payment that can help your designated beneficiary pay for funeral costs or other expenses

• Premiums will not increase due to changes in health or age • Accumulates cash value based on a non-forfeiture interest rate of 3.75%1 • Policy loans available, which can be used for emergencies • Benefit for the beneficiary that is typically tax-free

Provides cash surrender value at age 100 (when the policy endows)

ADDITIONAL COVERAGE OPTIONS Spouse term rider Cover your spouse with a death benefit up to $50,000, for 10 or 20 years. Juvenile Whole Life Plus policy Purchase a policy (paid-up at age 70) while children are young and premiums are low — whether or not you buy a policy for yourself. You may also increase the coverage when the child is 18, 21 and 24 without proof of good health. Children’s term rider

Your cost will vary based on the amount of coverage you select.

You may purchase up to $20,000 in term life coverage for all of your eligible dependent children and pay one premium. The children’s term rider may be added to either your policy or your spouse’s policy — not both.

WHOLE LIFE PLUS (IWL5000)

Benefits worksheet For use with your benefits counselor How much coverage do you need?

 YOU $________________________ Select the option:

 Paid-Up at Age 70  Paid-Up at Age 100  SPOUSE $___________________ Select the option:

 Paid-Up at Age 70  Paid-Up at Age 100  DEPENDENT STUDENT

$_____________________________ Select the option:

 Paid-Up at Age 70  Paid-Up at Age 100 Select any optional riders:

 Spouse term rider

$ _____________face amount for _________-year term period

 Children’s term rider

$ ______________ face amount

 Accidental death benefit rider  Chronic care accelerated death benefit rider

 Critical illness accelerated death benefit rider

 Guaranteed purchase option rider

ADDITIONAL COVERAGE OPTIONS (CONTINUED) Accidental death benefit rider The beneficiary may receive an additional benefit if the covered person dies as a result of an accident before age 70. The benefit doubles if the accidental bodily injury occurs while riding as a fare-paying passenger using public transportation, such as ride-sharing services. An additional 25% will be payable if the injury is sustained while driving or riding in a private passenger vehicle and wearing a seatbelt. Chronic care accelerated death benefit rider If a licensed health care practitioner certifies that you have a chronic illness, you may receive an advance on all or a portion of the death benefit, available in a one-time lump sum or monthly payments.2 A chronic illness means you require substantial supervision due to a severe cognitive impairment or you may be unable to perform at least two of the six Activities of Daily Living (bathing, continence, dressing, eating, toileting and transferring). Premiums are waived during the benefit period. Critical illness accelerated death benefit rider If you suffer a heart attack (myocardial infarction), stroke or end-stage renal (kidney) failure, a $5,000 benefit is payable.2 A subsequent diagnosis benefit is included. Guaranteed purchase option rider This rider allows you to purchase additional whole life coverage — without having to answer health questions — at three different points in the future. The rider may only be added if you are age 50 or younger when you purchase the policy. You may purchase up to your initial face amount, not to exceed a total combined maximum of $100,000 for all options. Waiver of premium benefit rider Premiums are waived (for the policy and riders) if you become totally disabled before the policy anniversary following your 65th birthday and you satisfy the six-month elimination period. Once you are no longer disabled, premium payments will resume.

 Waiver of premium benefit rider

1. Accessing the accumulated cash value reduces the death benefit by the amount accessed, unless the loan is repaid. Cash value will be reduced by any outstanding loans against the policy. 2. Any payout would reduce the death benefit. Benefits may be taxable as income. Individuals should consult with their legal or tax counsel when deciding to apply for accelerated benefits.

To learn more, talk with your benefits counselor.

EXCLUSIONS AND LIMITATIONS: If the insured dies by suicide, whether sane or insane, within two years (one year in ND) from the coverage effective date or the date of reinstatement, we will not pay the death benefit. We will terminate this policy and return the premiums paid without interest, minus any loans and loan interest to you. This information is not intended to be a complete description of the insurance coverage available. The policy or its provisions may vary or be unavailable in some states. The policy has exclusions and limitations which may affect any benefits payable. Applicable to policy forms ICC19IWL5000-70/IWL5000-70, ICC19-IWL5000-100/IWL5000-100, ICC19-IWL5000J/IWL5000J and rider forms ICC19-R-IWL5000-STR/R-IWL5000-STR, ICC19-R-IWL5000-CTR/R-IWL5000-CTR, ICC19-R-IWL5000-WP/R-IWL5000-WP, ICC19-R-IWL5000-ACCD/R-IWL5000-ACCD, ICC19-RIWL5000-CI/R-IWL5000-CI, ICC19-R-IWL5000-CC/R-IWL5000-CC, ICC19-R-IWL5000-GPO/RIWL5000-GPO. For cost and complete details of the coverage, call or write your Colonial Life benefits counselor or the company. Underwritten by Colonial Life & Accident Insurance Company, Columbia, SC.

ColonialLife.com

© 2021 Colonial Life & Accident Insurance Company. All rights reserved. Colonial Life is a registered trademark and marketing brand of Colonial Life & Accident Insurance Company. FOR EMPLOYEES 6-21 | 642298

PIERCE GROUP BENEFITS ADDITIONAL BENEFITS

THE FSASTORE FLEX SPENDING WITH ZERO GUESSWORK

Your Health, Your Funds, Your Choice Take control of your health and wellness with guaranteed FSA-eligible essentials. Pierce Group Benefits partners with the FSAstore to provide one convenient location for Flexible Spending Account holders to manage and use their FSA funds, and save on more than 4,000 health and wellness products using tax-free health money. Through our partnership, we’re also here to help answer the many questions that come along with having a Flexible Spending Account! – The largest selection of guaranteed FSA-eligible products – Phone and live chat support available 24 hours a day / 7 days a week – Fast and free shipping on orders over $50 – Use your FSA card or any other major credit card for purchases

Other Great FSAstore Resources Available To You – Eligibility List: A comprehensive list of eligible products and services – FSA Calculator: Estimate how much you can save with an FSA – Learning Center: Easy tips and resources for living with an FSA – Savings Center: Where you can save even more on FSA-eligible essentials – FSAPerks: Take your health and funds further with the FSAstore rewards program Shop FSA Eligible Products Through Our Partnership with The FSA Store! BONUS: Get $20 off any order of $150+ with code PGB20FSA (one use per customer).

Authorization for Colonial Life & Accident Insurance Company For the purpose of evaluating my application(s) for insurance submitted during the current enrollment and eligibility for benefits under any insurance issued including checking for and resolving any issues that may arise regarding incomplete or incorrect information on my application(s), I hereby authorize the disclosure of the following information about me and, if applicable, my dependents, from the sources listed below to Colonial Life & Accident Insurance Company (Colonial) and its duly authorized representatives. Health information may be disclosed by any health care provider or institution, health plan or health care clearinghouse that has any records or knowledge about me including prescription drug database or pharmacy benefit manager, or ambulance or other medical transport service. Health information may also be disclosed by any insurance company, Medicare or Medicaid agencies or the Medical Information Bureau (MIB). Health information includes my entire medical record, but does not include psychotherapy notes. Non-health information including earnings or employment history deemed appropriate by Colonial to evaluate my application may be disclosed by any person or organization that has these records about me, including my employer, employer representative and compensation sources, insurance company, financial institution or governmental entities including departments of public safety and motor vehicle departments. Any information Colonial obtains pursuant to this authorization will be used for the purpose of evaluating my application(s) for insurance or eligibility for benefits. Some information obtained may not be protected by certain federal regulations governing the privacy of health information, but the information is protected by state privacy laws and other applicable laws. Colonial will not disclose the information unless permitted or required by those laws. This authorization is valid for two (2) years from its execution and a copy is as valid as the original. A copy will be included with my contract(s) and I or my authorized representative may request access to this information. This authorization may be revoked by me or my authorized representative at any time except to the extent Colonial has relied on the authorization prior to notice of revocation or has a legal right to contest coverage under the contract(s) or the contract itself. If revoked, Colonial may not be able to evaluate my application(s) for insurance or eligibility for benefits as necessary to issue my contract(s). I may revoke this authorization by sending written notice to: Colonial Life & Accident Insurance Company, Underwriting Department, P.O. Box 1365, Columbia, SC 29202. You may refuse to sign this form; however, Colonial may not be able to issue your coverage. I am the individual to whom this authorization applies or that person’s legal Guardian, Power of Attorney Designee, or Conservator. ________________________ (Printed name of individual subject to this disclosure)

_____________ (Social Security Number)

___________________ (Signature)

________________ (Date Signed)

If applicable, I signed on behalf of the proposed insured as __________________________ (indicate relationship). If legal Guardian, Power or Attorney Designee, or Conservator.

________________________________ (Printed name of legal representative)

_____________________________ (Signature of legal representative)

___________ (Date Signed)

I’m Leaving, Now What? Other Benefits If you wish to continue coverage of any of the following benefits, Pierce Group Benefits will be happy to serve you:

• • • •

Dental and Vision Insurance Group Term Life Insurance Supplemental/Voluntary Insurances - Cancer, Disability, Life, etc. Flexible Spending Accounts

Please visit

www.piercegroupbenefits.com/individualfamily

or call 888-662-7500 for more information on these policies, as well as to enroll/continue your benefits. You may also click on the “Individual & Family” button on the Pierce Group Benefits homepage, www.piercegroupbenefits.com to access this information.

Transferring from one Employer to Another? If you are transferring from a current PGB client to another, some benefits may be eligible for transfer. Please call 888-662-7500 and a Service Specialist will be glad to help you.

CONTACT INFORMATION: BLUECROSS BLUESHIELD - HEALTH INSURANCE Contact the Customer Service Center at the number shown on your health plan ID card for questions • Website: www.bcbsnc.com

THE HARTFORD - LONG-TERM DISABILITY • Customer Service: 1-800-523-2233 • Website: www.thehartford.com/employee-benefits/employees

EMPLOYEE ASSISTANCE NETWORK EMPLOYEE ASSISTANCE PROGRAM

AMERITAS - DENTAL INSURANCE • Customer Service: 1-800-487-5553 • Website: www.ameritas.com

• Customer Service: 1-800-454-1477 • Website: www.EANNC.com or MyLifeExpert.com

EYEMED - VISION INSURANCE THE HARTFORD - TERM LIFE INSURANCE

• Customer Service: 1-866-804-0982 • Website: www.eyemed.com

• Customer Service: 1-800-523-2233 • Website: www.thehartford.com/employeebenefits

AMERIFLEX - FLEXIBLE SPENDING ACCOUNTS TO VIEW YOUR BENEFITS ONLINE

• Customer Service: 1-888-868-3539 • Website: www.myameriflex.com • Claims Mailing Address: P.O. Box 269009, Plano, TX 75026

MANAGE YOUR ACCOUNT ONLINE OR DOWNLOAD THE MYAMERIFLEX MOBILE APP

• • • •

Check your Balance Submit a Claim Check Claim Status Mark Your Card Lost or Stolen

Visit www.piercegroupbenefits.com/

EliadaHomes For additional information concerning plans offered to employees of Eliada Homes, please contact our North Carolina Service Center at 1-888-662-7500, ext. 100

COLONIAL LIFE VISIT COLONIALLIFE.COM TO SET UP YOUR PERSONAL ACCOUNT • Website: www.coloniallife.com • Claims Fax: 1-800-880-9325

• Customer Service & Wellness Screenings: 1-800-325-4368 • TDD for hearing impaired customers call: 1-800-798-4040

If you wish to file a Wellness/Cancer Screening claim for a test performed within the past 18 months, you need the name and date of the test performed as well as your doctor’s name and phone number. Colonial also needs to know if this is for you or another covered individual and their name and social security number. You may: • FILE BY PHONE! Call 1-800-325-4368 and provide the information requested by Colonial’s Automated Voice Response System, 24 hours per day, 7 days a week, or • SUBMIT ON THE INTERNET using the Wellness Claim Form at www.coloniallife.com, or • Write your name, address, social security number and/or policy/certificate number on your bill and indicate “Wellness Test.” Fax this to Colonial at 1-800-880-9325 or MAIL to PO Box 100195, Columbia, SC 29202 If your Wellness/Cancer Screening test was more than 18 months ago, you must fax or mail Colonial a copy of the bill or statement from your doctor indicating the type of procedure performed, the charge incurred and the date of service. Please write your full name, social security number, and current address on the bill. Please Note: If your cancer policy includes a second part to the screening benefit, bills for tests covered and a copy of the diagnostic report (reflecting the abnormal reading of your first test) must be mailed or faxed to us for benefits to be provided.

When you terminate employment, you have the opportunity to continue your Colonial coverage either through direct billing or automatic payment through your bank account. Please contact Colonial at 1-800-325-4368 to request the continuation of benefits form.