gates county government benefits booklet 2021

EMPLOYEE BENEFITS PLAN Gates County Government Plan Year: July 1, 2021 - June 30, 2022

ARRANGED BY:

www.piercegroupbenefits.com

EMPLOYEE BENEFITS GUIDE

TABLE OF CONTENTS Welcome to the Gates County Government 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: MAY 11, 2021 - MAY 13, 2021 EFFECTIVE DATES: JULY 1, 2021 - JUNE 30, 2022 Benefits Plan Overview

page

2

Disability Benefits

page

40

Online Enrollment Instructions

page

5

Accident Benefits

page

44

Health Benefits

page

7

Medical Bridge Benefits

page

48

Health Rates

page

15

Life Insurance

page

55

Dental Benefits

page

16

Additional Benefits Available

page

57

Vision Benefits

page

18

Cobra Continuation Of Coverage Rights

page

58

Authorization Form

page

60

Notice Of Insurance Information Practices

page

61

Continuation Of Coverage for Benefits Form

page

62

Group Term Life Insurance

Flexible Spending Accounts

page

page

19 24

Cancer Benefits

page

28

Critical Illness Benefits

page

31 Rev. 05/03/2021

PRE-TAX & POST-TAX BENEFITS

GATES COUNTY GOVERNMENT ENROLLMENT PERIOD: MAY 11, 2021 - MAY 13, 2021 EFFECTIVE DATES: JULY 1, 2021 - JUNE 30, 2022

PRE-TAX BENEFITS Dental Insurance

Health Insurance

AlwaysCare

NCLM/MedCost

Vision Insurance Superior

Flexible Spending Accounts

Ameriflex • Medical Reimbursement FSA Maximum: $1,500/year | Minimum $200/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.

IF YOU DO NOT RE-SIGN, YOUR CONTRIBUTION WILL STOP EFFECTIVE JUNE 30, 2021.

Cancer Benefits

Colonial Life

Accident Benefits

Colonial Life

Medical Bridge Benefits Colonial Life

POST-TAX BENEFITS Disability Benefits Colonial Life

Critical Illness Benefits Colonial Life

Group Term Life Insurance MetLife

Life Insurance

Colonial Life • Term Life Insurance • Whole Life Insurance

Please note your insurance products will remain in effect unless you see a representative to change them.

2

QUALIFICATIONS & IMPORTANT INFO

THINGS YOU NEED TO KNOW QUALIFICATIONS: • Employees who work 30 or more hours per week are eligible for Health benefits.

• Employees who work 37 or more hours per week are eligible for all other benefits.

• New employees are eligible for coverage the first day of employment, with exception of Flexible Spending Accounts employees must work 6 months and will be eligible to enroll during the next open enrollment.

IMPORTANT FACTS: • The plan year for NCLM/MedCost Health, AlwaysCare Dental, MetLife Group Term Life, Superior Vision, Colonial Insurance products and Spending Accounts lasts from July 1, 2021 through June 30, 2022.

• Deductions for NCLM/MedCost Health, AlwaysCare Dental, MetLife Group Term Life and Superior Vision will begin June 2021. Deductions for Colonial Insurance products and Spending Accounts will begin July 2021.

• Please visit www.piercegroupbenefits.com/gatescountygovernment to review plan summaries and other required health plan notices.

• If signing up for any coverage on your spouse and/or children, please have their dates of birth and social security numbers available when meeting with the Benefits Representative.

• If you will be receiving a new debit card, whether you are a new participant or to replace your expired 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 an FSA at the same time the other is contributing 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 July 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.

3

EMPLOYEE BENEFITS GUIDE

GATES COUNTY GOVERNMENT IN PERSON

ONLINE

You may enroll or make changes online to your flexible benefits plan. To enroll online, please see the information below and on the following pages.

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.

ENROLLMENT PERIOD: MAY 11, 2021 - MAY 13, 2021 YOU CAN MAKE THE FOLLOWING BENEFIT ELECTIONS ONLINE DURING THE ENROLLMENT PERIOD: • • • • • •

Enroll, change or cancel your Health Insurance.

Enroll, change or cancel your Vision Insurance.

Enroll, change or cancel your Dental Insurance.

Enroll/Re-Enroll in Flexible Spending Accounts⁺ (Medical Reimbursement and Dependent Care).

Enroll, change or cancel your Group Term Life Insurance.

Enroll, change or cancel your Colonial products (see the following pages for changes that can be completed online). ⁺You will need to re-sign for the spending accounts if you want them to continue each year.

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/gatescountygovernment 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.

4

Harmony

HARMONY ONLINE ENROLLMENT: COMPLETE THE STEPS BELOW TO BEGIN THE ONLINE ENROLLMENT PROCESS

HELPFUL TIPS:

• If you are a new employee and unable to log into the online system, please speak with the Benefits Representative assigned to your location, or contact Human Resources.

• If you are an existing employee and unable to log into the online system, please contact the Harmony Help Desk at 866-875-4772 between 8:30am and 6:00pm, or speak with the Benefits Representative assigned to your location.

Go to https://harmonyenroll.coloniallife.com 1.

• Enter your User Name: GAT7D6C- and then Last Name and then Last 4 of Social Security Number (GAT7D6C-SMITH6789) • Enter your Password: Four digit Year of Birth and then Last 4 of Social Security Number (19766789)

2.

The screen prompts you to create a NEW password [____________________________].

3.

Choose a security question and enter answer [______________________________________].

4.

Click on ‘I Agree’ and then “Enter My Enrollment”.

5.

The screen shows ‘Me & My Family’. Verify that the information is correct and enter the additional required information (title, marital status, work phone, e-mail address). Click ‘Save & Continue’ twice.

6.

The screen allows you to add family members. It is only necessary to enter family member information if adding or including family members in your coverage. Click ‘Continue’.

7.

The screen shows updated personal information. Verify that the information is correct and make changes if necessary. Click ‘Continue’.

8.

The screen shows ‘My Benefits’. Review your current benefits and make changes/selections for the upcoming plan year.

• HEALTH: You may enroll online in Health coverage.

• DENTAL: You may enroll online in Dental coverage.

• VISION: You may enroll online in Vision coverage.

• GROUP TERM LIFE: You may enroll online in Group Term Life coverage.

• HEALTH CARE FSA*: Enter annual amount. MAX $1,500/year MIN $200/year • DEPENDENT CARE FSA*: Enter annual amount. MAX $5,000/year *FSA Administrative Fee - By electing an FSA product, you also agree to the monthly service fee associated with this product.

<<< enrollment instructions continued on next page >>>

5

Harmony

HARMONY ONLINE ENROLLMENT CONT.:

• CANCER ASSIST You may enroll online in Cancer Assist coverage.

• DISABILITY 3000 You may enroll online in Disability 3000 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 You may enroll online in Whole Life 5000; however, employees wishing to purchase an individual policy for their spouse should speak with the Benefits Representative.

9.

Click ‘Finish’.

10.

Click ‘I Agree’ to electronically sign the authorization for your benefit elections.

11.

Click ‘Print a copy of your Elections’ to print a copy of your elections, or download and save the document.

Please do not forget this important step!

12.

Click ‘Log out & close your browser window’ and click ‘Log Out’.

6

Gates County of Government MedCost 5000 35-55 BASE PLAN Member Pays

Health Benefits

In-Network

Non-Network

Benefit Year Deductible (Individual/Family)

$5,000/$10,000

$10,000/$20,000

Coinsurance Maximum (Individual/Family)

$1,500/$3,000

$3,000/$6,000

Benefit Year Out-of-Pocket Maximum (Individual/Family)

$6,500/$13,000

$13,000/$26,000

Maximum Lifetime Benefit Per Member

Unlimited

Physician Office Services – Primary Care Physician

$35 copay per visit

100% deductible waived, limited to $500 maximum per Benefit Year 50% after deductible

Physician Office Services – Specialist

$55 copay per visit

50% after deductible

Routine Wellness/Preventive Services

100%, deductible waived

Teladoc Maternity Care

100%; deductible waived -Initial visit to confirm pregnancy -Physician (Global Fee) -Facility

Outpatient Lab and X-Ray Services (Hospital Outpatient or Independent Outpatient Facility)

Outpatient Diagnostic Scans (MRI,CT and PET) Urgent Care Services -Urgent Care Facility -Urgent Care Physician’s Office – Primary Care -Urgent Care Physician’s Office – Specialist Emergency Room Visits Must meet Emergency criteria

-As any Physician office visit -$150 copay then 100% -70% after deductible

-As any Physician office visit -50% after deductible -50% after deductible

100%; deductible waived

50% after deductible

70%; deductible waived

50% after deductible

-70% after deductible -$35 copay per office visit -$55 copay per office visit

-50% after deductible -$35 copay per office visit -$55 copay per office visit

$500 copay (copay waived if admitted)

Ambulance Services -Air (Precertification Required When Non-Emergent) -Ground

70% after In-Network Deductible

Physician Inpatient Services

70% after deductible

50% after deductible

Room and Board Precertification Required

70% after deductible

50% after deductible

Other Inpatient Services

70% after deductible

50% after deductible

Durable Medical Equipment (DME) The plan has benefits for the rental of DME if deemed medically necessary. These items may be bough rather than rented, with the cost not to exceed fair market value.

70% after deductible

50% after deductible

Page 1 of 2

7

Member Pays

Health Benefits

In-Network

Skilled Nursing Facility (Benefit Year max of 100 days)

Non-Network

70% after In-Network deductible

Home Health Care (includes Private Duty Nursing), Hospice

70% after deductible

50% after deductible

$55 copay per office visit

50% after deductible

As any admission

As any admission

As any outpatient facility expense

As any outpatient facility expense

100%; deductible waived per office visit

50% after deductible

Short-Term Therapy Mental Health and Substance Use Disorders Inpatient Outpatient Facility

Outpatient Physician Prescription Drug Coverage

Retail Pharmacy Copay covers up to a 30 day supply

Generic Preferred Brand Non-Preferred Brand Mandatory Specialty Pharmacy

Mail Order Copay covers up to a 90 day supply

$15 copay $60 copay $120 copay

$45 copay $180 copay $360 copay $120 copay

Certain Prescription Drugs must be purchased through the Plan’s Specialty Pharmacy.

This overview does not replace your Certificate of Coverage. Many words are defined in the Certificate, and other limitations or exclusions may be listed in other sections of your Certificate. Reading this overview by itself could give you an inaccurate impression of the terms of your coverage. This overview must be read with the rest of your Certificate of Coverage. Prior authorization is required for specific services.

NCLM Wellness Program Requirements: All active covered individuals (employees and spouses) must meet the following wellness screening requirements, as applicable: • Annual wellness screening from a primary care physician, urgent care facility or employer on-site assessment.

• Age appropriate cancer screenings, typically members follow American Cancer Society guidelines: o Mammograms: 1 per year for females age 45-54; 1 every 2 years for females age 55+ o Colonoscopy: 1 every 10 years for all individuals age 50+ o Pap: 1 every 3 years for females age 21+ (alternate guidelines for females who’ve had a hysterectomy) • Personal Care Management program participation (as invited).

Must be completed by December 31, 2020 in order to avoid 10% premium penalty commencing August 2021.

• • •

• •

Other Wellness Services and Programs (see your Benefits Administrator for more information): Personal Care Management (PCM) is individualized care designed to help create positive outcomes for those who are suffering from chronic conditions.

Online Personal Health Suite offers a one-stop shop site for employees looking for health and wellness tools and information.

SmartStarts Maternity Management is a voluntary Employee wellness program, focused on educating expectant mothers and mentoring them through each trimester of Pregnancy. The Plan provides an incentive for participation in this programs. Participants enrolled during their first trimester receive $150, or $75 if they enroll during their second trimester upon completion of the program Smoking Cessation Naturally Slim Program

Page 2 of 2

8

Gates County of Government MedCost 2500 35-55 BUY UP PLAN 1 Member Pays

Health Benefits

In-Network

Non-Network

Benefit Year Deductible (Individual/Family)

$2,500/$5,000

$5,000/$10,000

Coinsurance Maximum (Individual/Family)

$3,500/$4,000

$7,000/$14,000

Benefit Year Out-of-Pocket Maximum (Individual/Family)

$6,000/$12,000

$12,000/$24,000

Maximum Lifetime Benefit Per Member

Unlimited

Physician Office Services – Primary Care Physician

$35 copay per visit

100% deductible waived, limited to $500 maximum per Benefit Year 60% after deductible

Physician Office Services – Specialist

$55 copay per visit

60% after deductible

Routine Wellness/Preventive Services

100%, deductible waived

Teladoc Maternity Care

100%; deductible waived -Initial visit to confirm pregnancy -Physician (Global Fee) -Facility

Outpatient Lab and X-Ray Services (Hospital Outpatient or Independent Outpatient Facility)

Outpatient Diagnostic Scans (MRI,CT and PET) Urgent Care Services -Urgent Care Facility -Urgent Care Physician’s Office – Primary Care -Urgent Care Physician’s Office – Specialist Emergency Room Visits Must meet Emergency criteria

-As any Physician office visit -$150 copay then 100% -80% after deductible

-As any Physician office visit -60% after deductible -60% after deductible

100%; deductible waived

60% after deductible

80%; deductible waived

60% after deductible

-80% after deductible -$35 copay per office visit -$55 copay per office visit

-60% after deductible -$35 copay per office visit -$55 copay per office visit

$500 copay (copay waived if admitted)

Ambulance Services -Air (Precertification Required When Non-Emergent) -Ground

80% after In-Network Deductible

Physician Inpatient Services

80% after deductible

60% after deductible

Room and Board Precertification Required

80% after deductible

60% after deductible

Other Inpatient Services

80% after deductible

60% after deductible

Durable Medical Equipment (DME) The plan has benefits for the rental of DME if deemed medically necessary. These items may be bough rather than rented, with the cost not to exceed fair market value.

80% after deductible

60% after deductible

Page 1 of 2

9

Member Pays

Health Benefits

In-Network

Skilled Nursing Facility (Benefit Year max of 100 days)

Non-Network

80% after In-Network deductible

Home Health Care (includes Private Duty Nursing), Hospice

80% after deductible

60% after deductible

$55 copay per office visit

60% after deductible

As any admission

As any admission

As any outpatient facility expense

As any outpatient facility expense

100%; deductible waived per office visit

60% after deductible

Short-Term Therapy Mental Health and Substance Use Disorders Inpatient Outpatient Facility

Outpatient Physician Prescription Drug Coverage

Retail Pharmacy Copay covers up to a 30 day supply

Generic Preferred Brand Non-Preferred Brand Mandatory Specialty Pharmacy

Mail Order Copay covers up to a 90 day supply

$15 copay $60 copay $120 copay

$45 copay $180 copay $360 copay $120 copay

Certain Prescription Drugs must be purchased through the Plan’s Specialty Pharmacy.

This overview does not replace your Certificate of Coverage. Many words are defined in the Certificate, and other limitations or exclusions may be listed in other sections of your Certificate. Reading this overview by itself could give you an inaccurate impression of the terms of your coverage. This overview must be read with the rest of your Certificate of Coverage. Prior authorization is required for specific services.

NCLM Wellness Program Requirements: All active covered individuals (employees and spouses) must meet the following wellness screening requirements, as applicable: • Annual wellness screening from a primary care physician, urgent care facility or employer on-site assessment.

• Age appropriate cancer screenings, typically members follow American Cancer Society guidelines: o Mammograms: 1 per year for females age 45-54; 1 every 2 years for females age 55+ o Colonoscopy: 1 every 10 years for all individuals age 50+ o Pap: 1 every 3 years for females age 21+ (alternate guidelines for females who’ve had a hysterectomy) • Personal Care Management program participation (as invited).

Must be completed by December 31, 2020 in order to avoid 10% premium penalty commencing August 2021.

• • •

• •

Other Wellness Services and Programs (see your Benefits Administrator for more information): Personal Care Management (PCM) is individualized care designed to help create positive outcomes for those who are suffering from chronic conditions.

Online Personal Health Suite offers a one-stop shop site for employees looking for health and wellness tools and information.

SmartStarts Maternity Management is a voluntary Employee wellness program, focused on educating expectant mothers and mentoring them through each trimester of Pregnancy. The Plan provides an incentive for participation in this programs. Participants enrolled during their first trimester receive $150, or $75 if they enroll during their second trimester upon completion of the program Smoking Cessation Naturally Slim Program

Page 2 of 2

10

Gates County of Government MedCost 25/2500 BUY UP PLAN 2 Member Pays

Health Benefits

In-Network

Non-Network

Benefit Year Deductible (Individual/Family)

$2,500/$5,000

$5,000/$10,000

Coinsurance Maximum (Individual/Family)

$3,500/$4,000

$7,000/$14,000

Benefit Year Out-of-Pocket Maximum (Individual/Family)

$6,000/$12,000

$12,000/$24,000

Maximum Lifetime Benefit Per Member

Unlimited

Physician Office Services – Primary Care Physician

$25 copay per visit

100% deductible waived, limited to $500 maximum per Benefit Year 80% after deductible

Physician Office Services – Specialist

$50 copay per visit

80% after deductible

Routine Wellness/Preventive Services

100%, deductible waived

Teladoc Maternity Care

100%; deductible waived -As any Physician office visit -$150 copay then 100% -100% after deductible

-As any Physician office visit -80% after deductible -80% after deductible

100%; deductible waived

80% after deductible

Outpatient Diagnostic Scans (MRI,CT and PET)

100%; deductible waived

80% after deductible

Urgent Care Services -Urgent Care Facility -Urgent Care Physician’s Office – Primary Care -Urgent Care Physician’s Office – Specialist

-100% after deductible -$25 copay per office visit -$50 copay per office visit

-80% after deductible -$25 copay per office visit -$50 copay per office visit

-Initial visit to confirm pregnancy -Physician (Global Fee) -Facility Outpatient Lab and X-Ray Services (Hospital Outpatient or Independent Outpatient Facility)

Emergency Room Visits Must meet Emergency criteria

$500 copay (copay waived if admitted)

Ambulance Services -Air (Precertification Required When Non-Emergent) -Ground

100% after In-Network Deductible

Physician Inpatient Services

100% after deductible

80% after deductible

Room and Board Precertification Required

100% after deductible

80% after deductible

Other Inpatient Services

100% after deductible

80% after deductible

Durable Medical Equipment (DME) The plan has benefits for the rental of DME if deemed medically necessary. These items may be bough rather than rented, with the cost not to exceed fair market value.

100% after deductible

80% after deductible

Page 1 of 2

11

Member Pays

Health Benefits

In-Network

Skilled Nursing Facility (Benefit Year max of 100 days)

Non-Network

100% after In-Network deductible

Home Health Care (includes Private Duty Nursing), Hospice

100% after deductible

80% after deductible

$50 copay per office visit

80% after deductible

As any admission

As any admission

As any outpatient facility expense

As any outpatient facility expense

100%; deductible waived per office visit

80% after deductible

Short-Term Therapy Mental Health and Substance Use Disorders Inpatient Outpatient Facility

Outpatient Physician Prescription Drug Coverage

Retail Pharmacy Copay covers up to a 30 day supply

Generic Preferred Brand Non-Preferred Brand Mandatory Specialty Pharmacy

Mail Order Copay covers up to a 90 day supply

$10 copay $50 copay $100 copay

$30 copay $150 copay $300 copay $100 copay

Certain Prescription Drugs must be purchased through the Plan’s Specialty Pharmacy.

This overview does not replace your Certificate of Coverage. Many words are defined in the Certificate, and other limitations or exclusions may be listed in other sections of your Certificate. Reading this overview by itself could give you an inaccurate impression of the terms of your coverage. This overview must be read with the rest of your Certificate of Coverage. Prior authorization is required for specific services.

NCLM Wellness Program Requirements: All active covered individuals (employees and spouses) must meet the following wellness screening requirements, as applicable: • Annual wellness screening from a primary care physician, urgent care facility or employer on-site assessment.

• Age appropriate cancer screenings, typically members follow American Cancer Society guidelines: o Mammograms: 1 per year for females age 45-54; 1 every 2 years for females age 55+ o Colonoscopy: 1 every 10 years for all individuals age 50+ o Pap: 1 every 3 years for females age 21+ (alternate guidelines for females who’ve had a hysterectomy) • Personal Care Management program participation (as invited).

Must be completed by December 31, 2020 in order to avoid 10% premium penalty commencing August 2021.

• • •

• •

Other Wellness Services and Programs (see your Benefits Administrator for more information): Personal Care Management (PCM) is individualized care designed to help create positive outcomes for those who are suffering from chronic conditions.

Online Personal Health Suite offers a one-stop shop site for employees looking for health and wellness tools and information.

SmartStarts Maternity Management is a voluntary Employee wellness program, focused on educating expectant mothers and mentoring them through each trimester of Pregnancy. The Plan provides an incentive for participation in this programs. Participants enrolled during their first trimester receive $150, or $75 if they enroll during their second trimester upon completion of the program Smoking Cessation Naturally Slim Program

Page 2 of 2

12

personal care management

Become a healthier you

Getting and staying healthy isn’t easy. The Personal Care Management program can help you prevent serious health conditions and live the healthiest lifestyle possible.

If you hear from a MedCost nurse health coach, answer the call to participate and become a healthier you.

A winning strategy to improve your health

overnight. Together, you will set goals that are realistic and achievable. Your nurse coach will help you make

If you are asked to join the Personal Care Management (PCM) program, it’s because you may show early signs of or be at risk for developing a serious health condition. With the support and guidance of a MedCost Benefit Services nurse health coach, you can tackle any challenge. Your nurse health coach will work with you through regularly scheduled contact via phone calls, e-coaching and portal access to develop an action plan that is just right for you, based on where you are right now.*

small, incremental moves to bring you closer to the finish line. And, as you see your progress over time, you will be motivated to go even further.

It’s your move Changing your routine can be challenging, but the benefits of reducing your risk are well worth the effort.

This is your opportunity to receive free and confidential nurse health coaching and mentoring to meet your

A coach in your corner

specific needs. So, don’t wait! Complete your free

Improving your wellness is do-able, and communicating with your MedCost nurse health coach regularly can help you get and stay on track. You’ve spent a lifetime developing your present health habits, and your nurse coach understands that those habits won’t change

healthiest life.

online health assessment today and start living your

*All communications with your personal nurse health coach are confidential and will not be shared with your employer.

Taking the assessment is easy: 1. Log in to the secure Member portal on www.MedCost.com.

2. Choose Healthy & Whole under Quick Links.

3. Go to MyCarePath and follow the prompts to complete the

assessment.

1- 8 0 0 -722-2157 Me dCost .com REV03142019

MedCost Benefit Services d/b/a MBS Third Party Administrators in California

13

So many reasons to use Teladoc ®

new image

Teladoc gives you access 24 hours, 7 days a week to a U.S. board-certified doctor through the convenience of phone, video or mobile app visits.

It's an affordable option for quality medical care.

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GET THE CARE YOU NEED Teladoc doctors can treat many medical conditions, including: Talk to a doctor anytime, anywhere you happen to be

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Prompt treatment, median call back in 10 min

Receive quality care via phone, video or mobile app

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• • • • • • •

Cold & flu symptoms Allergies Pink Eye Respiratory infection Sinus problems Skin problems And more!

With your consent, Teladoc is A network of doctors that can treat every member of the family

Prescriptions sent to pharmacy of choice if medically necessary

Teladoc is less expensive than the ER or urgent care

happy to provide information about your Teladoc visit to your primary care physician

Talk to a doctor anytime for free!

Teladoc.com 1-800-Teladoc ©2002-2017 Teladoc, Inc. All rights reserved. Complete disclaimer at Teladoc.com. Apple and the Apple logo are trademarks of Apple Inc., registered in the U.S. and other countries. App Store is a service mark of Apple Inc.

14

03302016 10E-103B

Gates County Government Health Insurance Rates: July 1, 2021 - June 30, 2022

Employee Only

Employee + Spouse

Employee + Child(ren)

Family

Total Monthly Premium

$679.68

$1,152.68

$1,507.68

$1,689.68

County Contribution

$679.68

$679.68

$679.68

$679.68

$0.00

$473.00

$828.00

$1,010.00

Employee + Spouse $1,229.68 $679.68 $550.00

Employee + Child(ren) $1,608.68 $679.68 $929.00

Employee + Child(ren) $1,724.68

$1,932.68

5000 35-55 BASE PLAN

Employee Monthly Premium

2500 35-55 BUY UP PLAN 1 Total Monthly Premium County Contribution Employee Monthly Premium

Employee Only $723.68 $679.68 $44.00

Family $1,801.68 $679.68 $1,122.00

Total Monthly Premium

$774.68

Employee + Spouse $1,317.68

County Contribution

$679.68

$679.68

$679.68

$679.68

Employee Monthly Premium

$95.00

$638.00

$1,045.00

$1,253.00

25/2500 BUY UP PLAN 2

Employee Only

15

Family

Gates County Government Outline of Benefits Welcome to AlwaysCare! We are pleased to offer Dental benefits for you and your family effective July 1, 2021!

Selection of Providers: Members may choose any licensed dental provider. Members have access to our national network of over 170,000 participating access points where they can take advantage of discounts AlwaysCare has negotiated on their behalf. Further, in areas with relatively few participating providers, members have access to our list of an additional 46,000+ “certified” providers who, according to an independent resource, despite not participating in our network, offer excellent value for their customers. Members using participating providers will eliminate balance billing and reduce out-of-pocket expenses. No claim forms needed with participating providers. Visit www.AlwaysCareBenefits.com or call 1-888-400-9304 for a list of participating providers.

Deductible: Maximum 3 per family. Applies to Basic (Class B) and Major (Class C) Services.

$25 per benefit year

Coinsurance: The plan pays the following percentages of maximum allowable charges for each class:

Class A Class B Class C Class D

Benefit Maximums: (Class A, B, and C benefits).

$1000 per benefit year. Separate $1000 Lifetime Maximum on Orthodontia (Class D Services)

Carryover Benefit:

$250, Threshold Limit $500, Carryover Account Maximum $1000.

Monthly Employee Rates*:

Employee Only Employee & Spouse Employee & Children Employee & Family

*Rates valid from 07/01/2021 to 07/01/2023.

Preventive Basic Major Orthodontics

100% 80% 50% 50%

$0.00 $27.72 $38.16 $74.08

Covered Procedures and Waiting Periods: Preventive Services (Class A): No waiting period.

• Adjunctive Pre-Diagnostic Oral Cancer Screening (1 per 12 months for age 40+) • Bitewing x-rays (maximum of 4 films) (1 per 12 months) • Fluoride treatment for children up to age 16 (1 per 12 months) • Full mouth / panoramic x-rays (1 per 24 months) • Prophylaxis (2 per 12 months) o

• • •

Major Services (Class C): No waiting period.

• Anesthesia (subject to review, covered with complex oral surgery) • Repair of Crown, Denture, or Bridge • Crowns, Bridges, Dentures and Endosteal Implants (in lieu of an approved 3-unit Bridge) • Endodontics (Root Canals) • Inlays and Onlays • Simple Periodontics • Oral surgery (extractions and impacted teeth) • Surgical Periodontics

(1 additional cleaning or periodontal maintenance per 12 months if member is in 2nd or 3rd trimester of pregnancy)

Routine exams (2 per 12 months) Sealants for children up to age 16 (permanent molars 1 per 36 months) Space maintainers for children up to age 16 (1 per 24 months)

Orthodontics (Class D): No waiting period.

• Separate lifetime maximum benefit: $1000 • Up to 25% of lifetime allowance may be payable on initial banding.

• Dependent children to age 19 only.

Basic Services (Class B): No waiting period.

• Emergency treatment (1 per 12 months) • Simple restorative services (Fillings) (Benefit allowed for amalgam restorations on posterior teeth) • Simple extractions AlwaysCare Hearingsm Savings Plan • Available at no cost to all AlwaysCare Members • Material discounts between 30%-60% on all major name brand hearing instruments and accessories • Battery program discounts up to 40% off retail pricing To access call 1-888-400-9304

16

Dental Carryover Benefit Members who take care of their teeth, but use only part of their annual maximum benefit during a benefit period are rewarded with extra benefits in future years! If an Insured submits qualifying claims for covered expenses during a benefit year and, in that benefit year, receives benefits that are less than their group’s Threshold Limit, the Insured will be credited a Carryover Benefit. Carryover Benefits will be accrued and stored in the Insured’s Carryover Account to be used in the next benefit year. If an Insured reaches his or her Certificate Year Maximum Benefit, we will pay a benefit from the Insured’s Carryover Account up to the amount stored in the Insured’s Carryover Account.

The accrued Carryover Benefits stored in the Carryover Account may not be greater than the Carryover Account Limit.

Alternate Treatment: AlwaysCare Benefits, Inc. covers the least expensive most commonly used and accepted American Dental Association treatments. Plan members may elect a more expensive treatment, but will be responsible for the cost difference resulting from the more expensive procedure.

Exclusions/Limitations: AlwaysCare Members whose dental plan includes coverage of crowns and bridges will have the option of choosing an endosteal implant to replace a missing tooth instead of a conventional fixed 3-unit bridge, when a 3-unit bridge is approved for coverage. Crowns placed on implants will also be covered. Other implants or implant related services are not covered.

The following dental services are not covered: • any treatment which is elective or primarily cosmetic in nature and not generally recognized as a generally accepted dental practice by the American Dental Association, as well as any replacement of prior cosmetic restorations; • the correction of congenital malformations; • the replacement of lost, discarded, or stolen appliances; • replacement of bridges, dentures, crowns, inlays, onlays or dentures unless more than [5] years old and cannot be made serviceable; • appliances, services or procedures relating to: (i) the change or maintenance of vertical dimension; (ii) restoration of occlusion; (iii) splinting; (iv) correction of attrition, abrasion, erosion or a fraction; (v) bite registration; or (vi) bite analysis; • services provided for any type of temporomandibular joint (TMJ) dysfunctions, muscular, skeletal deficiencies involving TMJ or related structures, myofascial pain; • charges for implants (except noted above), removal of implants, precision or semi-precision attachments, denture duplication, overdentures and any associated surgery, or other customized services or attachments, and related procedures; • dentures for teeth missing prior to effective date of coverage; some exceptions apply and are detailed in the Certificate of Coverage; • multiple x-rays done on same date of service will be combined to a full-mouth x-ray; • cosmetic restorations on posterior permanent teeth and all primary teeth will be given alternate benefit; • Anesthesia is covered with complex oral surgery only. Charges are subject to review. Pre-treatment estimate is recommended.

The Limits for this Policy/Certificate are: Carryover Benefit $250, Threshold Limit $500, Carryover Account Limit $1000.

Other Specifications: • An Insured’s Carryover Account will be eliminated, and the accrued Carryover Benefits lost, if the Insured has a break in coverage of any length of time, for any reason.

• Eligibility for a Carryover Benefit will be established or reestablished at the time the first Qualifying Claim in a benefit year is received for Covered Expenses incurred during that benefit year.

• In order to be eligible to accumulate the Carryover Benefit, an Insured must be enrolled in the plan at least four months prior to the start of the new policy year. Example: If the plan effective date is January 1st, the Insured must be enrolled by September 1st.

• Only claims incurred on or after the start of the next Policy Year will count toward the Threshold Limit.

• Carryover Benefits will not be applied to an Insured’s Carryover Account until the Policy Year that starts one year from the date the rider first applies.

• If charges for Class C Services are not payable for an Insured due to a benefit waiting period for certain covered procedures, this rider will not apply to the Insured until the end of such waiting period.

And, if the waiting period ends within the three months prior to the start of this plan’s next benefit year, this rider will not apply to the Insured until the next benefit year.

• Carryover Benefits will not be applied to an Insured’s Carryover Account until the benefit year that starts one year from the date the rider first applies.

• Definitions: • “Benefit Year” means Calendar Year or Policy Year, according to the type of plan applicable under the Policy/Certificate to which this rider is attached.

• “Carryover Account” means the amount of an Insured’s accrued Carryover Benefits.

• “Carryover Account Limit” means the maximum amount of cumulative Carryover Benefits that an Insured can store in his or her Carryover Account.

• “Carryover Benefit” means the dollar amount, which will be added to an Insured’s Carryover Account when he or she receives benefits in a benefit year that do not exceed the Threshold Limit.

• Qualifying Claim means a claim under Procedure Classes A, B, C, and Class D, Orthodontia and must include 1 exam & 1 cleaning.

• “Threshold Limit” means the maximum amount of benefits for all procedure classes A, B, C and D that an Insured can receive during a benefit year and still be entitled to receive the Carryover Benefit.

Takeover Benefits: Takeover benefits apply if we are taking over a comparable benefits plan from another carrier and only if there is no break in coverage between the original plan and the takeover date. Takeover is available to those individuals insured under the employer’s dental plan in effect at the time of the employer’s application. If takeover benefits are included in your benefits, then waiting periods for service will be waived for the individuals currently insured under the employer’s previous plan during the month prior to coverage moving to us.

Application of takeover benefits is subject to Underwriting review and approval.

New hires with prior-like dental coverage (lapse in coverage must be less than 63 days) will receive takeover credit for the length of time they had with the prior carrier and must provide proof of coverage (including coverage dates) to receive takeover credit (i.e. one page benefit summary, certificate of creditable coverage, etc.).

Late entrants: Employees that waive coverage at initial enrollment (within 31 days of effective date) or in the new employee eligibility period and/or terminate coverage with AlwaysCare will have a twelve (12) month waiting period applied to basic and major services and orthodontia upon re-applying.

Dependent Children: Dependent age guidelines vary by state.

Please refer to your policy certificate or contact customer service at 888-400-9304,.

Services Not Listed: If you expect to require a dental or vision service not included on this brochure, it may still be covered. Please contact customer service at 1-888-400-9304 to confirm your exact benefits.

The prior carrier is responsible for reimbursement of costs for procedures begun prior to the effective date.

This brochure is a brief overview of the AlwaysCareSM dental plan. It does not list all benefits, nor does it list all exclusions and limitations. For more complete information, please refer to the Certificate, or the employer’s Master Policy, which will be issued when coverage becomes effective.

Underwritten by: Starmount Life Insurance Company Administered by: AlwaysCare Benefits, Inc. (a Starmount Life Insurance company), The Starmount Building,8485 Goodwood Boulevard Baton Rouge, LA 70806; PH: 1-888-400-9304.

Policy Forms: Dental – DN 2002 and DN 2007

17

Vision plan benefits for Gates County Government Copays

Services/frequency

Monthly premiums

Exam

$10

Emp. only

Materials1

$15

Contact lens fitting

$25

Emp. + 1 dependent Emp. + family

$7.74

Exam

12 months

$15.03 $22.07

Frame

24 months

(standard & specialty)

Contact lens fitting

12 months

Lenses

12 months

Contact lenses

12 months

(based on date of service)

Benefits through Superior National network Exam (ophthalmologist) Exam (optometrist) Frames Contact lens fitting (standard2) Contact lens fitting (specialty2) Lenses (standard) per pair Single vision Bifocal Trifocal Progressive lens upgrade Contact lenses4

In-network

Out-of-network

Covered in full Covered in full $150 retail allowance Covered in full $50 retail allowance

Up to $44 retail Up to $39 retail Up to $77 retail Not covered Not covered

Covered in full Covered in full Covered in full See description3 $150 retail allowance

Up to $34 retail Up to $48 retail Up to $64 retail Up to $64 retail Up to $100 retail

Co-pays apply to in-network benefits; co-pays for out-of-network visits are deducted from reimbursements 1 Materials co-pay applies to lenses and frames only, not contact lenses 2 Standard contact lens fitting applies to a current contact lens user who wears disposable, daily wear, or extended wear lenses only. Specialty contact lens fitting applies to new contact wearers and/or a member who wear toric, gas permeable, or multi-focal lenses.

3 Covered to provider’s in-office standard retail lined trifocal amount; member pays difference between progressive and standard retail lined trifocal, plus applicable co-pay.

4 Contact lenses are in lieu of eyeglass lenses and frames benefit

Discount features

Discounts on non-covered exam, services and materials5

Discounts on covered materials5

Exams, frames, and prescription lenses: 30% off retail Contacts, miscellaneous options: 20% off retail Disposable contact lenses: 10% off retail Retinal imaging: $39 maximum out-of-pocket

These discounts apply to the glasses and contacts that are covered under the vision benefits.

Frames: Conventional contacts Disposable contact

20% off amount over allowance 20% off amount over allowance 10% off amount over allowance

Lens type* Scratch coat Ultraviolet coat Tints, solid Tints, gradient Polycarbonate Blue light filtering Digital single vision Progressive lenses Standard/Premium/Ultra/Ultimate Anti-reflective coating Standard/Premium/Ultra/Ultimate Polarized lenses Plastic photochromic lenses High Index (1.67 / 1.74)

Laser vision correction (LASIK)5

Member out-of-pocket5 $15 $12 $15 $18 $40 $15 $30

Laser vision correction (LASIK) is a procedure that can reduce or eliminate your dependency on glasses or contact lenses. This corrective service is available to you and your eligible dependents at a special discount (20-50%) with your Superior Vision plan.

Contact QualSight LASIK at (877) 201-3602 for more information.

Hearing discounts5 A National Hearing Network of hearing care professionals, featuring Your Hearing Network, offers Superior Vision members discounts on services, hearing aids and accessories. These discounts should be verified prior to service.

$55 / $110 / $150 / $225 $50 / $70 / $85 / $120 $75 $80 $80 / $120

All allowances are retail; the member is responsible for paying the provider directly for all non-covered items and/or any amount over the allowances, minus available discounts. These are not covered by the plan.

North Carolina residents: Please contact our customer service department if you are unable to secure a timely (at least 30 days) appointment with your provider or need assistance finding a provider within a reasonable distance (30 miles) of your residence. Adjustments to your benefits may be available

* The above table highlights some of the most popular lens type and is not a complete listing. This table outlines member out-of-pocket costs5 and are not available for premium/upgraded options unless otherwise noted.

5

Not all providers participate in Superior Vision Discounts, including the member out-of-pocket features. Call your provider prior to scheduling an appointment to confirm if he/she offers the discount and member out-of-pocket features. The discount and member out-of-pocket features are not insurance. Discounts and member out-of-pocket are subject to change without notice and do not apply if prohibited by the manufacturer. Lens options may not be available from all Superior Vision providers/all locations.

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

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

Superior Vision Services, Inc. P.O. Box 967 Rancho Cordova, CA 95741 (800) 507-3800 superiorvision.com The Superior Vision Plan is underwritten by National Guardian Life Insurance Company. National Guardian Life Insurance Company is not affiliated with The Guardian Life Insurance Company of America, AKA The Guardian or Guardian Life NVIGRP 5-07 0421-BSv2/NC

18

Basic Term Life / AD&D

Plan Design for: Gates County Government For All Active Full Time Employees working at least 37 hours per week Basic Life

$15,000

Accidental Death & Dismemberment

An amount equal to Your Basic Life Insurance.

Plan Maximum

$15,000

Non-Medical Maximum

$15,000

Age Reduction Formula

Reduces by 35% at age 65, and to 50% of the original amount at age 70

Employee Contribution  Basic Life  AD&D

0% 0%

1

Term Life Features 2  Continuation of Life insurance while totally disabled as defined by the Group Policy 3  Total Control Account i

AD&D Features 4  Seat Belt Benefit  Common Carrier Benefit  Air Bag Benefit  Total Control Account

Copyright 2013. All rights reserved.

EN-BLIFE Enhanced Basic Life GCERT2000 Plan Summary

L0813339397[exp0915][All States][DC,GU,MP,PR,VI] Metropolitan Life Insurance Company, 200 Park Ave., New York, NY 10166

19

What Is Not Covered?

Like most insurance plans, this plan has exclusions. In addition, a reduction schedule may apply. Please see your benefits administrator or certificate for specific details.

Accidental Death & Dismemberment insurance does not include payment for any loss which is caused by or contributed to by: physical or mental illness, diagnosis of or treatment of the illness; an infection, unless caused by an external wound accidentally sustained; suicide or attempted suicide; injuring oneself on purpose; the voluntary intake or use by any means of any drug, medication or sedative, unless taken as prescribed by a doctor or an over-the-counter drug taken as directed; voluntary intake of alcohol in combination with any drug, medication or sedative; war, whether declared or undeclared, or act of war, insurrection, rebellion or riot; committing or trying to commit a felony; any poison, fumes or gas, voluntarily taken, administered or absorbed; service in the armed forces of any country or international authority, except the United States National Guard; operating, learning to operate, or serving as a member of a crew of an aircraft; while in any aircraft for the purpose of descent from such aircraft while in flight (except for self preservation); or operating a vehicle or device while intoxicated as defined by the laws of the jurisdiction in which the accident occurs.

Life and AD&D coverages are provided under a group insurance policy (Policy Form GPNP99 or G2130-S) issued to your employer by MetLife. Life and AD&D coverages under your employer’s plan terminates when your employment ceases when your Life and AD&D contributions cease, or upon termination of the group insurance policy. Should your life insurance coverage terminate for reasons other than non-payment of premium, you may convert it to a MetLife individual permanent policy without providing medical evidence of insurability.

This summary provides an overview of your plan’s benefits. These benefits are subject to the terms and conditions of the contract between MetLife and your employer. Specific details regarding these provisions can be found in the certificate. If you have additional questions regarding the Life Insurance program underwritten by MetLife, please contact your benefits administrator or MetLife. Like most group life insurance policies, MetLife group policies contain exclusions, limitations, terms and conditions for keeping them in force. Please see your certificate for complete details.

1 Features may vary depending on jurisdiction.

2 Total disability or totally disabled means your inability to do your job and any other job for which you may be fit by education, training or experience, due to injury or sickness. Please note that this benefit is only available after you have participated in the Basic/Supplemental Term Life Plan for 1 year and it is only available to the employee.

3 The Total Control Account (TCA) is provided for all Life and AD&D benefits of $5,000 or more. The TCA is not insured by the Federal Deposit Insurance Corporation or any government agency. The assets backing TCAs are maintained in MetLife’s general account and are subject to MetLife’s creditors. MetLife bears the investment risk of the assets backing the TCAs, and expects to receive a profit. Regardless of the investment experience of such assets, the interest credited to TCAs will never fall below the guaranteed minimum rate. Guarantees are subject to the financial strength and claims paying ability of MetLife.

4 The Seat Belt Benefit is payable if an insured person dies as a result of injuries sustained in an accident while driving or riding in a private passenger car and wearing a properly fastened seat belt _or a child restraint if the insured is a child_. In such case, his or her benefit can be increased by 10 percent of the Full Amount — but not less than $1,000 or more than $25,000.

Copyright 2013. All rights reserved.

EN-BLIFE Enhanced Basic Life GCERT2000 Plan Summary

L0813339397[exp0915][All States][DC,GU,MP,PR,VI] Metropolitan Life Insurance Company, 200 Park Ave., New York, NY 10166

20

Supplemental Term Life

Plan Design for: Gates County Government For All Active Full Time Employees working at least 37 hours per week Build Your Benefit With MetLife's Supplemental Term Life insurance, your employer gives you the opportunity to buy valuable life insurance coverage for yourself, your spouse and your dependent children -- all at affordable group rates.

Employee

Spouse & Child Spouse

Life Coverage: provides a benefit in the event of death Schedules: Non Medical Maximum Overall Benefit Maximum AD&D Coverage: provides a benefit in the event of death or dismemberment resulting from a covered accident Schedules:

AD&D Maximum

Employee Contribution

1

Child

2

Increments of $10,000

Increments of $5,000

Flat Amount: $1,000, $2,000, $4,000, $5,000, or $10,000

$100,000

$25,000

$10,000

The lesser of 5 times Your Basic Annual Earnings, or $250,000

$100,000

$10,000

Yes (benefit amount is same as Supplemental Term Life coverage)

Yes (benefit amount is same as Supplemental Term Life coverage)

Yes (benefit amount is same as Supplemental Term Life coverage)

Maximum amount is same as Supplemental Term Life coverage

Maximum amount is same as Supplemental Term Life coverage

Maximum amount is same as Supplemental Term Life coverage

100%

100%

100%

Any purchase or increase in benefits, which does not take place within 31 days of employee’s or dependent's eligibility effective date is subject to evidence of insurability. Coverage is subject to the approval of MetLife.

To request coverage: 1. Choose the amount of employee coverage that you want to buy.

2. Look up the premium costs for your age group for the coverage amount you are selecting on the chart below.

3. Choose the amount of coverage you want to buy for your spouse. Again, find the premium costs on the chart below.

Note: Premiums are based on your age, not your spouse’s.

4. Choose the amount of coverage you want to buy for your dependent children. The premium costs for each coverage option are shown below.

5. Fill in the enrollment form with the amounts of coverage you are selecting. (To request coverage over the non-medical maximum, please see your Human Resources representative for a medical questionnaire that you will need to complete.) Remember, you must purchase coverage for yourself in order to purchase coverage for your spouse or children.

L0314365531[exp0316] [All States][DC,GU,MP,PR,VI] Metropolitan Life Insurance Company, 200 Park Ave., New York, NY 10166

Copyright 2011. All rights reserved.

Supplemental Term Life Summary GCert 2000

21

Employee Age Under 30 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70+

Employee & Spouse Coverage -- Monthly Premium For: $1,000 $0.11 $0.13 $0.16 $0.26 $0.37 $0.66 $1.27 $1.86 $2.96 $5.33

$10,000 $1.07 $1.33 $1.61 $2.63 $3.72 $6.63 $12.71 $18.56 $29.61 $53.30

$20,000 $2.14 $2.66 $3.22 $5.26 $7.44 $13.26 $25.42 $37.12 $59.22 $106.60

$40,000 $4.28 $5.32 $6.44 $10.52 $14.88 $26.52 $50.84 $74.24 $118.44 $213.20

Due to rounding, your actual payroll deduction amount may vary slightly.

$50,000 $5.35 $6.65 $8.05 $13.15 $18.60 $33.15 $63.55 $92.80 $148.05 $266.50

$100,000 $10.70 $13.30 $16.10 $26.30 $37.20 $66.30 $127.10 $185.60 $296.10 $533.00

Dependent Child 3 Coverage Monthly Premium For: $1,000

$0.21

$2,000

$0.42

$4,000

$0.83

$5,000

$1.04

$10,000

$2.08

Features available with Supplemental Life

Will Preparation Service† Like life insurance, a carefully prepared Will is important. With a Will, you can define your most important decisions such as who will care for your children or inherit your property. By enrolling for Supplemental Term Life coverage, you will have in person access to Hyatt Legal Plans' network of 11,500+ participating attorneys for preparing or updating a will, living will and power of attorney. When you enroll in this plan, you may take advantage of this benefit at no additional cost to you if you use a participating plan attorney. To obtain the legal plan's toll-free number and your company's group access number, contact your employer or your plan administrator for this information.

MetLife Estate Resolution Services (ERS)† is a valuable service offered under the group policy. A Hyatt Legal Plan attorney will consult with your beneficiaries by telephone or in person regarding the probate process for your estate. The attorney will also handle the probate of your estate for your executor or administrator.. This can help alleviate the financial and administrative burden upon your loved ones in their time of need.

Portability*: If your present employment ends, you can choose to continue your current life benefits.

What Is Not Covered?

Like most insurance plans, this plan has exclusions. Supplemental and Dependent Life Insurance do not provide payment of benefits for death caused by suicide within the first two years (one year in North Dakota) of the effective date of the certificate, or payment of increased benefits for death caused by suicide within two years (one year in North Dakota or Colorado) of an increase in coverage. In addition, a reduction schedule may apply. Please see your benefits administrator or certificate for specific details.

Accidental Death & Dismemberment insurance does not include payment for any loss which is caused by or contributed to by: physical or mental illness, diagnosis of or treatment of the illness; an infection, unless caused by an external wound accidentally sustained; suicide or attempted suicide; injuring oneself on purpose; the voluntary intake or use by any means of any drug, medication or sedative, unless taken as prescribed by a doctor or an over-the-counter drug taken as directed; voluntary intake of alcohol in combination with any drug, medication or sedative; war, whether declared or undeclared, or act of war, insurrection, rebellion or riot; committing or trying to commit a felony; any poison, fumes or gas, voluntarily taken, administered or absorbed; service in the armed forces of any country or international authority, except the United States National Guard; operating, learning to operate, or serving as a member of a crew of an aircraft; while in any aircraft for the purpose of descent from such aircraft while in flight (except for self preservation); or operating a vehicle or device while intoxicated as defined by the laws of the jurisdiction in which the accident occurs.

Life and AD&D coverages are provided under a group insurance policy (Policy Form GPNP99 or G2130-S) issued to your employer by MetLife. Life and AD&D coverages under your employer’s plan terminates when your employment ceases, when your Life and AD&D contributions cease, or upon termination of the group insurance policy. Dependent Life coverage will terminate when a dependent no longer qualifies as a dependent. Should your life insurance coverage terminate for reasons other than non-payment of premium, you may convert it to a MetLife individual permanent policy without providing medical evidence of insurability.

This summary provides an overview of your plan’s benefits. These benefits are subject to the terms and conditions of the contract between MetLife and your employer and are subject to each state’s laws and availability. Specific details regarding these provisions can be found in the certificate.

If you have additional questions regarding the Life Insurance program underwritten by MetLife, please contact your benefits administrator or MetLife. Like most group life insurance policies, MetLife group policies contain exclusions, limitations, terms and conditions for keeping them in force. Please see your certificate for complete details.

L0314365531[exp0316] [All States][DC,GU,MP,PR,VI] Metropolitan Life Insurance Company, 200 Park Ave., New York, NY 10166

Copyright 2011. All rights reserved.

Supplemental Term Life Summary GCert 2000

22

1. Spouse amount cannot exceed 50% of the employee’s Supplemental Life benefit.

2. Child amount cannot exceed spouse amount.

3. Child benefits for children under 6 months old are limited.

† Will Preparation and MetLife Estate Resolution Services are offered by Hyatt Legal Plans, Inc., Cleveland, Ohio. In certain states, legal

services benefits are provided through insurance coverage underwritten by Metropolitan Property and Casualty Insurance Company and Affiliates, Warwick, Rhode Island. Will Preparation and Estate Resolution Services are subject to regulatory approval and currently available in all states. For New York sitused cases, the Will Preparation service is an expanded offering that includes office consultations and telephone advice for certain other legal matters beyond Will Preparation .

*Subject to state availability. To take advantage of this benefit, coverage of at least $10,000 must be elected.

Life Insurance coverage and Will Preparation Service you may need.

You now have the opportunity to enroll in the MetLife Supplemental Life1 insurance that can financially help protect your loved ones should something happen to you. And when you enroll in Supplemental Life insurance, you have access to another service to protect the ones you love — Will Preparation.2

Having an up-to-date will is one of the most important things you can do for your family.

Like life insurance, a carefully prepared will is important. With a will, you can define your most important decisions such as who will care for your children or inherit your property. The Will Preparation Service also includes the preparation of living wills and power of attorney. By enrolling for Supplemental Life coverage, you will have access to Hyatt Legal Plans’ network of more than 13,000 participating attorneys for preparing or updating these documents at no additional cost to you if you use a Hyatt Legal Plan’s participating attorney.

It’s easy to use the Will Preparation Service.

Once your Supplemental Life coverage becomes effective, you will receive information that will allow you to access the Will Preparation Service.

Step 1: Call Hyatt Legal Plans’ toll-free number 1-800-821-6400, and a Client Service Representative will assist you in locating a participating plan attorney in your area and provide you with a case number.

Step 2: Call and make an appointment with a participating attorney — many plan attorneys even have evening and weekend appointments for your convenience.

Step 3: That’s it! When you use a plan attorney, you do not need to submit any claim forms. You also have the flexibility of using a non-network attorney and being reimbursed for covered services according to a set fee schedule.3 Supplemental Life Insurance and Will Preparation Service are two important ways to protect yourself — and the ones you love.

1

Supplemental Life includes the Buy-Up portion of Core Buy-Up for Small Business.

2

Will Preparation Services are offered by Hyatt Legal Plans, Inc., Cleveland, Ohio. In certain states, legal services benefits are provided through insurance coverage underwritten by Metropolitan Property and Casualty Insurance Company and affiliates, Warwick, Rhode Island. For New York-sitused cases, the Will Preparation Service is an expanded offering that includes office consultations and telephone advice for certain other legal matters beyond Will Preparation.

3

If you chose a non-network attorney, you will be responsible for any attorneys’ fees that exceed the reimbursed amount.

Metropolitan Life Insurance Company 200 Park Avenue, New York, NY 10166, www.metlife.com 1405-1288 L0514373599[exp0715][All States][DC,GU,MP,PR,VI] © 2014 METLIFE, INC. PEANUTS © 2014 Peanuts Worldwide LLC

23

FLEXIBLE SPENDING ACCOUNTS

You made a great decision by enrolling in a flexible spending account (FSA) and/or dependent care account (DCA)! Now that you’ve gotten the difficult decisions out of the way, use this packet to learn how to best take advantage of your account. Let’s get started!

HOW YOUR FSA WORKS

Your FSA is a spending account that can be used to pay for a variety of healthcare expenses.

TWO GREAT PERKS COME WITH YOUR FSA: 1

You will have access to your entire election on the first day of the plan year.

2

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. That means you are increasing your take-home pay simply by participating!

WHAT CAN I SPEND MY FSA FUNDS ON? 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.

Certain over-the-counter (OTC) Diabetic equipment healthcare expenses such as and supplies, durable Band-aids, medicine, First Aid medical equipment, supplies, etc. Note: OTC and qualified medical medicines require a doctor’s products or services prescription to be eligible. provided by a doctor. ___________________________________________________________________________________________________________________ Routine exams, dental care, prescription drugs, eye care, and hearing aids.

Prescription glasses and sunglasses.

HOW YOUR DCA WORKS

Your DCA is a spending account that can be used to pay for services like daycare, nursery school, and elder care. By simply participating in a DCA, you get to experience benefits like:

1

A higher take-home pay thanks to your pre-tax payroll deductions

2

Savings on daycare and other dependent care services you’re already paying for

3

Easy-to-use MyAmeriflex Debit Mastercard to make purchases

WHAT CAN I SPEND MY DCA FUNDS ON?

The IRS determines what expenses are eligible under a DCA. Here are some examples of common eligible expenses

Summer day camp

Daycare Custodial care for dependent adults

Before and after school programs Nanny service

24

Nursery school

Pre-school

GETTING STARTED CHECKLIST Use this checklist to take full advantage of all the great resources made available to you through your Flexible Spending Account and/or Dependent Care Account.

1

2

3

4

5

6

Set up your MyAmeriflex account MyAmeriflex is where you’ll have real-time access to all of your account information, including your current balance, transaction history, payment status, and more. To register your account, visit myameriflex.com, select “Login to your account,” and click “Participants.” Then click the “New User” link to get started. You will be asked to enter an Employee ID, which will be your Social Security number with no dashes or spaces, as well as a Registration ID, which will either be your Ameriflex Debit Mastercard number or Employer ID. If you don’t know your Employer ID, please reach out to your HR representative or contact the Ameriflex Participants Services team at 888.868.FLEX (3539).

Download mobile app The MyAmeriflex App lets you access and manage your account anywhere you go, 24/7. It puts all of the great features of the MyAmeriflex Portal right at your fingertips. You can download the app on the Apple App Store and Google Play.

Register for complimentary ID theft protection Ameriflex is pleased to offer our cardholders complimentary access to Mastercard’s comprehensive Identity Theft Protection program*, powered by CSID®. You can rest assured knowing that if your MyAmeriflex Debit Mastercard (or any other debit/credit cards you choose to register!) gets misplaced or stolen, you can utilize Mastercard’s industry-leading ID theft protection and restoration services for everything you may need. To register, visit myameriflex.com/IDtheftprotection.

Use your card You will receive a MyAmeriflex Debit Mastercard that can be used to make eligible purchases. Your card will be mailed within 7-10 business days after your enrollment is processed by Ameriflex.

Enroll for direct deposit By enrolling for direct deposit, getting reimbursed is easier and faster anytime you need to pay for an eligible expenses out of pocket. Login to MyAmeriflex to set up direct deposit.

Start spending You’re ready to make purchases! Be sure to hang on to your receipts anytime you make a purchase. Login to MyAmeriflex for a full list of eligible expenses.

The “Use It or Lose It” 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 it or lose it” 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.

25

How do I pay for eligible expenses?

Using Your MyAmeriflex Debit Mastercard® The easiest way to pay for eligible expenses is to use your MyAmeriflex Debit Mastercard®, which provides you with access to your FSA accounts (healthcare or dependent care) with a single card. The MyAmeriflex Card works just like a regular debit card, but with three important differences: Its use is limited to specific merchants* and to expenses deemed eligible by your plan.

• You cannot use your MyAmeriflex Card at an ATM or to obtain “cash back” when making a purchase.

• When using the card at self-service merchant terminals, you may select the ‘credit’ option to sign for your purchase, if offered a choice. If you are prompted to enter a Personal Identification Number (PIN) and do not have it, ask the provider to process the transaction so that you may sign the receipt. (To set up a PIN, register your account online at myameriflex.com/register.)

•

Use of the MyAmeriflex Card is limited to day care providers; medical care providers such as hospitals, doctors’ offices, optometrists, dentist, orthodontists, pharmacies, or other merchants providing prescription and overthe-counter eligible products. Your card cannot be used at non-qualified businesses such as gas stations, retailers, convenience stores, etc.

Filing A Manual Claim If you do not use your MyAmeriflex Card to pay for an eligible expense, you can also pay for the expenses out-ofpocket and then get reimbursed from your FSA by filing a manual claim. To file a manual claim, simply complete the Claim Form (myameriflex.com/claim-form) and send it to Ameriflex along with verification of the claim. Acceptable forms of verification include itemized receipts and the Explanation of Benefits (EOB) from your insurance carrier.

Claims can be submitted through the following methods:

Online: Visit myameriflex.com/register to get started!

Mail: Ameriflex ATTN Claims Department | P.O. Box 269009 | Plano, TX 75026 • Email: claims@myameriflex.com • Fax: 888.631.1038 ATTN Claims Department • Mobile App: Visit myameriflex.com/mobile-app to get started!

• •

Other Helpful Information What if there’s not enough money in my account?

If you charge more than the available balance in your account, the transaction will be denied. You can obtain your current account balance by logging in to your account from the Ameriflex website (myameriflex.com/ register to get started) or by calling the Interactive Voice Response System (available 24/7) at 888.868.FLEX (3539).

Do I need my receipts?

Please save all your receipts as proof that FSA funds were used to pay for eligible expenses! For certain expenses, Ameriflex may need additional information (including receipts) to verify eligibility of the expense and to comply with IRS rules. That’s why it’s important to save your receipts and fax or mail them promptly if requested. Failure to comply could jeopardize the tax-exempt status of your account and cause the card to be deactivated.

26

ALWAYS KNOW EXACTLY HOW MUCH IS IN YOUR ACCOUNT!

Receive balance alerts straight to your cell phone upon your request. For instructions on how to set it up, visit: myameriflex.com/ text-my-balance

FREQUENTLY ASKED QUESTIONS

How do I check my account balance? You can check your real-time balance online by logging into MyAmeriflex or through the MyAmeriflex Mobile App. Ameriflex also provides 24/7 access to automated account information via telephone. Call 888.868.FLEX (3539) and follow the prompts to listen to balance and transaction information for your account.

How do I order a new card? You can request a free replacement card online through your Ameriflex account or through the MyAmeriflex Mobile App. What happens if I don’t use my FSA account balance by the end the year? By law, employers are not allowed to return leftover money to participants. Furthermore, funds are forfeited if you leave your employer.

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.

How do these programs save me money on taxes? Since the accounts are tax-advantaged, you get to leverage pretax payroll deductions -- increasing your take-home pay and saving you money on everyday expenses. In many cases, you can experience savings of up to 40% on expenses eligible under your employer-sponsored plan.

Can I change my annual election amount? FSA elections are irrevocable and cannot be changed during the period of coverage unless there is a permitted change in election event, such as a change in marital status, birth or adoption of a child, change in an employment status, etc. The event and contribution change must coincide.

How can I change my reimbursement setting to add direct deposit? To set up direct deposit, simply login to MyAmeriflex, select reimbursement settings under the my account tab, then enter your banking information. We also offer a paper direct deposit form that can be mailed, faxed, or emailed to Ameriflex.

Will pre-taxing have an impact on Social Security benefits? Reductions in your taxable pay may lead to a reduction in Social Security benefits; however, for most employees, the reduction in Social Security benefits is insignificant when compared to the value of paying lower taxes now.

Tax Credits vs. Dependent Care Spending Accounts If you participate in a Dependent Care Spending Account, you cannot claim credits on your income tax return for the same expenses. Also, any amount reimbursed under this plan will reduce the amount of other dependent care expenses that you can claim for purposes of tax credits. Before you enroll in a Dependent Day Care Account, evaluate whether the federal income tax credit or the Dependent Care Spending Account is best for you.

ONE-TIME CLAIM FOR DEPENDENT CARE SERVICES Ameriflex makes it easy to get reimbursed automatically from your account as your funds build up during the year. If you’re paying for childcare or elderly care each month, you can avoid submitting a manual claim every month to get reimbursed for expenses you paid out of pocket. All you have to do is submit one Claim Form for the entire year that shows the date range for which childcare/eldercare services will be provided, along with a signature from the service provider on the designated line of the form. As long as the form is signed by the provider, no receipt is needed. Once the recurring claim has been processed, Ameriflex will automatically reimburse you every month with a check or direct deposit as funds in your Dependent Care Account become available.

27

Cancer Insurance Our Cancer Assist plan helps employees protect themselves and their loved ones through their diagnosis, treatment and recovery journey.

Competitive advantages

n

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

n

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

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. receives inpatient or outpatient cancer treatment.

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.

Composite rates.

n

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.

n

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).

n

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

n

HSA compliant.

n

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.

28

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:

n

$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

29

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.

©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

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).

30

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%

31

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.

32

5-20 | 385403

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

PERCENTAGE OF APPLICABLE COVERAGE AMOUNT

Invasive cancer (including all breast cancer)

100%

Non-invasive cancer

25%

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

33

GCI6000 – PLAN 2 – CRITICAL ILLNESS AND CANCER

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

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 is payable for that critical illness.

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

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.

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

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.

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.

34

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.

35

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)

36

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.

37

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.

38

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.

39

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

Individual Short-Term Disability Insurance You never know when a disability could impact your way of life. Fortunately, there’s a way to help protect your income. If an accident or sickness prevents you from earning a paycheck, disability insurance can provide a monthly benefit to help you cover your ongoing expenses.

Can you afford to not protect your paycheck?

You don’t have the same lifestyle expenses as the next person. That’s why you need disability coverage that can be customized to fit your specific needs.

After calculating your monthly expenses, your benefits counselor can help you complete the benefits worksheet.

ESTIMATED MONTHLY EXPENSES

ColonialLife.com

AMOUNT

Mortgage or rent

$

Utilities (electric/gas, phone, water, TV, Internet)

$

Transportation costs (gas, car payments)

$

Food

$

Health (medical needs and prescription drugs)

$

Other

$

TOTAL

$

Benefits worksheet How much coverage do I need?

Monthly benefit amount for off-job accident and off-job sickness: ______________ Choose a monthly benefit amount between $400 and $6,500.* If your plan includes on-job accident/sickness benefits, the benefit is 50% of the off-job amount.

How long will I receive benefits?

Benefit period: _______ months The partial disability benefit period is three months.

When will my total disability benefits start?

After an accident: _______ days

After a sickness: _______ days

*Subject to income requirements

40

ISTD3000 BASE

Product information Total disability definition Totally disabled or total disability means you are: unable to perform the material and substantial duties of your job, not working at any job, and under the regular and appropriate care of a physician.

How partial disability works If you are able to return to work part-time after at least 14 days of being paid for a total disability, you may be able to still receive 50% of your total disability benefit.

Waiver of premium We will waive your premium payments after 90 consecutive days of a covered disability.

Geographical limitations If you are disabled while outside of the United States, Canada or Mexico, you may receive benefits for up to 60 days before you have to return to the U.S. in order to continue receiving benefits.

Issue age Coverage is available from ages 17 to 74.

Keep your coverage You can keep your coverage to age 75 at no additional cost, even if you change jobs, as long as you pay your premiums when they are due.

Premium Your premium is based on your age when you purchase coverage and the amount of coverage you are eligible to buy. Your premium will not change as you age.

For more information, talk with your benefits counselor.

EXCLUSIONS AND LIMITATIONS We will not pay benefits for losses that are caused by, contributed to by or occur as the result of: cosmetic surgery, felonies or illegal occupations, flying, hazardous avocations, intoxicants and narcotics, psychiatric or psychological conditions, racing, semi-professional or professional sports, substance abuse, suicide or injuries which you intentionally do to yourself, war or armed conflict. We will not pay for benefits due to being pregnant before the policy coverage effective date shown in the policy schedule, if medical advice, diagnosis, care or treatment was received or recommended within the one-year period immediately preceding the policy coverage effective date shown on the policy schedule. We will not pay for loss when the disability is a pre-existing condition as described in the policy.

For cost and complete details, see your Colonial Life benefits counselor. Applicable to policy form ISTD3000-NC and rider form ISTD3000-ADIB-NC. This is not an insurance contract and only the actual policy and 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.

41

7-15 | 101629-NC

Individual Short-Term Disability Insurance Health Screening Rider Benefit The optional health screening benefit can help you reduce the risk of serious illness through early detection.

Health screening benefit. ..................................................................................... $50 Maximum of one health screening test per calendar year; subject to a 30-day waiting period following the effective date of the rider

Blood test for triglycerides

Pap smear

Bone marrow testing

PSA (blood test for prostate cancer)

Breast ultrasound

Serum cholesterol test for HDL and LDL levels

CA 15-3 (blood test for breast cancer) CA 125 (blood test for ovarian cancer) Carotid Doppler CEA (blood test for colon cancer) Chest X-ray Colonoscopy Echocardiogram (ECHO) Electrocardiogram (EKG, ECG) Fasting blood glucose test

For more information, talk with your benefits counselor.

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

Flexible sigmoidoscopy Hemoccult stool analysis Mammography

With the health screening benefit: You’re paid regardless of any insurance you have with other companies.

You can keep coverage to age 75 as long as premiums are paid when they are due.

ColonialLife.com

Waiting period means the first 30 days following the rider coverage effective date, during which time no benefits are payable.

For cost and complete details, see your Colonial Life benefits counselor. Applicable to rider form ISTD3000-HS (including state abbreviations where used, for example: ISTD3000-HS-TX). Coverage may vary by state and may not be available in all states.

This is not an insurance contract and only the actual rider provisions will control. ©2016 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.

42

ISTD3000 – HEALTH SCREENING BENEFIT | 7-16 | 101634-1

Individual Short-Term Disability Insurance Psychiatric and Psychological Benefit

Although illnesses and accidents are often associated with disabilities, mental disorders can also leave you unable to earn an income.

If you’re disabled with a covered psychiatric or covered psychological condition, disability insurance from Colonial Life & Accident Insurance Company pays a monthly benefit that can help provide financial support while you focus on recovery.

Psychiatric and psychological benefit There is a maximum six-month benefit period limitation for any one occurrence of a psychiatric or psychological condition. There is a three-month benefit period limitation if you have a three-month benefit period.

For more information, talk with your benefits counselor.

There is a 24-month cumulative lifetime maximum benefit period for all psychiatric or psychological conditions. This maximum includes a combination of total disability and partial disability occurrences.

ColonialLife.com

The psychiatric and psychological benefit is only applicable when combined with the ISTD3000 base policy. The exclusions listed on the ISTD3000 base policy apply, except for the psychiatric or psychological conditions exclusion. For cost and complete details, talk with your Colonial Life benefits counselor. Applicable to policy form ISTD3000 and rider form ISTD3000-ADIB (plus state abbreviations where applicable, for example: ISTD3000-TX and ISTD3000-ADIB-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 and 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.

43

ISTD3000 – PSYCHIATRIC AND PSYCHOLOGICAL BENEFIT | 6-15 | 101630

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

l

Sports-related accidental injury Broken bone Burn Concussion Laceration

l

Back or knee injuries

l 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

l

Portable

l

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.

44

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

Initial Care l

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

l

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

l

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

l

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

l

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

l

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

l

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

l

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

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

l l

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

l

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

l

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

45

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

l

Lodging (family member or companion)................................................$125 per night up to 30 days for

a hotel/motel lodging costs

l

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

l

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

l

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

l

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)

l

l

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

l

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

l

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

l

Accidental Dismemberment l

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

l

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

l

Loss of the sight of both eyes

l

Loss of both hands or both feet

l

Loss of the hearing of both ears

l

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

l

Loss of the ability to speak

l

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

l

Named Insured

$25,000

$100,000

l

Spouse

$25,000

$100,000

l

Child(ren)

$5,000

$20,000

46

Health Screening Benefit

l

$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

l.

Hemoccult stool analysis

l.

Bone marrow testing

l.

Mammography

l.

Breast ultrasound

l.

Pap smear

l.

CA 15-3 (blood test for breast cancer)

l.

PSA (blood test for prostate cancer)

l.

CA125 (blood test for ovarian cancer)

l.

l.

Carotid doppler

Serum cholesterol test to determine level of HDL and LDL

l.

CEA (blood test for colon cancer)

l.

l.

Chest x-ray

Serum protein electrophoresis (blood test for myeloma)

Colonoscopy

l.

l.

Stress test on a bicycle or treadmill

Echocardiogram (ECHO)

l.

l.

Skin cancer biopsy

Electrocardiogram (EKG, ECG)

l.

l.

Thermography

Fasting blood glucose test

l.

l.

ThinPrep pap test

Flexible sigmoidoscopy

l.

l.

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

©2014 Colonial Life & Accident Insurance Company | Colonial Life insurance products are underwritten by Colonial Life & Accident Insurance Company, for which Colonial Life is the marketing brand.

6-14

47

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

48

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.

49

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)

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

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

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

– 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

– 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.

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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.

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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 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.

ColonialLife.com

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

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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

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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

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Whole Life Insurance Life insurance that comes with guarantees — because life doesn’t You can’t predict the future, but you can rest easier knowing you have life insurance with lifelong guarantees.

Whole life insurance provides guaranteed features – cash value accumulation, premium rates and a death benefit (minus any loans and loan interest) – that help ensure those benefits will be there to help protect your family’s way of life.

With this coverage: n Life insurance benefits for the beneficiary are typically tax-free. n You have three opportunities to purchase additional coverage with no proof of good health required if you are 50 or younger with the Guaranteed Purchase Option Rider. n The policy’s built-in terminal illness accelerated death benefit provides up to 75% of the policy’s death benefit (up to $150,000) if you’re diagnosed with a terminal illness.1 n A $3,000 immediate claim payment that can help your designated beneficiary pay for funeral costs or other expenses.

Talk with your Colonial Life benefits counselor to learn more.

ColonialLife.com

n You can take the policy with you even if you change jobs or retire; with no increase in premium.

n Paid-Up at Age 70 or Paid-Up at Age 100

These two plan options allow you to select what age your premium payments will end. You can choose to have your policy paid up when you reach age 70 or 100.

1 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.

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-16576-1

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PIERCE GROUP BENEFITS ADDITIONAL BENEFITS

THE FSA STORE

FLEX SPENDING WITH ZERO GUESSWORK Pierce Group Benefits partners with the FSA Store to provide one convenient location for all your FSA-eligible purchases. Through our partnership, Pierce Group Benefits and FSA Store can help you shop for FSA eligible items and answer the many questions that come along with having a Flexible Spending Account.

• The largest selection of guaranteed FSA-eligible products • 24/7 support, FREE shipping on orders over $50 • Are your health needs eligible? Easily check with our expansive Eligibility List • Need an Rx? We’ll work with you to make getting one easier • Learning Center - Get daily money-saving info • Use your FSA Card or any major credit card

Accessing FSA Store is easy. Simply visit FSAstore.com/PGBFL for the largest selection of guaranteed FSA-eligible products with zero guesswork.

Get $20 off $200+ with code PGBF20. One use per customer.

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General Notice of COBRA Continuation Coverage Rights ** Continuation Coverage Rights Under COBRA** Introduction You are receiving this notice because you recently gained coverage under a group health plan (the Plan). This notice has important information about your right to COBRA continuation coverage, which is a temporary extension of coverage under the Plan. This notice explains COBRA continuation coverage, when it may become available to you and your family, and what you need to do to protect your right to get it. When you become eligible for COBRA, you may also become eligible for other coverage options that may cost less than COBRA continuation coverage.

The right to COBRA continuation coverage was created by a federal law, the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA).

COBRA continuation coverage can become available to you and other members of your family when group health coverage would otherwise end.

For more information about your rights and obligations under the Plan and under federal law, you should review the Plan’s Summary Plan Description or contact the Plan Administrator.

You may have other options available to you when you lose group health coverage. For example, you may be eligible to buy an individual plan through the Health Insurance Marketplace. By enrolling in coverage through the Marketplace, you may qualify for lower costs on your monthly premiums and lower out-of-pocket costs. Additionally, you may qualify for a 30-day special enrollment period for another group health plan for which you are eligible (such as a spouse’s plan), even if that plan generally doesn’t accept late enrollees.

What is COBRA continuation coverage?

COBRA continuation coverage is a continuation of Plan coverage when it would otherwise end because of a life event. This is also called a “qualifying event.” Specific qualifying events are listed later in this notice. After a qualifying event, COBRA continuation coverage must be offered to each person who is a “qualified beneficiary.” You, your spouse, and your dependent children could become qualified beneficiaries if coverage under the Plan is lost because of the qualifying event. Under the Plan, qualified beneficiaries who elect COBRA continuation coverage must pay for COBRA continuation coverage.

If you’re an employee, you’ll become a qualified beneficiary if you lose your coverage under the Plan because of the following qualifying events: • Your hours of employment are reduced, or • Your employment ends for any reason other than your gross misconduct.

If you’re the spouse of an employee, you’ll become a qualified beneficiary if you lose your coverage under the Plan because of the following qualifying events: • Your spouse dies; • Your spouse’s hours of employment are reduced; • Your spouse’s employment ends for any reason other than his or her gross misconduct; • Your spouse becomes entitled to Medicare benefits (under Part A, Part B, or both); or • You become divorced or legally separated from your spouse.

Your dependent children will become qualified beneficiaries if they lose coverage under the Plan because of the following qualifying events: • The parent-employee dies; • The parent-employee’s hours of employment are reduced; • The parent-employee’s employment ends for any reason other than his or her gross misconduct; • The parent-employee becomes entitled to Medicare benefits (Part A, Part B, or both); • The parents become divorced or legally separated; or • The child stops being eligible for coverage under the Plan as a “dependent child.”

Sometimes, filing a proceeding in bankruptcy under title 11 of the United States Code can be a qualifying event. If a proceeding in bankruptcy is filed with respect to Gates County Government, and that bankruptcy results in the loss of coverage of any retired employee covered under the Plan, the retired employee will become a qualified beneficiary. The retired employee’s spouse, surviving spouse, and dependent children will also become qualified beneficiaries if bankruptcy results in the loss of their coverage under the Plan.

When is COBRA continuation coverage available?

The Plan will offer COBRA continuation coverage to qualified beneficiaries only after the Plan Administrator has been notified that a qualifying event has occurred. The employer must notify the Plan Administrator of the following qualifying events: • The end of employment or reduction of hours of employment; • Death of the employee; • Commencement of a proceeding in bankruptcy with respect to the employer; or • The employee’s becoming entitled to Medicare benefits (under Part A, Part B, or both).

For all other qualifying events (divorce or legal separation of the employee and spouse or a dependent child’s losing eligibility for coverage as a dependent child), you must notify the Plan Administrator within 60 days after the qualifying event occurs. You must provide this notice to: Christy Byrum at Gates County Government. Applicable documentation will be required i.e. court order, certificate of coverage etc.

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How is COBRA continuation coverage provided?

Once the Plan Administrator receives notice that a qualifying event has occurred, COBRA continuation coverage will be offered to each of the qualified beneficiaries. Each qualified beneficiary will have an independent right to elect COBRA continuation coverage. Covered employees may elect COBRA continuation coverage on behalf of their spouses, and parents may elect COBRA continuation coverage on behalf of their children.

COBRA continuation coverage is a temporary continuation of coverage that generally lasts for 18 months due to employment termination or reduction of hours of work. Certain qualifying events, or a second qualifying event during the initial period of coverage, may permit a beneficiary to receive a maximum of 36 months of coverage.

There are also ways in which this 18-month period of COBRA continuation coverage can be extended: Disability extension of 18-month period of COBRA continuation coverage If you or anyone in your family covered under the Plan is determined by Social Security to be disabled and you notify the Plan Administrator in a timely fashion, you and your entire family may be entitled to get up to an additional 11 months of COBRA continuation coverage, for a maximum of 29 months. The disability would have to have started at some time before the 60th day of COBRA continuation coverage and must last at least until the end of the 18-month period of COBRA continuation coverage.

Second qualifying event extension of 18-month period of continuation coverage If your family experiences another qualifying event during the 18 months of COBRA continuation coverage, the spouse and dependent children in your family can get up to 18 additional months of COBRA continuation coverage, for a maximum of 36 months, if the Plan is properly notified about the second qualifying event. This extension may be available to the spouse and any dependent children getting COBRA continuation coverage if the employee or former employee dies; becomes entitled to Medicare benefits (under Part A, Part B, or both); gets divorced or legally separated; or if the dependent child stops being eligible under the Plan as a dependent child. This extension is only available if the second qualifying event would have caused the spouse or dependent child to lose coverage under the Plan had the first qualifying event not occurred.

Are there other coverage options besides COBRA Continuation Coverage?

Yes. Instead of enrolling in COBRA continuation coverage, there may be other coverage options for you and your family through the Health Insurance Marketplace, Medicaid, or other group health plan coverage options (such as a spouse’s plan) through what is called a “special enrollment period.” Some of these options may cost less than COBRA continuation coverage. You can learn more about many of these options at www.healthcare.gov.

If you have questions Questions concerning your Plan or your COBRA continuation coverage rights should be addressed to the contact or contacts identified below. For more information about your rights under the Employee Retirement Income Security Act (ERISA), including COBRA, the Patient Protection and Affordable Care Act, and other laws affecting group health plans, contact the nearest Regional or District Office of the U.S. Department of Labor’s Employee Benefits Security Administration (EBSA) in your area or visit www.dol.gov/ebsa. (Addresses and phone numbers of Regional and District EBSA Offices are available through EBSA’s website.) For more information about the Marketplace, visit www.HealthCare.gov.

Keep your Plan informed of address changes To protect your family’s rights, let the Plan Administrator know about any changes in the addresses of family members. You should also keep a copy, for your records, of any notices you send to the Plan Administrator.

Plan contact information: Gates County Government, Christy Byrum PO Box 148, Gatesville, NC 27938 Phone: 252-357-2404 Fax: 252-357-0073 Health: MedCost Benefit Services 165 Kimel Park Dr, Winston-Salem, NC 27103 Phone: 800-217-5097 Dental: AlwaysCare – administered by Starmount Life Insurance Company 8485 Goodwood Boulevard, Baton Rouge, LA 70806 Phone: 888-400-9304 Vision: Superior Vision P.O. Box 967, Rancho Cordova, CA 95741 Phone: 800-507-3800 Flexible Spending and Dependent Care Accounts AmeriFlex 700 East Gate Drive, Mount Laurel, NJ 08054 Phone: 888-868-3539

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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)

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___________ (Date Signed)

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YES! I want to keep my Colonial Life Coverage.

My premiums are no longer being payroll-deducted.

Complete this form and mail it today — along with a check for your premium payment.

Name: ____________________________________ Daytime Telephone Number: (______) ________________________ Mailing Address: ____________________________ Social Security Number or Date of Birth:_____________________ City: ______________________________________ State:_______________________ Zip: _____________________

Policy number(s) to be continued: ______________________,

______________________, ______________________,

______________________,

Which Colonial Life & Accident Insurance do you want to continue? (check one or more) Accident

Disability

Hospital Income

Cancer or Critical Illness

Life

Please choose one of the following payment options:

M 1. Deduct premiums monthly from my bank account.

M 1st-5th M 6th-10th M 11th-15th M 16th-20th M 21st-26th Your draft will occur on one of the dates within the range you have selected. Please include a voided check or Routing #____________________________ and Account #________________________________

_______________________________ Signature of bank account owner

M 2. Bill me directly. (choose one of the following) M Quarterly

(Submit a payment 3 times your monthly premium)

Date: ____________________

M Semi-annually

(Submit a payment 6 times your monthly premium)

M Annually

(Submit a payment 12 times your monthly premium)

Policy Owner’s Signature:______________________________________________

Return To: Colonial Life & Accident Insurance Company P.O. Box 1365 Columbia, South Carolina 29202 1.800.325.4368 (phone) 1.800.561.3082 (fax)

Colonial Life products are underwritten by Colonial Life & Accident Insurance Company, for which Colonial Life is the marketing brand.

10-16 18514-16

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CONTACT INFORMATION: ALWAYSCARE- DENTAL INSURANCE

NCLM/MEDCOST - HEALTH INSURANCE If you have questions, please call the Customer Service Contact Center at the number shown on your health plan ID card

• Customer Service: 1-888-729-5433 • Website: www.AlwaysCareBenefits.com

Website: www.MedCost.com/MyMedCost See the inside of your Benefit Booklet for more details on how to access your benefits through NCLM/MedCost!

AMERIFLEX - FLEXIBLE SPENDING ACCOUNTS • 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

• • • •

SUPERIOR - VISION INSURANCE • Customer Service: 1-800-507-3800 • Website: www.superiorvision.com

HARMONY ONLINE ENROLLMENT • See pages 5-6 for online enrollment instructions • Technical Help Desk: 1-866-875-4772

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

METLIFE - TERM LIFE INSURANCE • Customer Service: 1-800-638-6420 • Website: www.metlife.com/mybenefits

TO VIEW YOUR BENEFITS ONLINE Visit www.piercegroupbenefits.com/

gatescountygovernment

For additional information concerning plans offered to employees of Gates County Government, 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.