Pierce Group Benefits 2019 Booklet - 19-20PY (11.4.19) - reduced file size

EMPLOYEE BENEFITS PLAN PIERCE GROUP BENEFITS PLAN YEAR: DECEMBER 1, 2019 - NOVEMBER 30, 2020

ARRANGED BY PIERCE GROUP BENEFITS WWW.PIERCEGROUPBENEFITS.COM

EMPLOYEE BENEFITS GUIDE

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

ENROLLMENT PERIOD: NOVEMBER 5, 2019 - NOVEMBER 11, 2019 EFFECTIVE DATES: DECEMBER 1, 2019 - NOVEMBER 30, 2020 Benefits Plan Overview

page

2

Disability Benefits

page

41

Online Enrollment Instructions

page

5

Accident Benefits

page

48

Health Benefits

page

9

Medical Bridge Benefits

page

52

Dental Benefits

page

19

Life Insurance

page

58

Vision Benefits

page

23

Additional Benefits Available

page

60

Group Term Life Insurance

page

25

Cobra Continuation Of Coverage Rights

page

61

Authorization Form

page

63

Notice Of Insurance Information Practices

page

64

Health Savings Account

page

28

Flexible Spending Accounts

page

29

Cancer Benefits

page

34

Critical Care Benefits

page

37 Rev. 11/04/2019

PRE-TAX & POST-TAX BENEFITS

PIERCE GROUP BENEFITS ENROLLMENT PERIOD: NOVEMBER 5, 2019 - NOVEMBER 11, 2019 EFFECTIVE DATES: DECEMBER 1, 2019 - NOVEMBER 30, 2020

PRE-TAX BENEFITS Dental Insurance

Health Insurance*

BlueCross BlueShield

MetLife

Vision Insurance EyeMed

Health Savings Accounts

HealthEquity • Employee Maximum $3,550/year • Family Maximum $7,100/year

HSA plans can only be established in conjunction with a qualified High-Deductible Health Plan (HDHP). Employee must be enrolled in the Base or Buy-Up HSA plan included in this booklet in order to participate in the Health Savings Account.

Flexible Spending Accounts**

Ameriflex • Medical Reimbursement FSA Maximum: $2,700/year • Limited Purpose FSA Maximum: $2,700/year*** • Dependent Care Reimbursement FSA Maximum: $5,000/year ***Limited Purpose FSA funds can only be used for qualifying vision, dental and orthodontia expenses

Cancer Benefits

Colonial Life

Accident Benefits

Colonial Life

Medical Bridge Benefits Colonial Life

**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 NOVEMBER 30, 2019.

POST-TAX BENEFITS Short-Term Disability Benefits

Long-Term Disability Benefits

Colonial Life

Sun Life

Group Term Life Insurance

Life Insurance

Sun Life

Critical Care Benefits Colonial Life

Employer-Paid Benefit

Colonial Life • Term Life Insurance • Whole Life Insurance

Identity Theft Shield & Life Events Legal Plan

Legal Shield

See Additional Benefits Page

**EMPLOYEES WILL NEED TO RE-ENROLL IN HEALTH BENEFITS IN ORDER TO CONTINUE COVERAGE FOR THE NEW PLAN YEAR BEGINNING DECEMBER 1, 2019.

Please note other 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 must work 30 hours or more per week to participate in benefits.

• New Employees should speak with Human Resources for benefit effective dates following employment.

IMPORTANT FACTS: • The plan year for BlueCross BlueShield Health, MetLife Dental, EyeMed Vision, Colonial Insurance products, Spending Accounts, Health Savings Accounts, Sun Life Long-Term Disability, Sun Life Voluntary Group Term Life and Legal Shield Identity Theft Shield & Life Events Legal Plan lasts from December 1, 2019 through November 30, 2020.

• Deductions for BlueCross BlueShield Health, MetLife Dental, EyeMed Vision, Colonial Insurance products, Spending Accounts, Health Savings Accounts, Sun Life Voluntary Group Term Life and Legal Shield Identity Theft Shield & Life Events Legal Plan will begin December 2019. The Sun Life Basic Group Term Life and Sun Life Long-Term Disability benefits are employer-paid and provided by Pierce Group Benefits.

• 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 Debbie Marshall, Human Resources Manager.

• 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.

• The Colonial Cancer plan and the Health Screening Rider on the Colonial Accident and Colonial Medical Bridge plan have a 30-day waiting period for new enrollees. Coverage, therefore, will not begin until December 31, 2019.

• 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.

FLEXIBLE SPENDING ACCOUNTS / HEALTH SAVINGS ACCOUNTS

If an employee enrolls in an employer-sponsored High Deductible Health Plan, he/she may participate in a Health Savings Account (HSA). If enrolling during annual enrollment, the employer will make an annual contribution of $250.00 to the employee’s HSA – 1/12 will be contributed to your HSA in December and 11/12 contributed in January. Employees hired during the year will receive a pro-rated amount. If the employee is hired before the 15th of the month, the pro-rated amount will be calculated from the first of that month; if hired the 15th or after, the pro-rated amount will be calculated from the next month. If the employee participates in an HSA, he/she may also participate in a Limited Purpose Flexible Spending Account (LPFSA).

-ORIf the employee enrolls in an employer-sponsored Preferred Provider Organization (PPO) plan, the employee may participate in a Flexible Savings Account (FSA). If enrolling during annual enrollment, the employer will make an annual contribution of $250.00 the first of the plan year to the employee’s FSA. Employees hired during the year will receive a pro-rated amount. If the employee is hired before the 15th of the month, the prorated amount will calculated from the first of that month; if hired the 15th or after, the pro-rated amount will be calculated from the next month.

If the employee does not wish to enroll in an employer-sponsored health plan, the employee may still participate in a Flexible Spending Account (FSA) or Limited Purpose Flexible Spending Account (LPFSA). No employer contributions will be made.

3

EMPLOYEE BENEFITS GUIDE

PIERCE GROUP BENEFITS 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: NOVEMBER 5, 2019 - NOVEMBER 11, 2019 YOU CAN MAKE THE FOLLOWING BENEFIT ELECTIONS ONLINE DURING THE ENROLLMENT PERIOD: • • • • • • • •

Enroll, change or cancel your Health Insurance*.

Enroll, change or cancel your Dental Insurance.

Enroll, change or cancel your Vision Insurance.

Enroll, change or cancel your Health Savings Account (HSA).

Sign up/re-enroll in your Flexible Spending Account(s) (Medical, Limited Purpose and Dependent Care)*.

Enroll, change or cancel your Voluntary Group Term Life Insurance.

Enroll, change or cancel your Pre-Paid Legal.

Enroll, change or cancel your Colonial products

*EMPLOYEES WILL NEED TO RE-ENROLL IN HEALTH BENEFITS & SPENDING ACCOUNTS IN ORDER TO CONTINUE COVERAGE FOR THE NEW PLAN YEAR BEGINNING DECEMBER 1, 2019.

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/piercegroupbenefits 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

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

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

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

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

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

1.

2.

3.

4.

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

www.paylocity.com | +1 888.873.8205 | Copyright Š 2017 Paylocity. All Rights Reserved.

5

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

Any field that has an asterisk next to it is required.

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

MAKING BENEFIT ELECTIONS Below is a sample of what the Benefit Election screen will look like.

To review all available plan options, click the View Plan Options link.

www.paylocity.com | +1 888.873.8205 | Copyright © 2017 Paylocity. All Rights Reserved

6

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

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

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

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

www.paylocity.com | +1 888.873.8205 | Copyright Š 2017 Paylocity. All Rights Reserved

7

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

Almost Finished!

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

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

CONFIRMATION

You can send yourself an email confirmation of your elections or print it for your records. Click the printer icon on the right-hand side of the screen.

Note: Although the online benefits enrollment site is a secure site and your information is encrypted during transit, it is important that you log off when you have completed your session. Click the Log Off icon in the upper right-hand corner of the enrollment site to do so. For security purposes, the system will automatically log you out if you leave your system idle for more than 30 minutes.

www.paylocity.com | +1 888.873.8205 | Copyright © 2017 Paylocity. All Rights Reserved

8

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

Deductibles, Out-of-Pocket Limits & Benefit Maximums

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

Embedded Deductibles

Out-of-network 1

In-network

Individual (per Benefit Period) Family (per Benefit Period)

$5,000 $10,000

$10,000 $20,000

Individual (per Benefit Period) Family (per Benefit Period)

$6,650 $13,300

$13,300 $26,600

Unlimited

Unlimited

Embedded Out-of-Pocket Limits

Benefit Maximums:

Lifetime Total Dollar Maximum Lifetime Infertility Benefit Maximum Ovulation Induction Cycles

3 Cycle Limits

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

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

Physical, Occupational and Chiropractic Therapies (combined) Speech Therapy Applied Behavioral Analysis (ABA) Therapy (ages 18 and younger) Skilled Nursing Facility Stay Provider Office visits for the evaluation and treatment of obesity

30 visits 30 visits $40,000 60 days 4

(maximum does not apply to dietician/nutritional visits)

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

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

Primary Care Provider Specialist

Vendor Telehealth

70% after deductible 70% after deductible

40% after deductible 40% after deductible

70% after deductible

Benefits not available

100% no deductible 100% no deductible

70% after deductible* 70% after deductible*

Includes Telehealth services for medical/acute care

Preventive Care (Primary Preventive Diagnosis Only) For the most updated list of general preventive/screenings, immunizations, wellbaby/well-child care, women’s preventive care services, nutritional counseling and other services mandated under Federal law, see our website at bcbsnc.com/preventive.

Primary Care Provider Specialist

*Only state mandated services including, but not limited to, colorectal screening, bone mass measurement, newborn hearing screening, prostate specific antigen tests (PSAs), gynecological exams, cervical cancer screening, ovarian cancer screening and screening mammograms are covered Out-of-Network.

Pierce Group Benefits

Prospect 350452, Quote 5280631

9

Effective Date: 12/2019

Quote Date: 10/08/2019

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

In-network 70% after deductible 70% after deductible 70% after deductible

Out-of-network 1 70% after deductible 70% after deductible 70% after deductible

70% after deductible 70% after deductible

40% after deductible 40% after deductible

70% after deductible

40% after deductible

70% after deductible

40% after deductible

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

40% after deductible 40% after deductible 70% after deductible 70% after deductible 40% after deductible

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

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

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

Inpatient Hospital Services Includes all Inpatient Hospital Services regardless of diagnosis (including, but not limited to, medical, mental health, substance abuse, infertility, therapies, transplants, deliveries, and surgeries.)

Inpatient Hospital Facility Services Inpatient Hospital Professional Services

Outpatient Services

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

Outpatient Diagnostic Services Outpatient lab tests when performed alone (Professional and Facility Services)

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

Pierce Group Benefits

Prospect 350452, Quote 5280631

10

Effective Date: 12/2019

Quote Date: 10/08/2019

Blue OptionsSM with HSA Fund Benefit Highlights (PPO) Prescription Drugs

In-network 100% no deductible

Out-of-network 1 100% no deductible

Preventive OTC Medications and Contraceptive Drugs and Devices as listed at bcbsnc.com/preventive All pharmacy coinsurance amounts below apply after the medical deductible is satisfied, and apply to the medical Out-of-Pocket limit.

MAC B Pricing (Brand Penalty when Generic Equivalent is available and Provider does not require Brand to be dispensed).

Penalty does not count toward OOP Limit. Essential 5 Tier Commercial, Limited NC Network Formulary.

Prior Plan approval, step therapy and quantity limits may apply.

Prescription drugs

70% after deductible

You are responsible for charges over the allowed amount received from an Out-of-Network pharmacy, and those amounts are not included in the Deductible or Out-of-Pocket limit.

Limits apply to Infertility drugs, refer to your benefit booklet.

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

Pierce Group Benefits

Prospect 350452, Quote 5280631

11

Effective Date: 12/2019

Quote Date: 10/08/2019

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

Deductibles, Out-of-Pocket Limits & Benefit Maximums

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

Aggregate Deductibles

Out-of-network 1

In-network

Individual (per Benefit Period) Family Member (per Benefit Period) Family (per Benefit Period)

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

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

Individual (per Benefit Period) Family Member (per Benefit Period) Family (per Benefit Period)

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

$6,250 $11,250 $13,750

Unlimited

Unlimited

Aggregate Out-of-Pocket Limits

Benefit Maximums:

Lifetime Total Dollar Maximum Lifetime Infertility Benefit Maximum Ovulation Induction Cycles

3 Cycle Limits

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

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

Physical, Occupational and Chiropractic Therapies (combined) Speech Therapy Applied Behavioral Analysis (ABA) Therapy (ages 18 and younger) Skilled Nursing Facility Stay Provider Office visits for the evaluation and treatment of obesity

30 visits 30 visits $40,000 60 days 4

(maximum does not apply to dietician/nutritional visits)

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

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

Primary Care Provider Specialist

Vendor Telehealth

100% after deductible 100% after deductible

70% after deductible 70% after deductible

100% after deductible

Benefits not available

100% no deductible 100% no deductible

70% after deductible* 70% after deductible*

Includes Telehealth services for medical/acute care

Preventive Care (Primary Preventive Diagnosis Only) For the most updated list of general preventive/screenings, immunizations, wellbaby/well-child care, women’s preventive care services, nutritional counseling and other services mandated under Federal law, see our website at bcbsnc.com/preventive.

Primary Care Provider Specialist

*Only state mandated services including, but not limited to, colorectal screening, bone mass measurement, newborn hearing screening, prostate specific antigen tests (PSAs), gynecological exams, cervical cancer screening, ovarian cancer screening and screening mammograms are covered Out-of-Network.

Pierce Group Benefits

Prospect 350452, Combo 342468

12

Effective Date: 12/2019

Quote Date: 10/08/2019

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

In-network 100% after deductible 100% after deductible 100% after deductible

Out-of-network 1 100% after deductible 100% after deductible 100% after deductible

100% after deductible 100% after deductible

70% after deductible 70% after deductible

100% after deductible

70% after deductible

100% after deductible

70% after deductible

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

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

100% after deductible 100% after deductible 100% after deductible 100% after deductible

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

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

Inpatient Hospital Services Includes all Inpatient Hospital Services regardless of diagnosis (including, but not limited to, medical, mental health, substance abuse, infertility, therapies, transplants, deliveries, and surgeries.)

Inpatient Hospital Facility Services Inpatient Hospital Professional Services

Outpatient Services

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

Outpatient Diagnostic Services Outpatient lab tests when performed alone (Professional and Facility Services)

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

Pierce Group Benefits

Prospect 350452, Combo 342468

13

Effective Date: 12/2019

Quote Date: 10/08/2019

Blue OptionsSM with HSA Fund Benefit Highlights (PPO) Prescription Drugs

In-network 100% no deductible

Out-of-network 1 100% no deductible

Preventive OTC Medications and Contraceptive Drugs and Devices as listed at bcbsnc.com/preventive All pharmacy coinsurance amounts below apply after the medical deductible is satisfied, and apply to the medical Out-of-Pocket limit.

MAC B Pricing (Brand Penalty when Generic Equivalent is available and Provider does not require Brand to be dispensed).

Penalty does not count toward OOP Limit. Essential 5 Tier Commercial, Limited NC Network Formulary.

Prior Plan approval, step therapy and quantity limits may apply.

Prescription drugs

100% after deductible

You are responsible for charges over the allowed amount received from an Out-of-Network pharmacy, and those amounts are not included in the Deductible or Out-of-Pocket limit.

Limits apply to Infertility drugs, refer to your benefit booklet.

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

Pierce Group Benefits

Prospect 350452, Combo 342468

14

Effective Date: 12/2019

Quote Date: 10/08/2019

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

Deductibles, Out-of-Pocket Limits & Benefit Maximums

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

Embedded Deductibles

Out-of-network 1

In-network

Individual (per Benefit Period) Family (per Benefit Period)

$3,500 $7,000

$7,000 $14,000

Individual (per Benefit Period) Family (per Benefit Period)

$7,150 $14,300

$14,300 $28,600

Unlimited

Unlimited

Embedded Out-of-Pocket Limits

Benefit Maximums:

Lifetime Total Dollar Maximum Lifetime Infertility Benefit Maximum Ovulation Induction Cycles

3 Cycle Limits

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

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

Physical, Occupational and Chiropractic Therapies (combined) Speech Therapy Applied Behavioral Analysis (ABA) Therapy (ages 18 and younger) Skilled Nursing Facility Stay Provider Office visits for the evaluation and treatment of obesity

30 visits 30 visits $40,000 60 days 4

(maximum does not apply to dietician/nutritional visits)

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

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

Primary Care Provider Specialist

Vendor Telehealth

$35 $70

50% after deductible 50% after deductible $35

Benefits not available

100% no deductible 100% no deductible

70% after deductible* 70% after deductible*

Includes Telehealth services for medical/acute care

Preventive Care (Primary Preventive Diagnosis Only) For the most updated list of general preventive/screenings, immunizations, wellbaby/well-child care, women’s preventive care services, nutritional counseling and other services mandated under Federal law, see our website at bcbsnc.com/preventive.

Primary Care Provider Specialist

*Only state mandated services including, but not limited to, colorectal screening, bone mass measurement, newborn hearing screening, prostate specific antigen tests (PSAs), gynecological exams, cervical cancer screening, ovarian cancer screening and screening mammograms are covered Out-of-Network.

Pierce Group Benefits

Prospect 350452, Quote 5280630

15

Effective Date: 12/2019

Quote Date: 10/08/2019

Blue OptionsSM Benefit Highlights (PPO) Urgent and Emergency Care Urgent Care Centers Emergency Room Visit* Ambulance

In-network $75 $500 80% after deductible

Out-of-network 1 $75 $500 80% after deductible

80% after deductible 80% after deductible

50% after deductible 50% after deductible

80% after deductible

50% after deductible

100% no deductible

70% after deductible

100% no deductible 80% after deductible 100% no deductible 80% after deductible

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

80% after deductible 80% after deductible 80% after deductible 80% after deductible

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

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

Inpatient Hospital Services Includes all Inpatient Hospital Services regardless of diagnosis (including, but not limited to, medical, mental health, substance abuse, infertility, therapies, transplants, deliveries, and surgeries.)

Inpatient Hospital Facility Services Inpatient Hospital Professional Services

Outpatient Services

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

Outpatient Diagnostic Services Outpatient lab tests when performed alone (Professional and Facility Services)

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

Pierce Group Benefits

Prospect 350452, Quote 5280630

16

Effective Date: 12/2019

Quote Date: 10/08/2019

Blue OptionsSM Benefit Highlights (PPO) Prescription Drugs

In-network 100% no deductible

Out-of-network 1 100% no deductible

Preventive OTC Medications and Contraceptive Drugs and Devices as listed at bcbsnc.com/preventive Up to 30 day supply. 31-60 day supply is two copayments and 61-90 day supply is three copayments.

Prescription Drug copayments*, coinsurance* and deductibles* (*if applicable) apply to the Out-of-Pocket limit.

MAC B Pricing (Brand Penalty when Generic Equivalent is available and Provider does not require Brand to be dispensed).

Penalty does not count toward OOP Limit. Essential 5 Tier Commercial, Limited NC Network Formulary.

Prior Plan approval, step therapy and quantity limits may apply.

Tier 1 Drugs $10 $10 Tier 2 Drugs $25 $25 Tier 3 Drugs $40 $40 Tier 4 Drugs $80 $80 Tier 5 Drugs 75% 75% There is a $100 per Prescription Minimum and a $200 per Prescription Maximum for each 30-day supply of Tier 5 drugs.

You are responsible for charges over the allowed amount received from an Out-of-Network pharmacy.

Limits apply to Infertility drugs, refer to your benefit booklet.

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

Pierce Group Benefits

Prospect 350452, Quote 5280630

17

Effective Date: 12/2019

Quote Date: 10/08/2019

Pierce Group Benefits December 1, 2019 - November 30, 2020

BLUE OPTIONS HSA BASE HSA PLAN Monthly Premium Employer Contribution Employee Contrbution Monthly Employee Contribution (24 deductions)

BLUE OPTIONS BUY-UP HSA Monthly Premium Employer Contribution Employee Contribution Monthly Employee Contribution (24 deductions)

BLUE OPTIONS BUY-UP PPO PLAN Monthly Premium Employer Contribution Employee Contribution Monthly Employee Contribution (24 deductions)

Employee Only

Employee/ Spouse

Employee/ Child(ren)

Family

$290.97 $290.97 $0.00 $0.00

$581.94 $411.01 $170.93 $85.47

$538.29 $411.01 $127.28 $63.64

$902.00 $411.01 $490.99 $245.50

Employee Only

Employee/ Spouse

Employee/ Child(ren)

Family

$443.96 $411.01 $32.95 $16.48

$857.28 $411.01 $446.27 $223.14

$821.30 $411.01 $410.29 $205.15

$1,376.28 $411.01 $965.27 $482.64

Employee Only

Employee/ Spouse

Employee/ Child(ren)

Family

$495.92 $411.01 $84.91 $42.46

$991.84 $411.01 $580.83 $290.42

$917.42 $411.01 $506.41 $253.21

$1,537.35 $411.01 $1,126.34 $563.17

18

De ntal - LOW PLAN Metropolitan Life Insurance Company

Plan Design for: Pierce Group Benefits Date Prepared: October 13, 2019 The Preferred Dentist Program was designed to help you get the dental care you need and help lower your costs. You get benefi ts for a wide range of covered services — both in and out of the network. The goal is to deliver affordable protection for a health ier smile and a healthier you.

Coverage Type:

Deductible3 Individual Family

Annual Maximum Benefit: Per Individual

2.

3.

4.

Out-of-Network1

$50 $150

$50 $150

$1000

$1000

% of PDP Fee 100% 80% 0%

Type A - Preventive Type B - Basic Restorative Type C - Major Restorative

1.

In-Network1

2

% of R&C Fee4 100% 80% 0%

"In-Netw ork Benefits" refers to benefits provided under this plan for covered dental services that are provided by a participating dentist. "Out-of-Netw ork Benefits" refers to benefits provided under this plan for covered dental services that are not provided by a participating dentist.

Negotiated fees refer to the fees that participating dentists have agreed to accept as payment in full for covered services, subject to any copayments, deductibles, cost sharing and benefits maximums. Negotiated fees are subject to change.

Applies to Type B and C services only.

Out-of-netw ork benefits are payable for services rendered by a dentist w ho is not a participating provider. The Reasonable and Customary charge is based on the low est of:  the dentist’s actual charge (the 'Actual Charge'),  the dentist’s usual charge for the same or similar services (the 'Usual Charge') or  the usual charge of most dentists in the same geographic area for the same or similar services as determined by MetLife (the 'Customary Charge'). For your plan, the Customary Charge is based on the 90th percentile. Services must be necessary in terms of generally accepted dental standards.

Employee Cost per Month Employee Only: Employee and Spouse: Employee and Child(ren): Family:

$0.00 $24.37 $38.66 $70.22

DN-GCERT- GOLD GCERT ER Dental Benefit Summary

19

200 Park Ave., New York, NY 10166 © 2019 MetLife Services and Solutions, LLC L0819517636[exp1020][xNM]

Selected Covered Services and Frequency Limitations* Type A - Preventive Oral Examinations Bitewing X-rays (Adult/Child) Prophylaxis - Cleanings Topical Fluoride Applications Sealants Space Maintainers

Type B - Basic Restorative

Full Mouth X-rays Amalgam and Composite Fillings Oral Surgery (Simple Extractions) Emergency Palliative Treatment

How Many/How Often: 2 in 12 months 1 in 12 months 2 in 12 months 1 in 12 months - Children to age 14 1 in 36 months - Children to age 16 No limit - Children up to age 14

How Many/How Often:

1 in 12 months 1 in 24 months. All teeth

Type C - Major Restorative

How Many/How Often:

TYPE C SERVICES ARE NOT COVERED WITH THIS COVERAGE TYPE.

*Alternate Benefits: Where two or more professionally acceptable dental treatments for a dental condition exist, reimbursement is based on the least costly treatment alternative. If you and your dentist have agreed on a treatment that is more costly than the treatment upon which the plan benefit is based, you will be responsible for any additional payment responsibility. To avoid any misunderstandings, we sugg est you discuss treatment options wi th your dentist before services are rendered, and obtain a pretreatment estimate of benefits prior to receiving certain high cost services such as crowns, bridges or dentures. You and your dentist will each receive an Explanation of Benefits (EOB) ou tlining the services provided, your plan’s reimbursement for those services, and your out -of-pocket expense. Actual payments may vary from the pretreatment estimate depending upon annual maximums, plan frequency limits, deductibles and other limits applicable at time of payment.

The service categories and plan limitations shown above represent an overview of your Plan of Benefits. This document present s many services within each category, but is not a complete description of the Plan. Please see your Plan description/Insurance certificate for complete details. In the event of a conflict with this summary, the terms of your insurance certificate will govern.

DN-GCERT- GOLD GCERT ER Dental Benefit Summary

20

200 Park Ave., New York, NY 10166 Š 2019 MetLife Services and Solutions, LLC L0819517636[exp1020][xNM]

De ntal - HIGH PLAN Metropolitan Life Insurance Company

Plan Design for: Pierce Group Benefits Date Prepared: October 13, 2019 The Preferred Dentist Program was designed to help you get the dental care you need and help lower your costs. You get benefi ts for a wide range of covered services — both in and out of the network. The goal is to deliver affordable protection for a health ier smile and a healthier you.

Coverage Type:

Deductible3 Individual Family

Annual Maximum Benefit: Per Individual

1.

2.

3.

4.

Out-of-Network1

$50 $150

$50 $150

$1500

$1500

% of PDP Fee 100% 80% 50% 50%

Type A - Preventive Type B - Basic Restorative Type C - Major Restorative Type D - Orthodontia

Orthodontia Lifetime Maximum Ortho applies to Child Only

In-Network1

2

$1500 per Person

% of R&C Fee4 100% 80% 50% 50%

Child to age 19

$1500 per Person

"In-Netw ork Benefits" refers to benefits provided under this plan for covered dental services that are provided by a participating dentist. "Out-of-Netw ork Benefits" refers to benefits provided under this plan for covered dental services that are not provided by a participating dentist.

Negotiated fees refer to the fees that participating dentists have agreed to accept as payment in full for covered services, subject to any copayments, deductibles, cost sharing and benefits maximums. Negotiated fees are subject to change.

Applies to Type B and C services only.

Out-of-netw ork benefit w ill be based on the Reasonable and Customary charge plus a $5.00 R&C Cutback Threshold. For your plan, the Customary Charge is based on the 90th percentile. Below are the three scenarios that determine how the Out-of-netw ork Reasonable and Customary charge w ill be adjusted to apply the $5.00. R&C Cutback Threshold:  If the amount charged by the Dentist for a Covered Service is less than the R&C charge, then the benefit w ill be based on the Dentist’s Charge.  If the amount charged by the Dentist for a Covered Service is less than or equal to the R&C charge plus the Threshold dollar amount, then the benefit w ill be based on the Dentist’s Charge.  If the amount charged by the Dentist for a Covered Service is greater than the R&C charge plus the Threshold dollar amount, then the benefit w ill be based on the R&C Charge.

Employee Cost per Month Employee Only: $13.89 Employee and Spouse: $51.10 Employee and Child(ren): $65.91 Family: $112.76

DN-GCERT- GOLD GCERT ER Dental Benefit Summary

21

200 Park Ave., New York, NY 10166 © 2019 MetLife Services and Solutions, LLC L0819517636[exp1020][xNM]

Selected Covered Services and Frequency Limitations* Type A - Preventive Oral Examinations Bitewing X-rays (Adult/Child) Prophylaxis - Cleanings Topical Fluoride Applications Sealants Space Maintainers

Type B - Basic Restorative Y4

Full Mouth X-rays Amalgam and Composite Fillings Oral Surgery (Simple Extractions) Emergency Palliative Treatment

How Many/How Often: 2 in 12 months 1 in 12 months 2 in 12 months 1 in 12 months - Children to age 16 1 in 36 months - Children to age 16 1 per lifetime per tooth area - Children up to age 16

How Many/How Often:

1 in 60 months 1 in 24 months. All teeth

Type C - Major Restorative Crowns/Inlays/Onlays Prefabricated Crowns Repairs Endodontics Root Canal Periodontal Surgery Periodontal Scaling & Root Planing Periodontal Maintenance Oral Surgery (Surgical Extractions) Other Oral Surgery Bridges Dentures General Anesthesia Consultations Implant Services

How Many/How Often: 1 per tooth in 5 years 1 per tooth in 5 years 1 in 12 months 1 per tooth in 24 months 1 in 36 months per quadrant 1 in 24 months per quadrant 2 in 1 year, includes 2 cleanings 1 in 5 years 1 in 5 years 1 in 12 months 1 service per tooth in 5 years - 1 repair per 12 months

Type D – Orthodontia    

Dependent children up to age 19. Age limitations may vary by state. Please see your Plan description for complete details. In the event of a conflict with this summary, the terms of the certificate will govern.

All dental procedures performed in connection with orthodontic treatment are payable as Orthodontia.

Benefits for the initial placement will not exceed 20% of the Lifetime Maximum Benefit Amount for Orthodontia. Periodic follow -up visits will be payable on a monthly basis during the schedule d course of the orthodontic treatment. Allowable expenses for the initi al placement, periodic follow-up visits and procedures performed in connection with the orthodontic treatment, are all subject to the Orthodontia coinsurance level and Lifetime Maximum Benefit Amount as defined in the Plan Summary.

Orthodontic benefits end at cancellation of coverage

Benefit Waiting Period

For employees who elect coverage during the 31-day application period, the following Dental Benefits will become effective after the satisfaction of the waiting period(s) shown below. In the case of the transferred busin ess, if employees elected coverage under the prior plan for which the employees were eligible, the following waiting period(s) will not apply.  Preventive Services ........... No waiting period  Major Services................ 12-month waiting perio d

 Basic Services ............... No waiting period  Orthodontic Services ......... 12-month waiting period if covered

*Alternate Benefits: Where two or more professionally acceptable dental treatments for a dental condition exist, reimbursement is based on the least costly treatment alternative. If you and your dentist have agreed on a treatment that is more costly than the treatment upon which the plan benefit is based, you will be responsible for any additional payment responsibility. To avoid any misunderstandings, we sugg est you discuss treatment options with your dentist before services are rendered, and obtain a pretreatment estimate of benefits prior to receiving certain high cost services such as crowns, bridges or dentures. You and your dentist will each receive an Explanation of Benefits (EOB) ou tlining the services provided, your plan’s reimbursement for those services, and your out -of-pocket expense. Actual payments may vary from the pretreatment estimate depending upon annual maximums, plan frequency limits, deductibles and other limits applicable at time of payment.

The service categories and plan limitations shown above represen t an overview of your Plan of Benefits. This document presents many services within each category, but is not a complete description of the Plan. Please see your Plan description/Insurance certificate for complete details. In the event of a conflict with this summary, the terms of your insurance certificate will govern.

DN-GCERT- GOLD GCERT ER Dental Benefit Summary

22

200 Park Ave., New York, NY 10166 © 2019 MetLife Services and Solutions, LLC L0819517636[exp1020][xNM]

H

Pierce Group Benefits SUMMARY OF BENEFITS

Additional discounts

40%

OFF

Complete pair of prescription eyeglasses

20

%

OFF

Non-prescription sunglasses

20%

OFF

Remaining balance beyond plan coverage These discounts are not insured benefits and are for in-network providers only.

Take a sneak peek before enrolling • You’re on the Insight Network

• For a complete list of in-network providers near you, use our Enhanced Provider Locator on eyemed.com or call 1-866-804-0982

Vision Care Services

In-Network Member Cost

Out of Network Reimbursement

Exam With Dilation as Necessary

$10 Copay

Up to $40

Retinal Imaging

Up to $39

N/A

Frames

$0 Copay; $130 allowance, 20% off balance over $130

Up to $91

Standard Plastic Lenses Single Vision Bifocal Trifocal Lenticular Standard Progressive Lens ∆ Premium Progressive Lens Tier 1 Tier 2 Tier 3 Tier 4

$10 Copay $10 Copay $10 Copay $10 Copay $65 Copay $95 Copay - $185 Copay $95 Copay $105 Copay $120 Copay $185 Copay

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

Lens Options (paid by the member and added to the base price of the lens) UV Treatment $15 Tint (Solid and Gradiant) $15 Standard Plastic Scratch Coating $15 Standard Polycarbonate - age 19 and over $40 Standard Polycarbonate - under age 19 $40 Standard Anti-Reflective Coating $45 ∆ $57 - $85 Premium Anti-Reflective Coating Tier 1 $57 Tier 2 $68 Tier 3 $85 Photochromic/Transitions $75 Polarized 20% off Retail Price Other Add-Ons and Services 20% off Retail Price

N/A N/A N/A N/A N/A Up to $5 Up to $5 Up to $5 Up to $5 Up to $5 N/A N/A N/A

Contact Lens Fit and Follow-up (Contact lens fit and two follow-up visits are available once a comprehensive eye exam has been completed.)

Standard Contact Lens Fit & Follow-Up: $40 N/A Premium Contact Lens Fit & Follow-Up: 10% off Retail Price N/A Contact Lenses (Contact Lens allowance includes materials only) Conventional Disposable Medically Necessary

$0 copay, $130 allowance, 15% off balance over $130 $0 copay, $130 allowance, plus balance over $130 $0 copay, Paid-In-Full

Up to $130 Up to $130 Up to $210

Laser Vision Correction LASIK or PRK from U.S. Laser Network

15% off the retail price or 5% off the promotional price

N/A

Hearing Care Hearing Health Care from Amplifon Hearing Network

40% off hearing exams and low price guarantee on discounted hearing aids

Frequency Examination Lenses (in lieu of contact lenses) Contacts (in lieu of lenses) Frame

Once every 12 months Once every 12 months Once every 12 months Once every 12 months

Monthly Premium Employer Monthly Contribution Employee Monthly Contribution Employee Deduction (24 deductions)

Employee Only $6.31 $6.31 $0.00 $0.00

Employee + 1 $10.17 $6.31 $3.86 $1.93

Family $15.52 $6.31 $9.21 $4.61

• For LASIK providers, call 1-877-5LASER6

QL-0000061486 Premium progressives and premium anti-reflective designations are subject to annual review by EyeMed’s Medical Director and are subject to change based on market conditions. Fixed pricing is reflective of brands at the listed product level . All providers are not required to carry all brands at all levels. Benefits are not provided from services or materials arising from: 1) Orthoptic or vision training, subnormal vision aids and any associated supplemental testing; Aniseikonic lenses; 2) Medical and/or surgical treatment of the eye, eyes or supporting structures; 3) Any eye or Vision Examination, or any corrective eyewear required by a Policyholder as a condition of employment; Safety eyewear; 4) Services provided as a result of anyWorkers’ Compensation law, or similar legislation, or required by any governmental agency or program whether federal, state or subdivisions thereof; 5) Plano (non-prescription) lenses; 6) Non-prescription sunglasses; 7) Two pair of glasses in lieu of bifocals; 8) Services or materials provided by any other group benefit plan providing vision care 9) Services rendered after the date an Insured Person ceases to be covered under the Policy, except when Vision Materials ordered before coverage ended are delivered, and the services rendered to the Insured Person are within 31 days from the date of such order. 10) Lost or broken lenses, frames, glasses, or contact lenses will not be replaced except in the next Benefit Frequency when Vision Materials would next become available. Benefits may not be combined with any discount, promotional offering, or other group benefit plans. Standard/Premium Progressive lens not covered-fund as a Bifocal lens. Standard Progressive lens covered-fund Premium Progressive as a Standard. Benefit allowance provides no remaining balance for future use within the same benefit year. Fees charged for a non-insured benefit must be paid in full to the Provider. Such fees or materials are not covered. ∆

Underwritten by Fidelity Security Life Insurance Company of Kansas City, Missouri, except in New York. Fidelity Security Life Policy number VC-19/VC-20, form number M-9083. This is a snapshot of your benefits. The Certificate of Insurance is on file with your employer.

23

Pierce Group Benefits

24

Basic Life Insurance PROTECTS YOUR LOVED ONES.

Life insurance provides your loved ones with money they can use for household expenses, tuition, mortgage payments and more.

HELPS PAY YOUR FINAL EXPENSES.

Your beneficiaries may use this money to pay for your burial or cremation, and pay any outstanding medical bills.

Even among people who have life insurance, about 1 in 5 saythey don’t have enough.1

PART OF YOUR BENEFIT PACKAGE. This benefit is completely paid for by your employer.

Remember to name your beneficiaries if you haven’t done so already.

BENEFITS For you

1 times your Basic Annual Earnings, up to a maximum of $75,000. No medical questions asked.

Benefits are reduced at age 70 and may reduce again in subsequent years as noted in your Certificate.

PIERCE GROUP BENEFITS, LLC All Eligible Non-Owners POLICY # 933663 Sun Life Assurance Company of Canada

800-786-5433 • sunlife.com/us

1389695 SEQ2 CL1 10/19/2019 08:10:23

25

Basic Life Insurance

Voluntary Life Insurance MORE PROTECTION FOR YOUR LOVED ONES.

BENEFITS (You can purchase this coverage at a group rate.)

For you*

The people you love and support could face financial challenges without you.

Life insurance provides your loved ones with money they can use for household expenses, tuition, mortgage payments and more.

HELPS YOU CLOSE ANY COVERAGE GAPS.

You can choose from $20,000 to $500,000—in increments of $10,000 not to exceed 5 times your Basic Annual Earnings. No medical questions asked up to the Guaranteed Issue amount of $100,000.

Benefits are reduced at age 70 and may reduce again in subsequent years as noted in your Certificate.

For your spouse*

You may have life insurance today, either on your own or through your employer. Now is a good time to ask yourself if you need more coverage.

If you elect coverage for yourself, you can choose from $5,000 to $250,000—in increments of $5,000. No medical questions asked up to the Guaranteed Issue amount of $25,000.

The amount you select for your spouse cannot exceed 50% of your coverage amount.

For your child(ren)*

If you elect coverage for yourself, you can choose $1,000, $5,000 or $10,000. No medical questions asked.

The amount you select for your child(ren) cannot exceed 50% of your coverage amount. Benefits may reduce as noted in your Certificate.

A full benefit is payable for a dependent child from birth to 26.

PIERCE GROUP BENEFITS, LLC All Eligible Employees

*This coverage includes Accidental Death and Dismemberment insurance.

POLICY #: 933663

Sun Life Assurance Company of Canada

1389695 SEQ4 CL1 10/19/2019 08:10:27

800-786-5433 • sunlife.com/us

Voluntary Life Insurance

26

Sun Life Voluntary Group Term Life Rates December 1, 2019 - November 30, 2020 EMPLOYEE*

SPOUSE

<20

Rate per $1,000 benefit $0.026

Rate per $1,000 benefit $0.026

20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75+

$0.052 $0.057 $0.078 $0.104 $0.161 $0.244 $0.437 $0.842 $1.248 $1.997 $3.614 $12.958

$0.052 $0.057 $0.078 $0.104 $0.161 $0.244 $0.437 $0.842 $1.248 $1.997 $3.614 $12.958

Age - Bands

*Employee's Age on Policy Anniversary determines rate

AD&D Rate per $1,000 benefit

Monthly

Semi-Monthly

Employee

$0.026

$0.013

Spouse

$0.026

$0.013

Monthly

Semi-Monthly

Life

$0.182

$0.091

AD&D

$0.026

$0.013

CHILD Rate per $1,000 benefit

27

GET STARTED WITH AN HSA TODAY

1

Select an HSA-qualified health plan

HSA eligibility

Enroll in an HSA-qualified plan. These plans typically cost less than traditional plans and provide tax saving opportunities. HealthEquity will work with your employer or health plan to automatically set up your account and supply a HealthEquity® Visa® Health Account Card1 to conveniently pay for eligible expenses.

2

Add money to your HSA

Fund your HSA through pre-tax payroll deductions or transfer money into your account through the HealthEquity member portal. To take full advantage of tax savings and to build a reserve for the future, consider maximizing your contributions as set by the IRS:

To make tax-free2 contributions to an HSA, the IRS requires that: • you are covered by an HSAqualified health plan.

• you have no other health coverage (such as other health plan, Medicare, military health benefits, medical FSAs).

• you cannot be claimed as a dependent on another person's tax return.

HSA CONTRIBUTION LIMITS

19

2019

FAMILY

$7,000

20

$3,550

20

FAMILY

$7,100

At age 55, an additional $1,000 is allowed annually.

1

2

This card is issued by The Bancorp Bank; member FDIC pursuant to a license from Visa U.S.A. Inc. Your card can be used everywhere Visa debit cards are accepted for qualified expenses. This card cannot be used at ATMs and you cannot get cash back, and cannot be used at gas stations, restaurants, or other establishments not health related. See Cardholder Agreement for complete usage restrictions.

HSAs are never taxed at a federal income tax level when used appropriately for qualified medical expenses. Also, most states recognize HSA funds as tax-free with very few exceptions. Please consult a tax advisor regarding your state’s specific rules.

28

Copyright © 2019 HealthEquity, Inc. All rights reserved.

2019

$3,500

INDIVIDUAL

2020 2020

20

INDIVIDUAL

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

29

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.

30

How do I pay for eligible expenses? sing our 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 ust 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.

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

• hen 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 Identi cation 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 myameri ex.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 itemi ed receipts and the Explanation of enefits EO from your insurance carrier.

Claims can be submitted through the following methods

n ine Visit myameriflex.com/register to get started ai Ameriflex ATTN Claims Department P.O. ox Plano, T • mai claims myameriflex.com • a . .

ATTN Claims Department • o i e pp Visit myameriflex.com/mobile-app to get started

• •

Other elpful 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. ou 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 / at . .FLE .

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 re uested. Failure to comply could eopardi e the tax-exempt status of your account and cause the card to be deactivated.

31

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.

How do these programs save me money on taxes?

Since the accounts are tax-advantaged, you get to leverage pre-tax 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.

32

LIMITED PURPOSE FSA Another flexible way to save money on vision and dental expenses.

How does a Limited Purpose FSA (LPFSA) for dental and vision expenses work?

A Limited Purpose Flexible Spending Account (LPFSA) is similar to a regular, general purpose healthcare FSA. After the LPFSA is set up by your employer, you can elect to set aside pre-tax dollars to pay for certain types of healthcare expenses. However, unlike a regular FSA, funds in a LPFSA can only be used to pay for qualifying dental, vision, and orthodontia expenses. The account is set up this way so it can be used alongside a Health Savings Account (HSA). IRS regulations prohibit contributions to an HSA if an individual participates in a traditional FSA. With an LPFSA, however, you (or your spouse) can make contributions to both the LPFSA and the HSA. In turn, this allows you to maximize your savings and tax benefits.

Other than the restriction of eligible expenses to vision, dental, and orthodontia, the rules governing the LPFSA are the same as those that apply to the FSA.

What expenses are considered eligible?

These include but are not limited to: • • • •

Vision exams LASIK surgery Contacts lenses and contact lens solution Eyeglasses

• • • •

Dental cleanings Dentures Dental x-rays, crowns, fillings, and other orthodontia work Dental and vision co-payments and deductibles

33

VISIT US ONLINE: MYAMERIFLEX.COM

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

This individual voluntary policy pays benefits that can be used for both medical and/or out-of-pocket, non-medical expenses traditional health insurance may not cover.

Available exclusively at the workplace, Cancer Assist is an attractive addition to any competitive benefits package that won’t add costs to a company’s bottom line.

Competitive advantages Composite rates.

Four distinct plan levels, each featuring the same benefits with premiums and benefit amounts designed to meet a variety of budgets and coverage needs (benefits overview on reverse).

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

The plan’s Family Care Benefit provides a daily benefit when a covered dependent child receives inpatient or outpatient cancer treatment.

Employer-optional cancer wellness/health screening benefits available: 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.

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

Family coverage includes eligible dependent children (to age 26) for the same rate, regardless of the number of children covered.

Attractive features Available for businesses with 3+ eligible employees.

Broad range of policy issue ages, 17-75.

Each plan level features full schedule of 30+ benefits and three optional riders (benefit amounts may vary based on plan level selected).

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

HSA compliant.

Guaranteed renewable.

Portable.

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.

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) 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.

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.

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.

34

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

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

Transportation for treatment more than 50 miles from covered person’s home: $0.50 per mile, up to $1,000-$1,500 per round trip Companion Transportation (for any companion, not just a family member) for commercial travel when treatment is more than 50 miles from covered person’s home: $0.50 per mile, up to $1,000-$1,500 per round trip 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

35

INDIVIDUAL CANCER INSURANCE

Cancer Insurance Wellness Benefits

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

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

.

Serum cholesterol test for HDL and LDL levels

.

Stress test on a bicycle or treadmill

Colonoscopy .

Flexible sigmoidoscopy Hemoccult stool analysis Mammography

.

Pap smear PSA [blood test for prostate cancer]

.

Serum protein electrophoresis [blood test for myeloma]

.

Skin biopsy Thermography ThinPrep pap test Virtual colonoscopy

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 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).

36

CANCER ASSIST WELLNESS – 101486

Group Specified Disease Insurance Plan 3 Full

If you’re diagnosed with a covered specified disease, group specified disease insurance* from Colonial Life can help with your expenses, so you can concentrate on what’s most important – your treatment, care and recovery. *The policy name is Specified Disease Group Insurance.

Face amount: $_______________ Plan features

A lump-sum payment that can be used as you see fit Adjustable face amount to best meet your personal needs May pay multiple times for a covered specified disease Guaranteed renewable Portable

Specified disease benefit For the diagnosis of this covered specified disease condition:1

For more information, talk with your benefits counselor.

ColonialLife.com

This percentage of the face amount is payable:

Heart attack (myocardial infarction)

100%

Stroke

100%

End-stage renal (kidney) failure

100%

Major organ failure

100%

Coma

100%

Permanent paralysis due to a covered accident

100%

Blindness

100%

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

100%

Coronary artery bypass graft surgery/disease2

25%

Subsequent diagnosis of a different specified disease3 If you receive a benefit for a specified disease, and later you are diagnosed with a different specified disease, the original percentage of the face amount is payable for that particular specified disease.

Subsequent diagnosis of the same specified disease3 If you receive a benefit for a specified disease, and later you are diagnosed with the same specified disease, 25% of the original face amount is payable. Specified disease conditions that do not qualify are: coronary artery bypass graft surgery/coronary artery disease2 and occupational infectious HIV or occupational infectious hepatitis B, C or D.

37

GROUP CRITICAL CARE PLAN 3 FULL - GUARANTEED RENEWABLE

1 Please refer to the certificate for complete definitions of covered conditions.

ColonialLife.com

2 Benefit for coronary artery disease applicable in lieu of benefit for coronary artery bypass graft surgery when health savings account (HSA) compliant plan is selected.

3 Dates of diagnoses of a covered specified disease must be separated by at least 180 days.

THIS POLICY PROVIDES LIMITED BENEFITS.

EXCLUSIONS AND LIMITATIONS FOR SPECIFIED DISEASE We will not pay the Specified Disease Benefit or Benefit Payable Upon Subsequent Diagnosis of a Specified Disease that occurs as a result of a covered personâ&#x20AC;&#x2122;s: alcoholism or drug addiction; felonies or illegal occupations; intoxicants and narcotics; psychiatric or psychological conditions; suicide or injuries which any covered person intentionally does to himself; 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 specified disease.

This is not an insurance contract and only the actual certificate provisions will control. Applicable to certificate form GCC1.0-C-GR-NC. Please see your Colonial Life benefits counselor for details.

Underwritten by Colonial Life & Accident Insurance Company, Columbia, SC Š2017 Colonial Life & Accident Insurance Company. All rights reserved. Colonial Life is a registered trademark and marketing brand of Colonial Life & Accident Insurance Company.

38

2-17 | NS-15526

Group Specified Disease Insurance First Diagnosis Building Benefit Rider (Specified Disease)

A specified disease can have a big impact on your finances. To help protect your way of life, you can add the first diagnosis building benefit rider to your group specified disease coverage. Available at an additional cost, the rider provides a lump-sum benefit when a covered specified disease* is first diagnosed.

First diagnosis building benefit rider Payable once per covered person per lifetime

¾ Named insured ............................................................ Accumulates $1,000 each year ¾ Covered spouse/dependent child ..................................... Accumulates $500 each year

The rider covers the same family members as your group specified disease insurance. The benefit amount accumulates each year the rider is in force before a diagnosis is made, up to a maximum of 10 years.

If you are diagnosed with a covered specified disease before the end of the first rider year, the rider will pay one-half of the annual building benefit amount.

For more information, talk with your benefits counselor.

ColonialLife.com

* Conditions that do not apply to the rider include coronary artery bypass graft surgery/coronary artery disease. Benefit for coronary artery disease applicable in lieu of benefit for coronary artery bypass graft surgery when health savings account (HSA) compliant plan is selected.

The certificate to which the rider is attached has exclusions and limitations. This is not an insurance contract and only the actual certificate provisions will control. Applicable to rider form R-GCC1.0-BB-NC. Please see your Colonial Life benefits counselor for details.

Underwritten by Colonial Life & Accident Insurance Company, Columbia, SC ©2017 Colonial Life & Accident Insurance Company. All rights reserved. Colonial Life is a registered trademark and marketing brand of Colonial Life & Accident Insurance Company.

GROUP CRITICAL CARE FIRST DIAGNOSIS BUILDING BENEFIT RIDER – SPECIFIED DISEASE | 1-17 | 100584-1

39

Specified Disease Insurance Health Screening Benefit

The optional health screening benefit can help you reduce the risk of serious illness through early detection.

Health screening benefit ................................................................ $_______________ Maximum of one screening test per covered person per calendar year.

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)

For more information, talk with your benefits counselor.

Fasting blood glucose test

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

ColonialLife.com

For cost and complete details, see your Colonial Life benefits counselor. Applicable to form CI-1.0-NC and GCC1.0-P-NC. Underwritten by Colonial Life & Accident Insurance Company, Columbia, SC ©2016 Colonial Life & Accident Insurance Company. All rights reserved. Colonial Life is a registered trademark and marketing brand of Colonial Life & Accident Insurance Company.

GROUP CRITICAL CARE, CRITICAL ILLNESS 1.0 – HEALTH SCREENING BENEFIT | 12-16 | 100595-2

40

Educator Income Protection Insurance

How long could you afford to go without a paycheck?

Monthly Expenses:

$_________________ Mortgage/rent

$_________________ Groceries

$_________________ Car

$_________________ Medical bills

$_________________ Utilities

$_________________ Other Total $_________________

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

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

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

= Total Disability

On-Job

Off-Job

First 3 months

$_____________/month

$_____________/month

Next 9 months

$_____________/month

$_____________/month

$____________/month

$_____________/month

= Partial Disability

Up to 3 months

When will my benefits start?

After an Accident: ___________ days

After a Sickness: ___________ day

What additional features are available? l.

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

l..

Waiver of Premium.

NCK 1000

l

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

How much will it cost?

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

41

Employee Coverage In addition to disability coverage, this plan also provides employees with benefits for medical fees related to accidents, hospital confinement, accidental death and dismemberment, as well as fractures and dislocations.

Even if youâ&#x20AC;&#x2122;re not disabled, the following benefits are payable for covered accidental injuries: Even if youâ&#x20AC;&#x2122;re not disabled, the following benefits are payable for covered accidental injuries:

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

Up to ................................................................................................................................................................................................. $350

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

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

Up to 3 months .................................................................................................................... $1,200/month ($40/day) The Hospital Confinement benefit increases to $6,200/month when the Total Disability benefit ends at age 70.

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

l

l

Accidental Death .............................................................................................................................................................. $10,000 Loss of a Finger or Toe Single Dismemberment ................................................................................................................................................. $750 Double Dismemberment ............................................................................................................................................$1,500 Loss of a Hand, Foot or Sight of an Eye Single Dismemberment ..............................................................................................................................................$5,000 Double Dismemberment ......................................................................................................................................... $10,000 Common Carrier Death (includes school bus for school activities) .............................................................. $20,000

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

42

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

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

l

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

l

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

l

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

Optional Spouse and Dependent Coverage You may cover one or all of the eligible dependent members of your family for an additional premium.

Eligible dependents include your spouse and ALL dependent children who are younger than age 26.

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

Up to ................................................................................................................................................................................................... $350

Hospital Confinement Benefit for Accident or Sickness

l

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

Accidental Death and Dismemberment Benefits

l

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

l

Loss of a Finger or Toe

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

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

l

Loss of a Hand, Foot or Sight of an Eye

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

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

l

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

43

Here are some

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

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

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

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

What is a pre-existing condition?

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

When am I considered totally disabled?

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

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

What if I want to return to work part-time after I am totally disabled?

You may be able to return to work part-time and still receive benefits. We call this “Partial Disability.” This means you may be eligible for coverage if: l You are unable to perform the material and substantial duties of your job for 20 hours or more per week, l You are able to work at your job or your place of employment for less than 20 hours per week, l Your employer will allow you to return to your job or place of employment for less than 20 hours per week; and l You are under the regular and appropriate care of a doctor.

The total disability benefit must have been paid for at least one full month immediately prior to your being partially disabled.

When do disability benefits end?

The Total Disability Benefit will end on the policy anniversary date on or next following your 70th birthday.

The Hospital Confinement benefit increases when the Total Disability Benefit ends.

What if I change employers or retire?

What is a covered accident or a covered sickness?

A covered accident is an accident. A covered sickness means an illness, infection, disease or any other abnormal physical condition.

A covered accident or covered sickness: Occurs after the effective date of the policy; l Occurs while the policy is in force; and l Is of a type listed on the Policy Schedule; and l Is not excluded by name or specific description in the policy. l

EXCLUSIONS We will not pay benefits for losses that are caused by or are the result of: alcoholism or drug addiction; flying; hazardous avocations; felonies or illegal occupations; having a pre-existing condition as defined and limited by the policy; psychiatric or psychological condition; racing; semi-professional or professional sports; suicide or self-inflicted injury, war or armed conflict.

For cost and complete details, see your Colonial Life benefits counselor. Applicable to policy form NCK1000-NC. This is not an insurance contract and only the actual policy provisions will control.

NCK 1000

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

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

© 2013 Colonial Life & Accident Insurance Company Colonial Life are underwritten byLife Colonial Life & Accident Colonial Life products are products underwritten

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

Company, for which Colonial Life is the marketing brand.

71381-1 7/13 62617-4

44

Long-Term Disability Insurance

HELPS YOU KEEP YOUR LIFE ON TRACK.

COMMON CAUSES OF DISABILITY Musculoskeletal conditions Circulatory conditions Cancer Nervous system disorders Injuries

If youâ&#x20AC;&#x2122;re unable to work because of a covered disability, Long-Term Disability insurances replaces a portion of your income. After your claim is approved, you will receive a monthly check for your benefits that helps you pay everyday expenses like your mortgage or rent, childcare and groceries.

HELPS YOU RETURN TO WORK.

If you are able, Sun Life has benefits and services, including guidance from vocational rehabilitation counselors, to help you return to work.

PART OF YOUR BENEFIT PACKAGE.

This benefit is completely paid for by your employer.

BENEFITS Monthly benefit after your claim is approved

You will receive a check for your benefits on a monthly basis. It will replace 60% of your Total Monthly Earnings, up to $10,000 each month.

When benefits begin

Benefits begin as soon as 90 days from the date of your disability.

Benefits may be paid for

Up to your Social Security Normal Retirement Age or longer, depending on your age at disability.

Additional plan This plan provides a benefit for covered disabilities resulting information from illness or injury that occur on or off the job.

LONG-TERM DISABILITY FAST FACTS PIERCE GROUP BENEFITS, LLC All Eligible Employees POLICY # 933663

34.6 months

The length of the average long-term disability claim.1

Sun Life Assurance Company of Canada

800-786-5433 â&#x20AC;˘ sunlife.com/us

You may receive additional benefits if your covered disability begins with a hospital stay of 14 days or more.

1371105 SEQ2 CL1 10/19/2019 07:10:58

45

Long-Term Disability Insurance

Frequently asked questions

How do I file a Long-Term Disability claim?

If you become disabled after the effective date of coverage, check with your employer to make sure you are eligible for benefits. You can file a claim with us by downloading forms from our website. We’ll ask you and your doctor to provide information about your medical condition and your expected recovery.

How do I qualify for benefits?

You’ll start receiving disability payments if you satisfy the Elimination Period (see “When benefits begin” in the table) and meet the policy’s definition of disability.

Generally, disability is defined as your inability to perform some or all of your job duties due to your injury, illness or pregnancy and may require that you have also had a certain percentage of earnings loss due to your disability. Please see your Certificate for details.

earnings. For more information, contact your benefits administrator.

How is my benefit taxed?

If you or your employer pays for all or part of the cost of coverage on a pre-tax basis, all or part of your benefit amount will be Form W-2 taxable income. In these situations, FICA tax deductions may reduce the amount we will pay you.

What if I have a pre-existing condition?

If you become disabled within 12 months of your insurance taking effect or 12 months following any increase in your amount of insurance, we will not pay any benefit for any pre-existing condition. A preexisting condition includes anything you have sought treatment for in the 3 months prior to your insurance becoming effective. Treatment can include consultation, advice, care, services or a prescription for drugs or medicine.

Can I work while I’m disabled?

Your plan is designed to encourage and support your return to work. If you are able to work part-time, for example, you may receive part of your benefit while working.

Will income from other sources affect my benefit?

Your benefit may be reduced by Social Security benefits; disability benefits from retirement, government plans or state disability income; other group disability plans; no-fault benefits, salary continuance or sick leave; and return-to-work

The group disability insurance policies described in this advertisement provide disability income insurance only.

1. “Chances of disability,” Council for Disability Awareness, disabilitycanhappen.org, last accessed April 2019.

Read the Important information section for more details including limitations and exclusions.

800-786-5433 • sunlife.com/us

Long-Term Disability Insurance

46

Important information The following coverage(s) do not constitute comprehensive health insurance (often referred to as “major medical coverage”). They do NOT provide basic hospital, basic medical, or major medical insurance.

To become insured, you must meet the eligibility requirements set forth by your employer.

Your coverage effective date will be determined by the Policy and may be delayed if you are not actively at work on the date your coverage would otherwise go into effect. Refer to the Certificate for details.

Limitations and exclusions

The below exclusions and limitations may vary by state law and regulations. This list may not be comprehensive. Please see the Certificate or ask your benefits administrator for details.

Long-Term Disability

We will not pay a benefit that is caused by, contributed to in any way or resulting from: intentionally self-inflicted injuries; committing or attempting to commit an assault, felony or other criminal act; war or an act of war; active participation in a riot, rebellion or insurrection; operation of a motorized vehicle while intoxicated. We will not pay a benefit if you do not submit proof of your loss as required by us (this covers medical examination, continuing care, death certificate, medical records, etc.); or for any Period of disability during which you are incarcerated. Disability benefits may be limited for certain conditions.

This Overview is preliminary to the issuance of the Policy. Refer to your Certificate for details. Receipt of this Overview does not constitute approval of coverage under the Policy.

In the event of a discrepancy between this Overview, the Certificate and the Policy, the terms of the Policy will govern. Product offerings may not be available in all states and may vary depending on state laws and regulations.

Sun Life Financial companies include Sun Life and Health Insurance Company (U.S.) and Sun Life Assurance Company of Canada (collectively, “Sun Life Financial” or “Sun Life”).

Group insurance policies are underwritten by Sun Life Assurance Company of Canada (Wellesley Hills, MA) in all states, except New York, under Policy Form Series 93P-LH, 12-GP-01, 12-DI-C-01, 15-GP-01, 16-DIC-01, TDBPOLICY-2006 and TDI-POLICY. © 2019 Sun Life Assurance Company of Canada, Wellesley Hills, MA 02481. All rights reserved. Sun Life and the globe symbol are trademarks of Sun Life Assurance Company of Canada. Visit us at www.sunlife.com/ us.

GVBH-EE-8384

SLPC 29579 5/19

800-786-5433 • sunlife.com/us

Long-Term Disability Insurance

47

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.

48

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 â&#x20AC;&#x201C; 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

49

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

50

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

51

71740-NC

Accident 1.0­-Preferred with Health Screening Benefit

When are covered accident benefits available? (check one)

Hospital Confinement Indemnity Insurance Plan 1 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

Health savings account (HSA) compatible

For more information, talk with your benefits counselor.

ColonialLife.com

This plan is compatible with HSA guidelines. This plan may also be offered to employees who do not have HSAs. Colonial Life & Accident Insurance Companyâ&#x20AC;&#x2122;s Individual Medical Bridge offers an HSA compatible plan in most states.

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. Š2015 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.

52

IMB7000 â&#x20AC;&#x201C; PLAN 1 | 7-15 | 101576-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)

53

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 n Breast

n Gynecological

n Cardiac

n Liver

n Digestive

n 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

n Skin

– Laparoscopic hernia repair – Skin grafting

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

Tier 2 outpatient surgical procedures n Breast

n Gynecological

n Cardiac

n Musculoskeletal system

– Breast reconstruction – Breast reduction

– Hysterectomy – Myomectomy

– Angioplasty – Cardiac catheterization

n Digestive

– Exploratory laparoscopy – Laparoscopic appendectomy – Laparoscopic cholecystectomy

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

n Thyroid

– Excision of a mass

n 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

n 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.

54

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

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

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

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

For more information, talk with your benefits counselor.

n Hemoccult stool analysis n Mammography n Pap smear n PSA (blood test for prostate cancer) n 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.

55

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 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

Doctorâ&#x20AC;&#x2122;s office visit ................................................................................... $25 per visit Maximum of three visits per calendar year for named insured coverage or maximum of five visits per calendar year for all covered persons combined

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

For more information, talk with your benefits counselor.

Maximum of two visits per covered person per calendar year

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

THIS POLICY PROVIDES LIMITED BENEFITS. EXCLUSIONS

ColonialLife.com

We will not pay benefits for losses which are caused by: alcoholism or drug addiction, dental procedures, elective procedures and cosmetic surgery, felonies or illegal occupations, pregnancy of a dependent child, psychiatric or psychological conditions, suicide or injuries which any covered person intentionally does to himself or herself, or war.

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. Š2016 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-MEDICAL TREATMENT PACKAGE NORTH CAROLINA EDUCATORS | 1-16 | NS-15014-NC

56

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

57

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

58

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

59

PIERCE GROUP BENEFITS ADDITIONAL BENEFITS

THE FSASTORE

Pierce Group Benefits partners with the FSAStore to provide one convenient location for all your FSA eligible purchases. Through this partnership, Pierce Group and the FSAStore can help you shop for FSA eligible items, search for local and eligible physicians, and answer the many questions that come along with having a Flexible Spending Account.

The FSAStore focuses on three main channels to help you better understand your benefits and eligible services and products as an FSA participant: • Products - Shop for more than 4,000 FSA eligible products • Services - Find FSA eligible services and providers in your area • Learning Center - Learn more about your FSA and get answers to your questions

Accessing the FSAStore is easy. Simply visit www.FSAStore.com

IDENTITY THEFT SHIELD & LIFE EVENTS LEGAL PLAN

Everyone deserves legal protection. And now, with LegalShield, everyone can access it. Welcome to total piece of mind. Welcome to LegalShield.

LegalShield gives you the ability to talk to an attorney on any matter without worrying about high hourly costs.

Life Events We Help With:

• Legal Advice - unlimited issues • Letters/calls made on your behalf • Contracts & Documents Reviewed up to 15 pages • Traffic-Related Issues • IRS Audit Assistance • 24/7 Emergency Access for covered situations

Lease Agreements Overcharges Defective Products Property Disputes Possible Foreclosure Traffic Tickets

Warranties Civil Rights Child Support Divorce Guardianship IRS Audits

Credit Liability Matters ……and much more Theft service by Kroll Advisory Solutions, IDShield - everyhing you would expect with a great Identity the world’s leading risk consulting company in identity theft restoration.

CONSULTATION -- RESTORATION -- PRIVACY MONITORING -- SECURITY MONITORING Legal Plan Only IDShield Individual Legal + IDShield Individual IDShield Family Legal + IDShield Family

24-Deductions 9.48 4.48 13.95 9.48 16.95

See pages 5-8 for online enrollment instructions

60

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 Pierce Group Benefits, 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: Debbie Marshall. Applicable documentation will be required i.e. court order, certificate of coverage etc.

61

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: Plan Administrator: Debbie Marshall, Pierce Group Benefits 4928 Linksland Drive, Holly Springs, NC 27540 Phone: 919-346-5458 Contact email address: dmarshall@piercegroupbenefits.com Health COBRA: WageWorks Phone:(877) 924-3967 Dental COBRA: Interactive Medical Systems PO Box 1349, Wake Forest, NC 27588 Phone: (919) 877-9933 Ext: 5054 Fax: (919)562-0021 Email: cobradept@ims-tpa.com Vision COBRA: Forrest T. Jones & Company P.O. Box 418131, Kansas City, MO 64141-8131 Darlene Wilkinson Admin Specialty Benefits Tel: (800) 821-7303 x 1419 Fax: (816) 751-6095 E-mail: dwilkinson@ftj.com

62

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 personâ&#x20AC;&#x2122;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)

63

___________ (Date Signed)

64

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

METLIFE - DENTAL INSURANCE • Customer Service: 1-800-438-6388 • Website: www.metlife.com/mybenefits

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

HEALTH EQUITY - HEALTH SAVINGS ACCOUNT • Customer Service: 1-866-346-5800 • Website: www.myhealthequity.com

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

• • • •

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

SUN LIFE - LONG-TERM DISABILITY TO VIEW YOUR BENEFITS ONLINE

• Customer Service: 1-800-247-6875 • Website: www.sunlife.com/us

Visit www.piercegroupbenefits.com/

piercegroupbenefits

SUN LIFE - TERM LIFE INSURANCE • Customer Service: 1-800-442-7742

For additional information concerning plans offered to employees of Pierce Group Benefits, 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.