2021-22 City of Lufkin Benefits Guide by theadvancedfinancialgroup

city of lufkin 2021-22

www.mybenefitshub.com/cityoflufkin

plan year: 2021-2022 1

General Information

2021 Benefit Highlights

Medical Insurance

MyMD Connect

Basic Life

Long Term Disability

Employee Assistance Program

Flexible Spending Account

Dental

Vision

Accident

Cancer

Hospital Indemnity

Permanent Life

Voluntary Group Life

Disclosures

HOWTO LOGIN

I 21 3I 1

VISIT www.mybenefitshub.com/cityoflufkin

CLICK LOGIN

ENTER USERNAME & PASSWORD All login credentials have been RESET to the default described below: Username: the first six (6) characters of your last name, followed by the first letter of your first name, followed by the last four (4) digits of your Social Security Number. Default Password: last name (excluding punctuation) followed by the last four (4) digits of your Social Security Number.

GENE

L INFORMATION

The City of Lufkin offers a wide range of benefits to eligible employees and their family members. All new or newly eligible employees will enroll in benefits online. The city benefit site contains all plan summaries, rate summaries, claim forms and additional product information for employees to access online. Employees are encouraged to browse the plan information provided on the benefit site prior to enrolling. The Advanced Financial Group is the Third-Party Administrator for the city's supplemental benefits and will be assisting on site during the open enrollment period. You can call them directly at 936.634.3378 for questions and technical support. The annual open enrollment period begins August 23rd and ends September 23rd. The plan options and coverage levels you select for the plan year will remain in effect from October 1, 2021 through September 30, 2022. New or newly eligible employees will have 31 days from their hire date to complete their enrollment. Failure to enroll within 31 days could result in exclusion from benefits. Employees will be required to provide the name, date of birth and social security number for any dependents (this includes spouse).

MAKING CHANGES/SPECIAL ENROLLMENT EVENTS After the initial open enrollment period, you can only add or change coverage during the year if you have a Qualified Family Status Change/Special Enrollment event such as: Marriage, Divorc e, Birth or adoption, Death, Court Order (child(ren) coverage only), or if a spouse gains or loses employment. You must submit all the required documentation to The Advanced Financial Group and make your plan changes within 31 days from the date of the event. If you do not request the appropriate changes during the applicable special enrollment period, the changes cannot be made until the next plan enrollment period or, if applicable, until another special enrollment event occurs.

ALL CURRENT BENEFIT ELECTIONS FROM 2020/21 WILL BE ROLLED FORWARD WITH THE EXCEPTION OF FSA. FLEXIBLE SPENDING ACCOUNT ANNUAL AMOUNTS MUST BE ENTERED EACH YEAR. WE HIGHLY ENCOURAGE EMPLOYEES TO LOGIN AND REVIEW BENEFITS AND BENEFICIARIES. 4

2021-22 highlights

changes for the 2021-22 plan year Blue Cross Blue Shield Medical Plan-Low Plan $70 Office Visit Co-Pay -High Plan $60 Office Visit Co-Pay MY MD Connect- Direct Primary Care -24/7 access to local Direct Primary Care Doctor (For all members on Blue Cross Plan) -$0 Co-Pay for office visits, labs & x-rays, and virtual visits 100% covered

updates/ reminders -The 2021 FSA maximum annual contribution limit remains at $2750. The IRS has allowed the "carryover" provision to be increased from $500 to $550 this year. You must login to elect this benefit and assign the annual contribution amount. -THERE ARE NO PREMIUM CHANGES THIS YEAR TO THE BLUE CROSS MEDICAL PLAN. -1800MD will be canceled effective 10/01/21. -Open Enrollment > August 23rd- September 23rd -This is a passive enrollment. If you do not login all benefits will "roll forward" with the exception of FSA. That benefit has to be actively elected each year. -If you have questions or issues during enrollment, please contact The Advanced Financial Group at 936.634.3378.

YOUR BENEFITS

=======-��-======================MEDICAL INSURANCE

ABOUT THIS BENEFIT: Medical insurance, also known as health insurance, is coverage that helps you pay the high cost of medical and hospital expenses. Health insurance is a type of coverage that typically pays for medical, surgical, and prescription drug expenses incurred by the insured. Health insurance can reimburse the insured for expenses incurred from illness or injury, or pay the care provider directly.

*This benefit booklet highlights certain features from the different policies and riders but is not the insurance contract. Please refer to the group master application or your policy for a full disclosure of benefits. 6

ACTIVE CITY OF LUFKIN MEDICAL PLAN BLUE CROSS BLUE SHIELD OCTOBER, 2021-SEPTEMBER, 2022 BENEFIT Oct. 2021-Sept. 2022 Deductible Year Total Out of Pocket Including Deductible

CATEGORY

ER Facility Copay ER Physician/other Non Emergencies in ER MyMDSelect

Employer paid Benefit

Office Visit Copay Urgent Care Copay Specialist Office Visit Copay Prescription Copays

Generic In-Network Pharmacies

Preferred Brand Non-Preferred Specialty Mail Order Prescription Copays

Generic 90 days Preferred 90 days Non-Preferred Specialty/Available through Prime Therapeutics Mail Order

Employee Premiums Employee Only Employee + Spouse Employee + Child(ren) Employee + Family Wellness Benefits /Pref Lab

LOW PLAN $2,500 3 per family $7,150 $14,300 family

HIGH PLAN $1,500 3 per family $5,000 $12,000 family

$500 then 20% 80% after deductible

$250 then 20% 80% after deductible

All charges 80% after deductible

$70 $115 $70

$60 $90 $60

$5- 34 days $12 – 90 days

$5 – 34 days $12 – 90 days

$ 50 $100 $100 deductible then 50%

$150 $300 $100 deductible then 50%

Monthly Premium $ 75.00 $315.00 $170.00 $375.00

Monthly Premium $ 140.00 $420.00 $275.00 $550.00

100%

MYMD CONNECT DIRECT PRIMARY CARE

Through the The City of Lufkin health program, MyMD Connect makes it easier than ever to take control of your health and healthcare! Follow the steps below to register, complete your Intake Form, and get connected to your dedicated doctor.

INTAKE FORM

DOWNLOAD MOBILE APP

Complete the medical intake form at the link below. The information provided is key for your MyMD Connect Doctor to provide diagnosis and treatment plan.

Lufkin.MyMDCOnnect.com

GET CONNECTED

After your intake is processed you will be sent a text message by your dedicated DPC doctor inviting you to download the Spruce APP. This may take 24-48 hours to process.

CONTACT

MYMD CONNECT Phone: (936) 205-9922 or Text on Spruce Mobile App

Members must download the mobile app from the text message link you receive from MyMD!

STEPS TO DOWNLOAD THE APP & CONNECT WITH YOUR PROVIDER Open the link sent to you via text or email on your mobile phone (example: spruce.app/____) 2. When you click the link a webpage will open 3. Click "Get the App & Connect" on the webpage 4. Select Spruce - Care Messenger app and download from the app store 5. Once download is complete, open the Spruce app on your phone and click "Continue" 6. Select "Create" a new account, and enter your personal mobile number. You will receive a verification code via text. 7. Enter verification code on next screen, select "Next" and enter your information to complete your setup. 8. Once steps are complete you can begin to message with your provider! 1.

*IMPORTANT* downloading the Spruce APP without the unique link will not work!

MEET YOUR CONCIERGE DOCTOR YOUR PHYSICIAN. ANYTIME. ANYWHERE.

DR. JEREMY SMITH In 2003, Dr. Smith graduated with a Medical Degree from the University of Texas Medical Branch in Galveston, Texas. His residency in Family Medicine was completed in 2006 at University of Texas Health Science Center in Tyler, Texas. Following residency, Dr. Smith moved his medical practice and his family to Nacogdoches, Texas.

MYMD SELECT (936) 205-9922

Dr. Smith was formally educated at Midwestern State University where he completed a Bachelors of Science focused on zoology and premedical sciences. Several highlights during his undergraduate study and postgraduate training include time spent in the Dalquest Field research areas of West Texas, University of Oklahoma’s Lake Texhoma Biological Institute, and study abroad to King’s College in London, England at Waterloo.

HOW I CAN HELP YOU

GET CONNECTED

Complete Intake Form

Acute Care

Prescriptions

Preventive Care

Chronic Conditions

Urgent Care*

Wellness & Lifestyle

Download Spruce App

Specalist Care*

Management

After your intake is processed you will be sent a text message by your dedicated DPC doctor inviting you to download the Spruce APP.

Lufkin.MyMDConnect.com

Care Coordination *Services outside of MyMD Connect will have a separate discounted fee.

MyMDConnect.com | (936) 634-9105

MYMD CONNECT YOUR PHYSICIAN. ANYTIME. ANYWHERE.

DEDICATED CONCIERGE PHYSICIAN The best way for us to reduce our healthcare costs is to prioritize our health and wellness. Through the City of Lufkin health plan MyMD Connect makes this easier than ever! Your dedicated physician can help you wherever you are in your health journey; from day-to-day illness to managing chronic conditions. Additionally, MyMD Connect Physicians are experts in the City of Lufkin health plan. Whether you are trying to save money on a prescription or need assistance locating affordable care, your concierge Physician can act as your Personal Healthcare Advocate. Access to care is as easy as getting out your phone and communicating with your physician whenever needed!

PLAN FEATURES INITIAL INTAKE VISIT

TO COMPLETE YOUR INTAKE FORM, PLEASE VISIT THE FOLLOWING LINK:

Lufkin.MyMDConnect.com TO CONTACT YOUR PHYSICIAN PLEASE CALL: (936) 205-9922

MYMD CONNECT BENEFITS COVERED AT 100%

(Includes Consultation & Bloodwork)

VIRTUAL VISIT

COVERED AT 100%

(Acute Care, Chronic Conditions, Rx Maintenance)

LABS

COVERED AT 100%

(When Coordinated through MyMD Connect)

X-RAY & ULTRASOUNDS

DISCOUNTED

(When Coordinated through MyMD Connect)

DIAGNOSTIC TESTING & SLEEP STUDIES

DISCOUNTED

(When Coordinated through MyMD Connect)

CT, MRI & PET SCANS (When Coordinated through MyMD Connect)

DISCOUNTED

MyMDConnect.com | (936) 634-9105

YOUR BENEFITS

BASIC LIFE INSURANCE EMPLOYER PAID BENEFIT

ABOUT THIS BENEFIT: The city of Lufkin provides eligible full time employees with Basic Life insurance at no cost. The coverage is equal to the employee base annual earnings up to a maximum of $200,000. Coverage reduces by 35% at age 65 and 50% at 70. Please make sure that you have updated the beneficiary for this policy inside the system if there are changes.

City of Lufkin provides this valuable benefit at no cost to you. Full-Time Employees

Term Life and AD&D Insurance Safeguard the most important people in your life. Think about what your loved ones may face after you’re gone. Term life insurance can help them in so many ways, like covering everyday expenses, paying off debt, and protecting savings. AD&D provides even more coverage if you die or suffer a covered loss in an accident. AT A GLANCE: • A cash benefit of one times basic annual earnings, rounded to the next higher $1,000, up to $200,000 without providing evidence of insurability ($200,000 maximum) to your loved ones in the event of your death, plus a matching cash benefit if you die in an accident • A cash benefit to you if you suffer a covered loss in an accident, such as losing a limb or your eyesight • LifeKeys® services, which provide access to counseling, financial, and legal support • TravelConnect® services, which give you and your family access to emergency medical assistance when you're on a trip 100+ miles from home ADDITIONAL DETAILS Conversion: You can convert your group term life coverage to an individual life insurance policy without providing evidence of insurability if you lose coverage due to leaving your job or for another reason outlined in the plan contract. AD&D benefits cannot be converted. Benefit Reduction: Coverage amounts begin to reduce at age 65 and benefits terminate at retirement. See the plan certificate for details. For complete benefit descriptions, limitations, and exclusions, refer to the certificate of coverage. This is not intended as a complete description of the insurance coverage offered. Controlling provisions are provided in the policy, and this summary does not modify those provisions or the insurance in any way. This is not a binding contract. A certificate of coverage will be made available to you that describes the benefits in greater detail. Refer to your certificate for your maximum benefit amounts. Should there be a difference between this summary and the contract, the contract will govern. LifeKeys® services are provided by ComPsych® Corporation, Chicago, IL. ComPsych®, EstateGuidance® and GuidanceResources® are registered trademarks of ComPsych® Corporation. TravelConnect® services are provided by On Call International, Salem, NH. ComPsych® and On Call International are not Lincoln Financial Group® companies. Coverage is subject to actual contract language. Each independent company is solely responsible for its own obligations. Insurance products (policy series GL1101) are issued by The Lincoln National Life Insurance Company (Fort Wayne, IN), which does not solicit business in New York, nor is it licensed to do so. Product availability and/or features may vary by state. Limitations and exclusions apply. Lincoln Financial Group is the marketing name for Lincoln National Corporation and its affiliates. Affiliates are separately responsible for their own financial and contractual obligations. Limitations and exclusions apply.

YOUR BENEFITS

LONG TERM DISABILITY EMPLOYER PAID BENEFIT

ABOUT THIS BENEFIT: If you are disabled and unable to work for more than 90 days, you may be eligible for Long Term Disability benefits. The City provides you with LTD coverage that will replace up to 60% of your base pay up to a maximum of $5,000/mo. Benefits are payable to age 65 if you are disabled and unable to return to work.

City of Lufkin provides this valuable benefit at no cost to you. Full-Time Employees

Long-term Disability Insurance Keep getting a check when you’re hurt or sick. You always have bills to pay, even when you can’t get to work due to injury, illness, or surgery. Long-term disability insurance helps you make ends meet during this difficult time. AT A GLANCE: • A cash benefit of 60% of your monthly salary (up to $5,000) starting 90 days after you are out of work and continuing up to age 65 or Social Security Normal Retirement Age (SSNRA), whichever is later • EmployeeConnectSM services, which give you and your family confidential access to counselors as well as personal, legal, and financial assistance. • Program Services include: Unlimited, 24/7 access to information and referrals In-person help for short-term issues; up to five sessions with a counselor per person, per issue, per year. One free consultation with a network attorney (with subsequent meetings at a reduced fee) Online tools, tutorials, videos and much more ADDITIONAL DETAILS Coverage Period for Your Occupation: 24 months. After this initial period, you may be eligible to continue receiving benefits if your disability prohibits you from performing any employment for which you are reasonably suited through your training, education, and experience. In this case, your benefits may be extended through the end of your maximum coverage period (benefit duration). Pre-existing Condition: If you have a medical condition that begins before your coverage takes effect, and you receive treatment for this condition within the 3 months leading up to your coverage start date, you may not be eligible for benefits for that condition until you have been covered by the plan for 12 months. For complete benefit descriptions, limitations, and exclusions, refer to the certificate of coverage. This is not intended as a complete description of the insurance coverage offered. Controlling provisions are provided in the policy, and this summary does not modify those provisions or the insurance in any way. This is not a binding contract. A certificate of coverage will be made available to you that describes the benefits in greater detail. Refer to your certificate for your maximum benefit amounts. Should there be a difference between this summary and the contract, the contract will govern. EmployeeConnectSM services are provided by ComPsych® Corporation, Chicago, IL. ComPsych® is a registered trademark of ComPsych® Corporation. ComPsych® is not a Lincoln Financial Group® company. Coverage is subject to actual contract language. Each independent company is solely responsible for its own obligations. Insurance products (policy series GL3001) are issued by The Lincoln National Life Insurance Company (Fort Wayne, IN), which does not solicit business in New York, nor is it licensed to do so. Product availability and/or features may vary by state. Limitations and exclusions apply. Lincoln Financial Group is the marketing name for Lincoln National Corporation and its affiliates. Affiliates are separately responsible for their own financial and contractual obligations. Limitations and exclusions apply. 14

YOUR BENEFITS

EMPLOYEE ASSISTANCE PROGRAM EMPLOYER PAID BENEFIT

ABOUT THIS BENEFIT: An Employee Assistance Program, or EAP is provided at no cost as a city of Lufkin employee. EAP is a work-based program that offers free and confidential assessments, short-term counseling, referrals, and follow-up services to employees who have personal and/or work-related problems. EAP's address a broad and complex body of issues affecting mental and emotional well-being, such as alcohol and other substance abuse, stress, grief, family problems, and psychological disorders. This is a confidential service available to employees and their dependents.

Employee Assistance Program

The resources you need to meet life’s challenges EmployeeConnect SM offers professional, confidential services to help you and your loved ones improve your quality of life.

In-person guidance Some matters are best resolved by meeting with a professional in person. With EmployeeConnect SM, you and your family get: In-person help for short-term issues (up to five sessions with a counselor per person, per issue, per year) In-person consultations with network lawyers, including one free 30-minute in-person consultation per legal issue, and 25% off subsequent meetings

Unlimited 24/7 assistance

Online resources

You and your family can access the following services anytime — online, on the mobile app or with a toll-free call:

EmployeeConnect SM offers a wide range of information and resources you can research and access on your own. Expert advice and support tools are just a click away when you visit GuidanceResources.com or download the GuidanceNowSM mobile app. You’ll find:

Information and referrals on family matters, such as child and elder care, pet care, vacation planning, moving, car buying, college planning and more Legal information and referrals for family law, estate planning, consumer and civil law Financial guidance on household budgeting and short- and long-term planning

Articles and tutorials Videos Interactive tools, including financial calculators, budgeting worksheets and more

EmployeeConnect SM EMPLOYEE ASSISTANCE PROGRAM SERVICES

Confidential help 24 hours a day, seven days a week for employees and their family members. Get help with: Family Parenting Addictions

Emotional Legal Financial

Relationships Stress



LTD-EAPEE-FLI001_Z01_FINAL.indd 1

Insurance products issued by: The Lincoln National Life Insurance Company Lincoln Life & Annuity Company of New York Lincoln Life16 Assurance Company of Boston

LTD-EAPEE-FLI001_Z01

12/19/19 3:34 PM

We partner with your employer to offer this service at no additional cost to you!

EmployeeConnectSM counselors are experienced and credentialed. When you call the toll-free line, you’ll talk to an experienced professional who will provide counseling, work-life advice and referrals. All counselors hold master’s degrees, with broad-based clinical skills and at least three years of experience in counseling on a variety of issues. For face-to-face sessions, you’ll meet with a credentialed, state-licensed counselor.

You’ll receive customized information for each work-life service you use.

To take advantage of the EmployeeConnect SM program or for more information: Visit GuidanceResources.com (username: LFGSupport, password: LFGSupport1), download the GuidanceNowSM mobile app or call 888-628-4824.

EmployeeConnectSM services are provided by ComPsych® Corporation, Chicago, IL. ComPsych® and GuidanceResources® are registered trademarks of ComPsych® Corporation. ComPsych® is not a Lincoln Financial Group® company. Coverage is subject to actual contract language. Each independent company is solely responsible for its own obligations. Insurance products are issued by The Lincoln National Life Insurance Company, Fort Wayne, IN, Lincoln Life & Annuity Company of New York, Syracuse, NY, and Lincoln Life Assurance Company of Boston, Dover, NH. The Lincoln National Life Insurance Company does not solicit business in New York, nor is it licensed to do so. Product availability and/or features may vary by state. Limitations and exclusions apply. Lincoln Financial Group is the marketing name for Lincoln National Corporation and its affiliates. Affiliates are separately responsible for their own financial and contractual obligations.

EmployeeConnectSM EMPLOYEE ASSISTANCE PROGRAM SERVICES To find out more: Visit GuidanceResources.com (username: LFGSupport  password: LFGSupport1) Download the GuidanceNowSM mobile app Call 888-628-4824



LTD-EAPEE-FLI001_Z01_FINAL.indd 2

12/19/19 3:34 PM

YOUR BENEFITS

FLEXIBLE SPENDING ACCOUNT

ABOUT THIS BENEFIT: A flexible spending account (FSA) is one of several tax-advantaged financial accounts that can be set up through a cafeteria plan adopted by your employer. A medical FSA is the most common type of LEARN MORE flexible spending account and allows you to set aside a portion of your earnings to pay for qualified expenses, most commonly for medical costs, such as doctors, dentists, and optometrist copays. You CANNOT use FSA funds for expenses incurred outside the plan year! Employees can "carryover" no more than $550 of unused funds to the 2021-22 plan-year. *This benefit booklet highlights certain features from the different policies and riders but is not the insurance contract. Please refer to the group master application or your policy for a full disclosure of benefits. 18

Partial List of Eligible Expenses:

How to Spend

Medical/Dental/Vision Copays and deductibles Prescription Drugs

Flexible Spending Account (FSA) Two types of FSAs

Physical Therapy Chiropractor First-Aid Supplies Lab Fees Psychiatrist/Psychologist

For a health FSA, start by choosing an annual election amount. This amount will be available on day one of your plan year for eligible medical expenses.

Vaccinations

Then, payroll deductions will be made throughout the plan year to fund your account.

Eyeglasses, Contact Lenses, Lens Solution

Dental Work/Orthodontia Eye Exams Laser Eye Surgery Prescribed OTC Medications

Account access is easy

What if I don’t use it all?

Both are pre-tax benefits your employer offers through a cafeteria plan. Choose one or both —whichever is right for you. Enrollment Considerations

A cafeteria plan enables you to save money on group insurance, healthcare expenses, and dependent care expenses. Your contributions are deducted from your paycheck by your employer before taxes are with withheld. These deductions lower your taxable income which can save you up to 35% on income taxes!

Our convenient NBS Benefits Card allows you to avoid out-of-pocket expenses, cumbersome claim forms and reimbursement delays. Or you may also utilize the “pay a provider” option on our web portal.

Get account information from our easy-to-use online portal and mobile app. See your account balance, contributions and account history in real time.

A dependent care FSA works differently than a health FSA. Money is only available as it is contributed and can only be used for dependent care expenses.

What’s a cafeteria plan?

Spending is easy

After the enrollment period ends, you may increase, decrease, or stop your contribution only when you experience a qualifying “change of status” (e.g. marriage, divorce, employment change, dependent change). Be conservative in the total amount you elect to avoid forfeiting money at the end of the plan year. 19

Because an FSA is a planning tool with great tax benefits, you must use the account balance in its entirety before the end of the plan year or it will be forfeited. This is known as the “use-it-or-lose-it” rule. Your employer may offer a grace period or a $550 rollover to help if you miss the mark a little bit. Just make sure to plan carefully when you enroll.

Healthcare Expense Account

Sample Expenses Medical Expenses •

Acupuncture

•

Diabetes (insulin, glucose monitor)

•

Physical exams

•

Addiction programs

•

Eye patches

•

Pregnancy tests

•

Adoption (medical expenses for baby birth)

•

Fertility treatment

•

Prescription drugs

•

Alternative healer fees

•

First aid (i.e. bandages, gauze)

•

Ambulance

Hearing aids & batteries

Psychiatrist/psychologist (for mental illness)

•

Physical therapy

Body scans

Hypnosis (for treatment of illness)

•

Incontinence products (i.e. Depends, Serene)

Speech therapy

Brest pumps

•

Vaccinations

•

Care for mentally handicapped

•

Joint support bandages and hosiery

•

Vaporizers or humidifiers

•

Chiropractor

•

Lab fees

•

Copayments

•

Weight loss program fees (if prescribed by physician

•

Crutches

Monitoring device (blood pressure, cholesterol)

•

Wheelchair

Dental Expenses

Items that generally do not qualify for reimbursement

•

Artificial teeth

•

Health club or fitness program fees

•

Copayments

Personal hygiene (deodorant, soap, body powder, sanitary products Addiction products

Homeopathic supplement or herbs

Deductible

•

Dental work

Allergy relief (oral meds, nasal spray)

Household or domestic help

•

Dentures

Antacids and heart burn relief

Laser hair removal

•

Anti-itch and hydrocortisone creams

Laxatives

Orthodontia expenses

•

Preventative care at dentist oﬃce

Athlete’s foot treatment

Massage therapy

•

Bridges, crown, etc.

Arthritis pain relieving creams

Motion sickness medication

•

Vision Expenses

Cold medicines (i.e. syrups, drops, tablets)

Nutritional and dietary supplements (i.e. bars, milkshakes, power drinks, Pedialyte)

•

Cosmetic surgery

•

Cosmetics (i.e. makeup, lipstick, cotton swabs, cotton balls, baby oil

Skin care (i.e. sun block, moisturizing lotion, lip balm)

•

Sleep aids (i.e. oral meds, snoring strips)

•

Smoking cessation relief (i.e. patches, gum)

•

Braille - books & magazines

•

Contact lenses

•

Contact lens solutions

•

Counseling (i.e. marriage/family

•

Eye exams

•

Eye glasses

•

Laser surgery

•

Oﬃce fees

•

Guide dog and upkeep/other animal aid

Dental care - routine (i.e. toothpaste, toothbrushes, dental floss, anti• bacterial mouthwashes, fluoride rinses, teeth whitening/bleaching) • Exercise equipment

• • •

Fever & pain reducers (i.e. Aspirin, Tylenol)

Stomach & digestive relief (i.e. PeptoBismol, Imodium) Tooth and mouth pain relief (Orajel, Anbesol)

•

Vitamins

•

Wart removal medicine

Haircare (i.e. hair color, shampoo, • conditioner, brushes, hair loss products)

Weight reduction aids (i.e. Slimfast, appetite suppressant)

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

Best Practices

Using your NBS Benefits Card

The NBS Benefits Card makes using your FSA easy by allowing you to pay your provider directly with funds from your FSA eliminating cashflow hardships. But even these transactions require substantation. Follow these tips to save time and simplify your experience.

Understanding Claim Substantiation The rules that govern Flexible Spending Accounts require that all claims be reviewed and adjudicated to ensure they are being used for eligible medical expenses under section 125 of the Internal Revenue Code. NBS uses Merchant Category Codes (MCCs), Inventory Information Approval Systems, and sophisticated matching systems to auto-substantiate 80% of all debit card transactions. For transactions that cannot be auto-substantiated, you will be asked to submit documentation to support your expense. Documentation may include an itemized receipt and/or a doctor’s note of medical necessity. Use the NBS mobile app to take a picture of your receipt and upload it to the portal where it will be reviewed and eligible expenses will be approved. You will be notified if the expense requires any further documentation or if the expense is ineligible. In the case of ineligible expenses, you will be asked to refund your account or offset the expense with other eligible expenses.

Use your debit card at your provider.

Save your receipt.

Upload the receipt to NBS using the NBS Mobile App or my.nbsbenefits.com.

NBS will take care of the rest!

Before you leave, ask for a detailed receipt. Receipt must include: •

The service or product

•

The date of the service (Billing/ Statement Date insufficient)

•

The amount of the charge

Over-the-counter medications will require a doctor’s note of medical necessity. 21

service@nbsbenefits.com

Making it Easy

When you’re on the go, save time and hassle with the NBS Mobile App.

NBS Mobile App

Submit claims, check your balances, view transactions, and submit documentation using your device’s camera.

Easy and secure •

•

Shares user authentication with the NBS portal. Registered users can download the app and log in immediately to gain access to their benefit accounts, with no need to register their phone or your account.

Mobile app features

No sensitive account information is ever stored on your mobile device and all transmissions use encryption.

The NBS mobile app supports a wide variety of features, empowering you to proactively manage your account.

Includes virtual assistant ‘Emma’

•

View account balances

•

View claims

•

View reimbursement history

•

Submit claims

•

Submit documentation using your device’s camera

•

Pay providers

•

Setup a variety of SMS alerts

•

Edit your personal information

•

View contribution details

•

View plan information

•

View calendar deadlines

•

Contact a service representative

•

View Benefits Card information

•

The first voice-activated intelligent assistant for consumer-driven healthcare. Ask Emma questions about your account such as: How much is my account balance? What is the annual contribution limit? Can I change my election amount?

Unum Dental

A smile-worthy dental plan

Outstanding Customer Service

Plan features: - See any dentist or maximize your benefits by utilizing our national network of more than 323,000+ dental access points1 with discounted fees for in-network services.



Professionally-staffed customer service with extended hours from 8:00 a.m. to 8:00 p.m. Monday-Friday and Saturday 10 a.m. to 4 p.m. (ET).



Our service statistics exceed the industry average:2

- Find an in-network provider at unumdentalcare.com - Manage benefits online with AlwaysAssist.com and on-the-go with the AlwaysAssist mobile app.

o 80% calls answered within 30 seconds on average. o Less than 2% of our calls are abandoned.

Monthly Premium Rates*: *Rates guaranteed from 10/1/2020 to 10/1/2022 and at least 5 enrolled in each plan. Minimum participation requirement of 70% of the total eligible lives.

HIGH OPTION

o We resolve 95% of issues during the first call.

LOW OPTION

Employee Only

$33.67

Employee Only

$27.96

Employee & Spouse

$68.84

Employee & Spouse

$57.21

Employee & Children

$97.05

Employee & Children

$71.95

$132.21

Employee & Family



An interactive voice response system is available 24/7 for benefit and eligibility information.



We are highly skilled in the area of “takeover” business and offer an extremely smooth business transition process. 1. Netminder data (September 2016) 2. Starmount/AlwaysCare Benefits internal data (2016).

$101.21

Overview: Outline of Benefits

High Option

Low Option

Benefit Year Maximum $2500 for Class A, B, C.

$1000 for Class A, B.

Deductible

$50 per benefit year. Maximum 3 per family. Applies to Basic (Class B) and Major (Class C) Services.

Carryover Benefit

Included

Coinsurance Class A Class B Class C Class D

In-Network 100% 80% 50% 50%

Non-Network 100% 80% 50% 50% 24

Class A Class B Class C

In-Network 100% 70% 40%

Non-Network 100% 70% 40%

Covered procedures and waiting periods: Outline of Benefits

High Option

Low Option

Class A

Waiting Period: None

Preventative Services

 

       Class B Basic Services

Waiting Period: None       

Class C Major Services

 

Orthodontics

Fillings (Benefit allowed for amalgam restorations on posterior teeth) Anesthesia (subject to review, covered with complex oral surgery) Simple extractions Oral surgery (surgical extractions & impactions) Non-surgical periodontics Endodontics (root canals) Surgical periodontics (gum treatments)

 



      

Routine exams (2 per 12 months) Prophylaxis (2 per 12 months) o (1 additional cleaning or periodontal maintenance per 12 months, if member is in 2nd or 3rd trimester of pregnancy) Bitewing x-rays (max 4 films; 1 per 12 months) Full mouth x-ray (1 per 24 months) Fluoride to age 16 (1 per 12 months) Adjunctive Pre-Diagnostic Oral Cancer Screening (1 per 12 months for age 40+) Emergency pain (1 per 12 months) Sealants to age 16 (permanent molars, 1 per 36 months) Space maintainers to age 16 (1 per 24 months)

       

Fillings(Benefit allowed for amalgam restorations on posterior teeth) Anesthesia (subject to review, covered with complex oral surgery) Simple extractions Non-surgical periodontics Oral surgery (surgical extractions & impactions) Endodontics (root canals) Surgical periodontics (gum treatments) Repair of Crown, denture, or bridge

Waiting Period: None

Inlays and Onlays Repair of Crown, denture, or bridge Crowns, Bridges, Dentures and Endosteal Implants (in lieu of an approved 3-unit bridge)

Waiting Period: None 



Waiting Period: None

Waiting Period: None 

Class D

Routine exams (2 per 12 months) Prophylaxis (2 per 12 months) o (1 additional cleaning or periodontal maintenance per 12 months, if member is in 2nd or 3rd trimester of pregnancy) Bitewing x-rays (max 4 films; 1 per 12 months) Full mouth x-ray (1 per 24 months) Fluoride to age 16 (1 per 12 months) Sealants to age 16 (permanent molars, 1 per 36 months) Adjunctive Pre-Diagnostic Oral Cancer Screening (1 per 12 months for age 40+) Emergency pain (1 per 12 months) Space maintainers to age 16 (1 per 24 months)

 

Inlays and Onlays Crowns, Bridges, Dentures and Endosteal Implants (in lieu of an approved 3-unit bridge)

Not Covered

Separate Lifetime maximum: $2000 Up to 25% of lifetime allowance may be payable on initial banding. Dep. Children to age 19 only

Dental carryover benefit

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

Members who take care of their teeth, but use only part of their annual maximum benefit during a benefit period are rewarded with extra benefits in future years! If an Insured submits qualifying claims for covered expenses during a benefit year and, in that benefit year, receives benefits that are less than their group’s threshold limit, the insured will be credited a carryover benefit. Carryover benefits will be accrued and stored in the insured’s carryover account to be used in the next benefit year. If an insured reaches his or her certificate year maximum benefit, we will pay a benefit from the insured’s carryover account up to the amount stored in the insured’s carryover account. The accrued carryover benefits stored in the carryover account may not be greater than the carryover account limit.

Exclusions/limitations: Unum members whose dental plan includes coverage of crowns and bridges will have the option of choosing an endosteal implant to replace a missing tooth instead of a conventional fixed 3-unit bridge, when a 3-unit bridge is approved for coverage. Crowns placed on implants will also be covered. Other implants or implant related services are not covered. The following dental services are not covered:  any treatment which is elective or primarily cosmetic in nature and not generally recognized as a generally accepted dental practice by the American Dental Association, as well as any replacement of prior cosmetic restorations;  the correction of congenital malformations;  the replacement of lost, discarded, or stolen appliances;  replacement of bridges, dentures, crowns, inlays, onlays or dentures unless more than [5] years old and cannot be made serviceable;  appliances, services or procedures relating to: (i) the change or maintenance of vertical dimension; (ii) restoration of occlusion; (iii) splinting; (iv) correction of attrition, abrasion, erosion or a fraction; (v) bite registration; or (vi) bite analysis;  services provided for any type of temporomandibular joint (TMJ) dysfunctions, muscular, skeletal deficiencies involving TMJ or related structures, myofascial pain;  charges for implants (except noted above), removal of implants, precision or semi-precision attachments, denture duplication, overdentures and any associated surgery, or other customized services or attachments, and related procedures;  dentures for teeth missing prior to effective date of coverage; some exceptions apply and are detailed in the Certificate of Coverage;  multiple x-rays done on same date of service will be combined to a fullmouth x-ray;  cosmetic restorations on posterior permanent teeth and all primary teeth will be given alternate benefit;  Anesthesia is covered with complex oral surgery only. Charges are subject to review. Pre-treatment estimate is recommended.

The limits for this policy/certificate are:  

High Option - Carryover benefit $400, threshold limit $800, carryover account Limit $1500. Low Option - Carryover benefit $250, threshold limit $500, carryover account Limit $1000.

Other specifications:   

  



An insured’s carryover account will be eliminated, and the accrued carryover benefits lost, if the insured has a break in coverage of any length of time, for any reason. Eligibility for a carryover benefit will be established or reestablished at the time the first qualifying claim in a benefit year is received for covered expenses incurred during that benefit year. In order to be eligible to accumulate the carryover benefit, an insured must be enrolled in the plan at least four months prior to the start of the new policy year. Example: If the plan effective date is January 1st, the insured must be enrolled by September 1st. Only claims incurred on or after the start of the next policy year will count toward the threshold Limit. Carryover benefits will not be applied to an insured’s carryover account until the policy year that starts one year from the date the rider first applies. If charges for Class C services are not payable for an insured due to a benefit waiting period for certain covered procedures, this rider will not apply to the insured until the end of such waiting period. And, if the waiting period ends within the three months prior to the start of this plan’s next benefit year, this rider will not apply to the insured until the next benefit year. Carryover benefits will not be applied to an insured’s carryover account until the benefit year that starts one year from the date the rider first applies.

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

Definitions:      

“Benefit year” means calendar year or policy year, according to the type of plan applicable under the policy/certificate to which this rider is attached. “Carryover account” means the amount of an insured’s accrued carryover benefits. “Carryover account limit” means the maximum amount of cumulative Carryover benefits that an insured can store in his or her carryover account. “Carryover benefit” means the dollar amount, which will be added to an insured’s carryover account when he or she receives benefits in a benefit year that do not exceed the threshold limit. Qualifying claim means a claim under procedure classes A, B, C, and class D, orthodontia and must include 1 exam & 1 cleaning. “Threshold limit” means the maximum amount of benefits for all procedure classes A, B, C and D that an insured can receive during a benefit year and still be entitled to receive the carryover benefit.

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

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

Dependent children: Dependent age guidelines vary by state. Please refer to your policy certificate or contact customer service at (888) 400-9304.

Services not listed: If you expect to require a dental or vision service not

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

included on this brochure, it may still be covered. Please contact customer service at (888) 400-9304 to confirm your exact benefits.

AlwaysAssist.com Access your ID card, locate providers and more!

How to register: Visit AlwaysAssist.com or download the mobile app to register for access. Select “Member Registration” on the login screen and complete the required information.

Trouble logging in? Contact us. Customer Service: (888) 400-9304

Find all the information you need to manage your coverage — like printing your member ID card or benefit summaries, locating providers, checking claim status and learning about good dental and vision health. Website features › › › ›

Print ID cards View coverage Manage claim privacy View Frequently Asked Questions

› › › ›

Email customer service View current benefit elections Change email address Access forms and documents

AlwaysAssistSM mobile app features TRY THE APP NOW!

Scan this code to go directly to the app download page, or visit bit.ly/AlwaysAssist-App.

Always have up-to-date dental & vision ID cards.

Find in-network dental & vision providers near you.

Review your dental & vision claims.

Download the AlwaysAssist Mobile App for your Apple iPhone & iPad or Android devices for easy, on-the-go access to your ID cards, benefits, claims and more. It’s simple, secure and free! › Schedule appointments › Manage your AlwaysAssist account › Connect to the AlwaysAssist site

› Register in the app › Access dental & vision benefits information

Vision Plan Benefits for City of Lufkin Co-Pays

Exam Materials

$10 $25

Monthly Premiums Emp. only Emp. + spouse Emp. + child(ren) Emp. + family

Services/Frequency $7.55 $15.14 $12.81 $21.13

Exam Frame Lenses Contact Lenses

12 months 12 months 12 months 12 months

(Based on date of service)

Benefits through Superior Select Southwest Network Exam Frames Lenses (standard) per pair Single Vision Bifocal Trifocal Progressive Polycarbonate Ultraviolet Coating Contact Lenses2 Medically Necessary Contact Lenses Lasik Vision Correction3

In-Network

Covered in full $130 retail allowance

Out-of-Network Up to $35 retail Up to $70 retail

Covered in full Up to $25 retail Covered in full Up to $40 retail Covered in full Up to $45 retail See description1 Up to $45 retail Covered in full Up to $20 retail Covered in full Up to $20 retail $130 retail allowance Up to $80 retail Covered in full Up to $150 retail $200 allowance

Co-pays apply to in-network benefits; co-pays for out-of-network visits are deducted from reimbursements 1 Covered to provider’s in-office standard retail lined trifocal amount; member pays difference between progressive and standard retail lined trifocal, plus applicable co-pay 2 Contact lenses and related professional services (fitting, evaluation and follow-up) are covered in lieu of eyeglass lenses and frames benefit 3 Lasik Vision Correction is in lieu of eyewear benefit, subject to routine regulatory filings and certain exclusions and limitations

Discount Features Non-Covered Eyewear Discount: Members may also receive a discount of 20% from a participating provider’s usual and customary fees for eyewear purchases which exceed the benefit coverage (except disposable contact lenses, for which no discount applies). This includes eyeglass frames which exceed the selected benefit coverage, specialty lenses (i.e. progressives) and lens “extras” such as tints and coatings. Eyewear purchased from a Walmart Vision Center does not qualify for this additional discount because of Walmart’s “Always Low Prices” policy. The National LASIK Network of laser vision correction providers, featuring LasikPlus, offers members special program pricing on services. The program pricing should be verified prior to service.

SuperiorVision.com Customer Service 800.507.3800

The Plan discount features are not insurance. All allowances are retail; the member is responsible for paying the provider directly for all non-covered items and/or any amount over the allowances, minus available discounts. These are not covered by the plan. Discounts are subject to change without notice. Disclaimer: All final determinations of benefits, administrative duties, and definitions are governed by the Certificate of Insurance for your vision plan. Please check with your Human Resources department if you have any question

Superior Select Southwest

FINDING IN-NETWORK PROVIDERS It’s Easy to Find a Superior Provider Find an In-Network Provider Near You 

Go to SuperiorVision.com and click on Locate a Provider.



On the next screen, enter your location information.



Select Insurance Through Your Employer as your coverage type.



A drop-down menu will appear. Select the Superior Select Southwest network.



Then, choose the distance for your search and click the Find Providers button.

Narrow Your Search Results On the search results page, you can refine your search by: 

Practice name



Provider name



Selecting from a list of services

Once You’ve Selected a Superior Vision Provider  Call your selected eye care provider prior to your

appointment to verify provider network participation and to confirm services and acceptance of your vision plan.  It’s important to note that not all providers at each

office or optical store location are in-network providers, nor do they participate in all networks.

You may also contact Customer Service at contactus@superiorvision.com or 800.507.3800 for assistance in locating an in-network provider.

GROUP VOLUNTARY ACCIDENT INSURANCE BENEFIT HIGHLIGHTS City of Lufkin

With Accident insurance, you’ll receive payment(s) associated with a covered injury and related services. You can use the payment in any way you choose – from expenses not covered by your major medical plan to day-to-day costs of living such as the mortgage or your utility bills.

More More than than 3.5 3.5 million million

To learn more about Accident insurance, visit thehartford.com/employeebeneﬁts

children children ages ages 14 14 and and younger younger get get hurt hurt annually annually playing playing sports sports or or participating participating in in recreational recreational activities. activities.11

COVERAGE INFORMATION

This insurance provides beneﬁts when injuries, medical treatment and/or services occur as the result of a covered accident. Unless otherwise noted, the beneﬁt amounts payable under each plan are the same for you and your dependent(s).

PLAN INFORMATION Coverage Type

Off-job only

BENEFITS EMERGENCY, HOSPITAL & TREATMENT CARE Accident Follow-Up Acupuncture/Chiropractic Care Physical Therapy Ambulance – Air Ambulance – Ground Blood/Plasma/Platelets Child Care Daily Hospital Confinement Daily ICU Confinement Diagnostic Exam Emergency Dental Emergency Room Hospital Admission Initial Physician Office Visit Lodging Medical Appliance Rehabilitation Facility Transportation Urgent Care X-ray

Up to 3 visits per accident Up to 10 visits each per accident Up to 10 visits each per accident Once per accident Once per accident Once per accident Up to 30 days per accident while insured is conﬁned Up to 365 days per lifetime Up to 30 days per accident Once per accident Once per accident Once per accident Once per accident Once per accident Up to 30 nights per lifetime Once per accident Up to 15 days per lifetime Up to 3 trips per accident Once per accident Once per accident

SPECIFIED INJURY & SURGERY Abdominal/Thoracic Surgery Arthroscopic Surgery Burn Burn – Skin Graft Concussion Dislocation Eye Injury Fracture

Once per accident Once per accident Once per accident Once per accident for third degree burn(s) Up to 3 per year Once per joint per lifetime Once per accident Once per bone per accident

CITY OF LUFKIN ACCIDENT BHS_PUBLICATION DATE: 6/5/2019

32 00096270

$100 $25 $60 $600 $200 $600 $25 $200 $400 $100 Up to $150 $200 $1,000 $100 $200 $250 $200 $400 $100 $200 $2,000 $300 $1,000 50% of burn beneﬁt $300 Up to $8,000 Up to $200 Up to $8,000 PAGE 1 OF 4

Hernia Repair Joint Replacement Knee Cartilage Laceration Ruptured Disc Tendon/Ligament/Rotator Cuff

Once per accident Once per accident Once per accident Once per accident Once per accident Up to 1 per accident

$100 $1,500 Up to $1,000 Up to $200 $1,000 Up to $1,500

CATASTROPHIC Accidental Death Common Carrier Death Coma Dismemberment Home Health Care Paralysis Prosthesis

Within 90 days; Spouse @ 50% and child @ 25% Within 90 days Once per accident Once per accident Up to 30 days per accident Once per accident Up to 2 per accident

FEATURES

$40,000 5 times death beneﬁt $20,000 Up to $40,000 $50 Up to $30,000 Up to $2,000

Ability Assist® EAP2 – 24/7/365 access to help for ﬁnancial, legal or emotional issues

Included

HealthChampion

Included

SM2

– Administrative & clinical support following serious illness or injury

ASKED & ANSWERED

WHO IS ELIGIBLE? You are eligible for this insurance if you are an active full-time employee who works at least 15 hours per week on a regularly scheduled basis, and are less than age 80. Your spouse and child(ren) are also eligible for coverage. Any child(ren) must be under age 26. CAN I INSURE MY DOMESTIC OR CIVIL UNION PARTNER? Yes. Any reference to “spouse” in this document includes your domestic partner, civil union partner or equivalent, as recognized and allowed by applicable law. AM I GUARANTEED COVERAGE? This insurance is guaranteed issue coverage – it is available without having to provide information about your or your family’s health. All you have to do is elect the coverage to become insured. HOW DO I PAY FOR THIS INSURANCE? Premiums will be automatically paid through payroll deduction, as authorized by you during the enrollment process. This ensures you don’t have to worry about writing a check or missing a payment. WHEN CAN I ENROLL? You may enroll during any scheduled enrollment period, or within 31 days of the date you have a change in family status, or within 31 days of the completion of any eligibility waiting period established by your employer. WHEN DOES THIS INSURANCE BEGIN? The initial effective date of this coverage is September 1, 2019. Subject to any eligibility waiting period established by your employer, if you enroll for coverage prior to this date, insurance will become effective on this date. If you enroll for coverage after this date, insurance will become effective in accordance with the terms of the certificate (usually the first day of the month following the date you elect coverage). You must be actively at work with your employer on the day your coverage takes effect. Your spouse and child(ren) must be performing normal activities and not be confined (at home or in a hospital/care facility).

.VOLUNTARY

ACCIDENT INSURANCE Monthly Premium Amount (Cost per Pay Period – 12/Year) COVERAGE TIER Employee Only Employee & Spouse/Partner Employee & Child(ren) Employee & Family

CITY OF LUFKIN ACCIDENT BHS_PUBLICATION DATE: 6/5/2019

PLAN 1 $12.59 ($0.41 per day) $19.42 ($0.64 per day) $24.00 ($0.79 per day) $31.79 ($1.05 per day)

33 00096270

PAGE 2 OF 4

CITY OF LUFKIN

Premium Worksheet

.VOLUNTARY

ACCIDENT INSURANCE Monthly Premium Amount (Cost per Pay Period – 12/Year) COVERAGE TIER Employee Only Employee & Spouse/Partner Employee & Child(ren) Employee & Family

PLAN 1 $12.59 ($0.41 per day) $19.42 ($0.64 per day) $24.00 ($0.79 per day) $31.79 ($1.05 per day)

VOLUNTARY HOSPITAL INDEMNITY INSURANCE Monthly Premium Amount (Cost per Pay Period – 12/Year) COVERAGE TIER

PLAN 2

Employee Only

$17.77 ($0.58 per day)

Employee & Spouse/Partner

$36.87 ($1.21 per day)

Employee & Child(ren)

$33.46 ($1.10 per day)

Employee & Family

$54.89 ($1.80 per day)

Prepare. Protect. Prevail. With The Hartford. ® The Hartford® is The Hartford Financial Services Group, Inc. and its subsidiaries, including issuing companies Hartford Life Insurance Company and Hartford Life and Accident Insurance Company. Home Office is Hartford, CT. This document explains the general purpose of the insurance described, but in no way changes or affects the policy as actually issued. In the event of a discrepancy between this document and the policy, the terms of the policy apply. Benefits are subject to state availability. Policy terms and conditions vary by state. Complete details are in the Certificate of Insurance issued to each insured individual and the Master Policy as issued to the policyholder.

PAGE 1 OF 1

CREATION DATE: 6/5/2019 CITY OF LUFKIN

GC14

Limited Benefit Group Specified Disease Cancer Indemnity Insurance

For Employees of Cit of Lufkin

THE INSURANCE POLICY UNDER WHICH THIS CERTIFICATE IS ISSUED IS NOT A POLICY OF WORKERS’ COMPENSATION INSURANCE. YOU SHOULD CONSULT YOUR EMPLOYER TO DETERMINE WHETHER YOUR EMPLOYER IS A SUBSCRIBER TO THE WORKERS’ COMPENSATION SYSTEM.

Summary of Benefits

Plan 1

Cancer Treatment Policy Benefits

Level 3

Radiation Therapy, Chemotherapy, Immunotherapy - Maximum per 12-month period

$15,000

Hormone Therapy - Maximum of 12 treatments per calendar year

$50 per treatment

Experimental Treatment

paid in same manner and under the same maximums as any other benefit

Cancer Screening Rider Benefits

Level 1

Diagnostic Testing - 1 test per calendar year

$50 per test

Follow-Up Diagnostic Testing - 1 test per calendar year

$100 per test

Medical Imaging - per calendar year

$500 per test / 1 per calendar year

Surgical Rider Benefits

Level 1

Surgical

$30 unit dollar amount Max $3,000 per operation

Anesthesia

25% of amount paid for covered surgery

Bone Marrow Transplant - Maximum per lifetime

$6,000

Stem Cell Transplant - Maximum per lifetime

$600

Prosthesis - Surgical Implantation/Non-Surgical (not Hair Piece) 1 device per site, per lifetime

$1,000 / $100

Miscellaneous Care Rider Benefits

Level 1

Cancer Treatment Center Evaluation or Consultation - 1 per lifetime

not included

Evaluation or Consultation Travel and Lodging - 1 per lifetime

not included

Second / Third Surgical Opinion - per diagnosis of cancer

$300 / $300

Drugs and Medicine - Inpatient / Outpatient (maximum $150 per month)

$150 per confinement $50 per prescription

Hair Piece (Wig) - 1 per lifetime

$150

Transportation - Maximum 12 trips per calendar year for all modes of transportation combined Travel by bus, plane or train Travel by car Lodging - up to a maximum of 100 days per calendar year Family Transportation - Maximum 12 trips per calendar year for all modes of transportation combined Travel by bus, plane or train Travel by car Family Lodging - up to a maximum of 100 days per calendar year

actual coach fare or $0.40 per mile $0.40 per mile $50 per day actual coach fare or $0.40 per mile $0.40 per mile $50 per day

Blood, Plasma and Platelets

$300 per day

Ambulance - Ground/Air - Maximum of 2 trips per Hospital Confinement for all modes of transportation combined

$200 / $2,000 per trip

Inpatient Special Nursing Services - per day of Hospital Confinement

$150 per day

Outpatient Special Nursing Services - Up to same number of Hospital Confinement days

$150 per day

Medical Equipment - Maximum of 1 benefit per calendar year

not included

Physical, Occupational, Speech, Audio Therapy & Psychotherapy / Maximum per calendar year

$25 per visit / $1,000

Waiver of Premium

Waive Premium

Internal Cancer First Occurrence Rider Benefits

Level 2

Lump Sum Benefit - Maximum 1 per Covered Person per lifetime

$5,000

Lump Sum for Eligible Dependent Children - Maximum 1 per Covered Person per lifetime

$7,500

Hospital Intensive Care Unit Rider Benefits

Level 1

Intensive Care Unit

$600 per day

Step Down Unit - Maximum of 45 days per Confinement for any combination of Intensive Care Unit or Step Down Unit

$300 per day

APSB-22347(TX)-0320

Page 1 of 3

GC 14 Limited Benefit Group Specified Disease Cancer Indemnity Insurance Total Monthly Premiums by Plan** Issue Ages

Individual

Individual & Spouse

1 Parent Family

2 Parent Family

18 +

$21.78

$45.74

$27.70

$51.64

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

Benefits are only payable following a diagnosis of cancer for a loss incurred for the treatment of cancer while covered under the policy. A charge must be incurred for benefits to be payable. When coverage terminates for loss incurred after the coverage termination date, our obligation to pay benefits also terminates for a specified disease that manifested itself while the person was covered under the policy. All benefits are subject to the benefit maximums.

Cancer Treatment Benefits Eligibility

You and your eligible dependents are eligible to be insured under this certificate if you and your eligible dependents meet our underwriting rules and you are actively at work with the policyholder and qualify for coverage as defined in the master application. A covered person is a person who is eligible for coverage under the certificate and for whom the coverage is in force. An eligible dependent means your lawful spouse; your natural, adopted or stepchild who is under the age of 26; and/or any child under the age of 26 who is under your charge, care and control, and who has been placed in your home for adoption, or for whom you are a party in a suit in which adoption of the child is sought; or any child under the age of 26 for whom you must provide medical support under an order issued under Chapter 154 of the Texas Family Code, or enforceable by a court in Texas; or grandchildren under the age of 26 if those grandchildren are your dependents for federal income tax purposes at the time application for coverage of the grandchild is made.

Limitations and Exclusions

No benefits will be paid for any of the following: treatment by any program engaged in research that does not meet the definition of experimental treatment; or losses or medical expenses incurred prior to the covered person’s effective date regardless of when specified disease was diagnosed.

Termination of Coverage

Insurance coverage for a covered person under the certificate and any attached riders for a covered person will end as follows: the date the policy terminates; the date the certificate terminates; the end of the grace period if the premium remains unpaid; the end of the certificate month in which the policyholder requests to terminate the coverage for an eligible dependent; the date a covered person no longer qualifies as an insured or eligible dependent; or the date of the covered person’s death. We may end the coverage of any Covered Person who submits a fraudulent claim.

Cancer Screening Benefits Limitations and Exclusions

No benefits will be paid for any of the following: treatment by any program engaged in research that does not meet the definition of experimental treatment; losses or medical expenses incurred prior to the covered person’s effective date of this rider; or loss incurred during the pre-existing condition exclusion period following the covered person’s effective date of this rider as a result of a pre-existing condition.

Surgical Benefits

Limitations and Exclusions

No benefits will be paid for any of the following: treatment by any program engaged in research that does not meet the definition of experimental treatment; losses or medical expenses incurred prior to the covered person’s effective date of this rider regardless of when a specified disease was diagnosed; or loss incurred during the pre-existing condition exclusion period following the covered person’s effective date of this rider as a result of a pre-existing condition.

Miscellaneous Benefits Waiver of Premium

Only Loss for Cancer

The policy pays only for loss resulting from definitive cancer treatment including direct extension, metastatic spread or recurrence. Proof must be submitted to support each claim. The policy also covers other conditions or diseases directly caused by cancer or the treatment of cancer. The policy does not cover any other disease, sickness or incapacity which existed prior to the diagnosis of cancer, even though after contracting cancer it may have been complicated, aggravated or affected by cancer or the treatment of cancer.

Pre-Existing Condition Exclusion

No benefits are payable for any loss incurred during the pre-existing condition exclusion period, following the covered person’s effective date as the result of a pre-existing condition. Pre-existing conditions specifically named or described as excluded in any part of the policy are never covered. If any change to coverage after the certificate effective date results in an increase or addition to coverage, incontestability and pre-existing condition exclusion for such increase will be based on the effective date of such increase.

Termination of Certificate

Insurance coverage under the certificate and any attached riders will end on the earliest of these dates: the date the policy terminates; the end of the grace period if the premium remains unpaid; the date insurance has ceased on all persons covered under this certificate; the end of the certificate month in which the policyholder requests to terminate this coverage; the date you no longer qualify as an insured; or the date of your death.

When the certificate is in force and you become disabled, we will waive all premiums due including premiums for any riders attached to the certificate. Disability must be due to cancer and occur while receiving treatment for such cancer. You must remain disabled for 60 continuous days before this benefit will begin. The waiver of premium will begin on the next premium due date following the 60 consecutive days of disability. This benefit will continue for as long as you remain disabled until the earliest of either of the following: the date you are no longer disabled; the date coverage ends according to the termination provisions in the certificate; or the date coverage ends according to the termination provisions in this rider. Proof of disability must be provided for each new period of disability before a new waiver of premium benefit is payable.

Limitations and Exclusions

No benefits will be paid for any of the following: treatment by any program engaged in research that does not meet the definition of experimental treatment; losses or medical expenses incurred prior to the covered person’s effective date of this rider regardless of when a specified disease was diagnosed; or loss incurred during the pre-existing condition exclusion period following the covered person’s effective date of this rider as a result of a pre-existing condition.

APSB-22347(TX)-0320

Page 2 of 3

Termination of Cancer Screening, Surgical & Miscellaneous Benefit Riders

The above listed rider(s) will terminate and coverage will end for all covered persons on the earliest of: the end of the grace period if the premium for the rider remains unpaid; the date the policy or certificate to which the rider is attached terminates; the end of the certificate month in which APL receives a request from the policyholder to terminate the rider; or the date of your death. Coverage on an eligible dependent terminates under the rider when such person ceases to meet the definition of eligible dependent.

the armed forces, or military service for any country at war (if coverage is suspended for any covered person during a period of military service, we will refund the pro-rata portion of any premium paid for any such covered person upon receipt of the policyholder’s written request); participation in any activity or event while intoxicated or under the influence of any narcotic unless administered by a physician or taken according to the physician’s instructions; participation in, or attempting to participate in, a felony, riot or insurrection (a felony is defined by the law of the jurisdiction in which the activity takes place).

Termination

Pays a lump sum benefit amount when a covered person receives a first diagnosis of internal cancer. Only one benefit per covered person, per lifetime is payable under this benefit and the lump sum benefit amount will reduce by 50% at age 70.

This rider will terminate and coverage will end for all covered persons on the earliest of any of the following: the end of the grace period if the premium for this rider remains unpaid; the date the policy or certificate to which this rider is attached terminates; the end of the certificate month in which we receive a request from the policyholder to terminate this rider or the date of the covered person’s death. Coverage on an eligible dependent terminates under this rider when such person ceases to meet the definition of eligible dependent.

Limitations and Exclusions

Optionally Renewable

Internal Cancer First Occurrence Benefits

We will not pay benefits for a diagnosis of internal cancer received outside the territorial limits of the United States or a metastasis to a new site of any cancer diagnosed prior to the covered person’s effective date, as this is not considered a first diagnosis of an internal cancer.

Pre-Existing Condition Exclusion

No benefits are payable for any loss incurred during the pre-existing condition exclusion period following the covered person’s effective date of this rider as the result of a pre-existing condition.

Termination

This rider will terminate and coverage will end for all covered persons on the earliest of any of the following: the end of the grace period if the premium for this rider remains unpaid; the date the policy or certificate to which this rider is attached terminates; the end of the certificate month in which we receive a request from the policyholder to terminate this rider; the date of covered person’s death or the date the lump sum benefit amount for internal cancer has been paid for all covered persons under this rider. Coverage on an eligible dependent terminates under this rider when such person ceases to meet the definition of eligible dependent.

Hospital Intensive Care Unit Benefits

Pays a daily benefit amount, up to the maximum number of days for any combination of confinement, for each day charges are incurred for room and board in an intensive care unit (ICU) or step-down unit due to an accident or sickness. Benefits will be paid beginning on the first day a covered person is confined in an ICU or step-down unit due to an accident or sickness that begins after the effective date of this rider. This benefit will reduce by 50% at age 70.

Limitations and Exclusions

For a newborn child born within the 10-month period following the effective date, no benefits under this rider will be provided for confinements that begin within the first 30 days following the birth of such child. No benefits under this rider will be provided during the first two years following the effective date for confinements caused by any heart condition when any heart condition was diagnosed or treated prior to the end of the 30-day period following the covered person’s effective date. The heart condition causing the confinement need not be the same condition diagnosed or treated prior to the effective date. We will not pay benefits for any loss caused by or resulting from any of the following: intentionally self-inflicted bodily injury, suicide or attempted suicide, whether sane or insane; alcoholism or drug addiction; any act of war, declared or undeclared, or any act related to war, or active service in

This policy/riders are optionally renewable. The policyholder or we have the right to terminate the policy/riders on any premium due date after the first anniversary following the policy/riders effective date. We must give at least 60 days written notice to the policyholder prior to cancellation.

Portability Amendment Rider

When you no longer meet the definition of Insured, you will have the option to continue this coverage, including any attached riders. No Evidence of Insurability will be required. Portability must meet all of the following conditions: the certificate has been continuously in force for the last 12 months; we receive a request and payment of the first premium for the portability coverage no later than 30 days after the date you no longer qualify as an eligible insured; and the policy, under which this certificate was issued, continues to be in force on the date you cease to qualify for coverage. All future premiums due will be billed directly to you. You are responsible for payment of all premiums for the portability coverage. The benefits, terms and condition of the portability coverage will be the same as those elected under the certificate immediately prior to the date you exercised portability. Portability coverage may include any eligible dependents who were covered under the certificate at the time you ceased to qualify as an eligible insured. No new eligible dependents may be added to the portability coverage except as provided in the New Born and Adopted Children provision. No increases in coverage will be allowed while you are exercising your rights under this rider. The premium for the portability coverage will be based on the premium tables used for such coverage at the time of the portability request. Coverage under this rider will terminate in accordance with the provisions of the Termination of Coverage in the certificate. If the policy is no longer in force, then portability coverage is not available.

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

Underwritten by American Public Life Insurance Company. This is a brief description of the coverage. For complete benefits, limitations, exclusions and other provisions, please refer to the policy and riders. This coverage does not replace Workers’ Compensation Insurance. This product is inappropriate for people who are eligible for Medicaid coverage. | This policy is considered an employee welfare benefit plan established and/or maintained by an association or employer intended to be covered by ERISA, and will be administered and enforced under ERISA. Group policies issued to governmental entities and municipalities may be exempt from ERISA guidelines. | Policy Form GC14 Series | TX | Limited Benefit Group Specified Disease Cancer Indemnity Insurance | (03/20) 38

APSB-22347(TX)-0320

Page 3 of 3

GROUP VOLUNTARY HOSPITAL INDEMNITY INSURANCE BENEFIT HIGHLIGHTS City of Lufkin

Hospital indemnity (HI) insurance pays a cash benefit if you or an insured dependent (spouse or child) are confined in a hospital for a covered illness or injury. Even with the best primary health insurance plan, out-of-pocket costs from a hospital stay can add up.

A 4-day stay in the hospital could cost

The benefits are paid in lump sum amounts to you, and can help offset expenses that primary health insurance doesn’t cover (like deductibles, co-insurance amounts or copays), or benefits can be used for any non-medical expenses (like housing costs, groceries, car expenses, etc.).

around $10,000.1 To learn more about Hospital Indemnity insurance, visit thehartford.com/employeebenefits

COVERAGE INFORMATION Benefit amounts are based on the plan in effect for you or an insured dependent at the time the covered event occurs. Unless otherwise noted, the benefit amounts payable under each plan are the same for you and your dependent(s).

PLAN INFORMATION Coverage Type

On and off-job (24 hour)

Covered Events

Illness and injury

HSA Compatible

Yes

BENEFITS HOSPITAL CARE2 First Day Hospital Confinement Daily Hospital Confinement (Day 2+) Daily ICU Confinement VALUE ADDED SERVICES

Up to 1 day per year Up to 30 days per year Up to 30 days per year

$1,500 $100 $200

Ability Assist® EAP4 – 24/7/365 access to help for financial, legal or emotional issues HealthChampionSM5 – Administrative & clinical support following serious illness or injury

Included Included

PREMIUMS See the Premium Worksheet.3

ASKED & ANSWERED IS THIS COVERAGE HSA COMPATIBLE? If you (or any dependent(s)) currently participate in a Health Saving Account (HSA) or if you plan to do so in the future, you should be aware that the IRS limits the types of supplemental insurance you may have in addition to a HSA, while still maintaining the taxexempt status of the HSA. This plan design was designed to be compatible with Health Savings Accounts (HSAs). However, if you have or plan to open an HSA, please consult your tax and legal advisors to determine which supplemental benefits may be purchased by employees with an HSA. WHO IS ELIGIBLE? You are eligible for this insurance if you are an active employee who works at least 15 hours per week on a regularly scheduled basis. Your spouse and child(ren) are also eligible for coverage. Any child(ren) must be under age 26. CAN I INSURE MY DOMESTIC OR CIVIL UNION PARTNER? Yes. Any reference to “spouse” includes your domestic partner, civil union partner or equivalent, as recognized and allowed by applicable law. 40

AM I GUARANTEED COVERAGE? This insurance is guaranteed issue coverage – it is available without having to provide information about your or your family’s health. All you have to do is elect the coverage to become insured.5 HOW DO I PAY FOR THIS INSURANCE? Premiums will be automatically paid through payroll deduction, as authorized by you during the enrollment process. This ensures you don’t have to worry about writing a check or missing a payment. WHEN CAN I ENROLL? You may enroll during any scheduled enrollment period, within 31 days of the date you have a change in family status, or within 31 days of the completion of any eligibility waiting period established by your employer. WHEN DOES THIS INSURANCE BEGIN? The initial effective date of this coverage is September 1, 2019. Subject to any eligibility waiting period established by your employer, if you enroll for coverage prior to this date, insurance will become effective on this date. If you enroll for coverage after this date, insurance will become effective in accordance with the terms of the certificate (usually the first day of the month following the date you elect coverage). You must be actively at work with your employer on the day your coverage takes effect. Your spouse and child(ren) must be performing normal activities and not be confined (at home or in a hospital/care facility). WHEN DOES THIS INSURANCE END? This insurance will end when you or your dependent(s) no longer satisfy the applicable eligibility conditions, premium is unpaid, you are no longer actively working, you leave your employer, or the coverage is no longer offered. CAN I KEEP THIS INSURANCE IF I LEAVE MY EMPLOYER OR AM NO LONGER A MEMBER OF THIS GROUP? Yes, you can take this coverage with you. Coverage may be continued for you and your dependent(s) under a group portability policy. Your spouse may also continue insurance in certain circumstances.

1“Hospital

Adjusted Expenses per Inpatient Day.” Kaiser Family Foundation. 2015. Web. 2 Mar. 2017. Hospital Care benefits, when an insured is eligible for more than one benefit in a single day, only the highest benefit will be paid. 3Rates and/or benefits may be changed. 4AbilityAssist® services are offered through The Hartford by ComPsych®. ComPsych is not affiliated with The Hartford and is not a provider of insurance services. The Hartford is not responsible and assumes no liability for the goods and services provided by ComPsych and reserves the right to discontinue any of these services at any time. Ability Assist is a registered trademark of The Hartford. Services may not be available in all states. Visit https://www.thehartford.com/employee-benefits/value-added-services for more information. 5HealthChampion℠ services are provided through The Hartford by ComPsych®. ComPsych is not affiliated with The Hartford and is not a provider of insurance services. The Hartford doesn’t provide basic hospital, basic medical, or major medical insurance. HealthChampion specialists are only available during business hours. Inquiries outside of this timeframe can either request a call-back the next day or schedule an appointment. The Hartford is not responsible and assumes no liability for the goods and services provided by ComPsych and reserves the right to discontinue any of these services at any time. Health Champion is a service mark of ComPsych. Services may not be available in all states. Visit https://www.thehartford.com/employee-benefits/value-added-services for more information. 2For

Prepare. Protect. Prevail. With The Hartford. ®

The Hartford® is The Hartford Financial Services Group, Inc. and its subsidiaries, including issuing companies Hartford Life Insurance Company and Hartford Life and Accident Insurance Company. Home Office is Hartford, CT. 5962h NS 08/16 © 2016 The Hartford Financial Services Group, Inc. All rights reserved. This Benefit Highlights document explains the general purpose of the insurance described, but in no way changes or affects the policy as actually issued. In the event of a discrepancy between this document and the policy, the terms of the policy apply. Benefits are subject to state availability. Policy terms and conditions vary by state. Complete details including the provisions, terms, conditions, limitations and exclusions are in the Certificate of Insurance issued to each insured individual and the Master Policy as issued to the policyholder. Hospital does not include: convalescent homes, or convalescent, rest or nursing facilities; facilities affording primarily custodial, educational or rehabilitory care; or facilities primarily for care of the aged/elderly, persons with substance abuse issues/disorders or mental/nervous disorders. Confinement means the assignment to a bed in a medical facility for a period of at least 20 consecutive hours. Required hours may vary by state. The Hartford compensates both internal and external producers, as well as others, for the sale and service of our products. For additional information regarding Hartford’s compensation practices, please review our website http://thehartford.com/group-benefits-producer-compensation. Hospital Income Plan Form Series includes GBD-2800, GBD-2900, or state equivalent.

LIMITATIONS & EXCLUSIONS This insurance coverage includes certain limitations and exclusions. The certificate details all provisions, limitations, and exclusions for this insurance coverage. A copy of the certificate can be obtained from your employer. GROUP HOSPITAL INDEMNITY INSURANCE LIMITATIONS AND EXCLUSIONS The benefits payable are based on the insurance in effect on the date of the covered event, subject to the definitions, limitations, exclusions and other provisions of the policy. Additional limitations and exclusions are described in the certificate. You and your dependent(s) must be citizens or legal residents of the United States, its territories and protectorates. Other Hospital Indemnity Policy Limitation (Over-insurance Limitation): If an employee is insured under any other hospital indemnity policy underwritten by The Hartford, any claim for benefit is only payable under the one policy elected by the employee (or beneficiary or estate, in the event of death). We will return the amount of premium paid for any other policy that is declined by the employee retroactive to the later of: • the last date any benefit was paid for any covered person under the other policy • the effective date of insurance for the employee under the other policy Exclusions. This insurance does not provide benefits for any loss that results from or is caused by: • Suicide or attempted suicide, whether sane or insane, or intentional self-infliction • Voluntary intoxication (as defined by the law of the jurisdiction in which the illness or injury occurred) or while under the influence of any narcotic, drug or controlled substance, unless administered by or taken according to the instruction of a physician or medical professional • Voluntary intoxication through use of poison, gas or fumes, whether by ingestion, injection, inhalation or absorption • Voluntary commission of or attempt to commit a felony, voluntary participation in illegal activities (except for misdemeanor violations), voluntary participation in a riot, or voluntary engagement in an illegal occupation • Incarceration or imprisonment following conviction for a crime • Travel in or descent from any vehicle or device for aviation or aerial navigation, except as a fare-paying passenger in a commercial aircraft (other than a charter airline) on a regularly scheduled passenger flight or while traveling on business of the policyholder • Ride in or on any motor vehicle or aircraft engaged in acrobatic tricks/stunts (for motor vehicles), acrobatic/stunt flying (for aircraft), endurance tests, offroad activities (for motor vehicles), or racing • Participation in any organized sport in a professional or semi-professional capacity • Participation in abseiling, base jumping, Bossaball, bouldering, bungee jumping, cave diving, cliff jumping, free climbing, freediving, freerunning, hang gliding, ice climbing, Jai Alai, jet powered flight, kite surfing, kiteboarding, luging, missed climbing, mountain biking, mountain boarding, mountain climbing, mountaineering, parachuting, paragliding, parakiting, paramotoring, parasailing, Parkour, proximity flying, rock climbing, sail gliding, sandboarding, scuba diving, sepak takraw, slacklining, ski jumping, skydiving, sky surfing, speed flying, speed riding, train surfing, tricking, wingsuit flying, or other similar extreme sports or high risk activities • Travel or activity outside the United States or Canada • Active duty service or training in the military (naval force, air force or National Guard/Reserves or equivalent) for service/training extending beyond 31 days of any state, country or international organization, unless specifically allowed by a provision of the certificate • Involvement in any declared or undeclared war or act of war (not including acts of terrorism), while serving in the military or an auxiliary unit attached to the military, or working in an area of war whether voluntarily or as required by an employer This insurance also does not provide benefits, unless required by law, for: • Elective abortion or complications thereof • Artificial insemination, in vitro fertilization, test tube fertilization • Sterilization, tubal ligation or vasectomy, and reversal thereof • Aroma therapeutic, herbal therapeutic, or homeopathic services • Any mental and nervous disorder, unless specifically allowed by a provision of the certificate • Substance abuse, unless specifically allowed by a provision of the certificate • Medical mishap or negligence on the part of any physician, medical professional, or therapist, including malpractice; • Treatment, supplies or services provided by, through or, behalf of any government agency or program; unless payment is required by a covered person • Custodial care, unless specifically allowed by a benefit provision in the certificate or any rider attached to the policy (if applicable) • Elective or cosmetic surgery or procedures, except for reconstructive surgery: - Incidental to or following surgery for disease, infection or trauma of the involved body part - Due to congenital anomaly or disease of a dependent child which has resulted in a functional defect • Dental care or treatment, except for: - Treatment due to an Injury to sound natural teeth within 12 months of an accident - Treatment necessary due to congenital disease or anomaly Exclusions will vary by the jurisdiction/state in which the policy is issued.

YOUR BENEFITS

PERMANENT LIFE

ABOUT THIS BENEFIT: Life insurance becomes necessary the moment someone else depends on you. It can be your spouse, children, or even your parents. If your death would affect the lifestyle of someone you love, it's time to enroll. Individual life provides a specified lump-sum benefit to your beneficiary at the time of your death. These policies do not expire, and the price of your premiums typically won't change from the date you enroll. And, even if you leave your employer the policy stays with you.

life insurance you can keep!

purelife-plus

Life insurance can be an ideal way to provide money for your family when they need it most. purelife-plus offers permanent insurance with a high death benefit and long guarantees1 that can provide financial peace of mind for you and your loved ones. purelife-plus is an ideal complement to any group term and optional term life insurance your employer might provide and has the following features:

You own it

You can take it with you when you change jobs or retire

You pay for it through convenient payroll deductions

You can cover your spouse, children and grandchildren, too2

You can get a living benefit if you become terminally ill3

It’s Affordable

QUICK QUESTIONS

You can qualify by answering just 3 questions – no exams or needles.

DURING THE LAST SIX MONTHS, HAS THE PROPOSED INSURED: 1

Been actively at work on a full time basis, performing usual duties?

Been absent from work due to illness or medical treatment for a period of more than 5 consecutive working days?

1. After the guarantee period, premiums may go down, stay the same or go up. 2. Coverage not available on children in WA or on grandchildren in WA or MD. In MD, children must reside with the applicant to be eligible for coverage. 3. Conditions apply. Flexible Premium Adjustable Life Insurance to age 121. Policy Form ICC18PRFNG-NI-18 or Form Series PRFNG-NI-18. Some limitations apply. See the PureLife-plus brochure for details. Texas Life is licensed to do business in the District of Columbia and every state but New York. 19M016-C 1092 (exp0321)

Been disabled or received tests, treatment or care of any kind in a hospital or nursing home or received chemotherapy, hormonal therapy for cancer, radiation, dialysis treatment, or treatment for alcohol or drug abuse?

case overview Overview for CITY OF LUFKIN August 3, 2021 employee and spouse express issue Lifetime Maximum Amounts for Issue Ages Shown (1)(2) Express (2)

Proposed Insured

Employee

Spouse

Ages

Minimum

Maximum

17 to 34

$25,000

$100,000

35 to 39

15,000

100,000

40 to 49

10,000

100,000

50 to 65

10,000

50,000

66 to 70 (5)

10,000

17 to 34

25,000

50,000

35 to 39

15,000

50,000

40 to 49

10,000

50,000

50 to 60

10,000

25,000

N/A

15 days - 26

(4)

25,000

15 days - 18

(4)

25,000

61 to 70 (5) Child Policy Grandchild(ren)

1. One policy and one risk classification available per insured at each enrollment. 2. At the insured’s current issue age, Maximum shown is the cumulative maximum available, inclusive of all in-force plus currently applied for face amounts. 3. Minimum Employee participation for Express Issue is the greater of five lives or 30% of eligible Employees. 4. The Dependent’s signature is required for 19 and older in some states. Coverage is not available on children in Washington or on grandchildren in Washington or Maryland. In Maryland, child must reside with the applicant to be eligible for coverage. 5. In the state of Washington, no coverage available for employees & spouses over age of 65.

riders Proposed

Accidental Death

Disability Waiver Prem

Insured

(Ages 17-59)

Employee

Spouse

Child(ren)

Grandchild(ren)

implementation and enrollment target dates Enrollment Start Date:

August 23, 2021

End of Enrollment Date:

September 23, 2021

First Deduction Date:

October 8, 2021

Policy Issue Date:

November 1, 2021

Payroll Frequency:

Weekly

Bi-weekly

Semi-monthly

X Monthly

Other

Form: 18M065 PureLifePlus2018-C4ABB5ND9DM R06/21

Since 1901

45 900 washington ave post office box 830 waco, texas 76703-0830

800-283-9233 254-752-6521 www.texaslife.com

monthly p r e m i u m s PureLife-plus

—

Standard Risk Table Premiums

—

Non-Tobacco

—

Express Issue GUARANTEED

Monthly Premiums for Life Insurance Face Amounts Shown

PERIOD

Age

10.05 10.35 10.80 11.25 12.00 12.75 13.80 15.00 16.05 17.10 18.15 19.35 20.40 21.45 22.80 24.30 26.10 28.05 29.55 31.05 32.70 34.20 36.00 37.65 39.45 41.70 43.65 46.05 48.45 51.00 53.85

$20,000

12.65 13.05 13.65 14.25 15.25 16.25 17.65 19.25 20.65 22.05 23.45 25.05 26.45 27.85 29.65 31.65 34.05 36.65 38.65 40.65 42.85 44.85 47.25 49.45 51.85 54.85 57.45 60.65 63.85 67.25 71.05

$25,000 9.25 9.50 9.75 10.00 10.25 10.25 10.50 10.75 11.00 11.50 11.75 12.00 12.25 13.00 13.50 14.25 15.25 15.75 16.50 17.25 18.50 19.75 21.50 23.50 25.25 27.00 28.75 30.75 32.50 34.25 36.50 39.00 42.00 45.25 47.75 50.25 53.00 55.50 58.50 61.25 64.25 68.00 71.25 75.25 79.25 83.50 88.25

Coverage is Guaranteed at

$30,000

$40,000

$50,000

$75,000

$100,000

11.85 12.15 12.45 12.75 13.35 13.65 13.95 14.25 15.15 15.75 16.65 17.85 18.45 19.35 20.25 21.75 23.25 25.35 27.75 29.85 31.95 34.05 36.45 38.55 40.65 43.35 46.35 49.95 53.85 56.85 59.85 63.15 66.15 69.75 73.05 76.65 81.15 85.05 89.85 94.65 99.75 105.45

15.05 15.45 15.85 16.25 17.05 17.45 17.85 18.25 19.45 20.25 21.45 23.05 23.85 25.05 26.25 28.25 30.25 33.05 36.25 39.05 41.85 44.65 47.85 50.65 53.45 57.05 61.05 65.85 71.05 75.05 79.05 83.45 87.45 92.25 96.65 101.45 107.45 112.65 119.05 125.45 132.25 139.85

18.25 18.75 19.25 19.75 20.75 21.25 21.75 22.25 23.75 24.75 26.25 28.25 29.25 30.75 32.25 34.75 37.25 40.75 44.75 48.25 51.75 55.25 59.25 62.75 66.25 70.75 75.75 81.75 88.25 93.25 98.25 103.75 108.75 114.75 120.25 126.25 133.75 140.25 148.25 156.25 164.75 174.25

26.25 27.00 27.75 28.50 30.00 30.75 31.50 32.25 34.50 36.00 38.25 41.25 42.75 45.00 47.25 51.00 54.75 60.00 66.00 71.25 76.50 81.75 87.75 93.00 98.25 105.00

34.25 35.25 36.25 37.25 39.25 40.25 41.25 42.25 45.25 47.25 50.25 54.25 56.25 59.25 62.25 67.25 72.25 79.25 87.25 94.25 101.25 108.25 116.25 123.25 130.25 139.25

oba

9.25 9.95 10.75 11.45 12.15 12.85 13.65 14.35 15.05 15.95 16.95 18.15 19.45 20.45 21.45 22.55 23.55 24.75 25.85 27.05 28.55 29.85 31.45 33.05 34.75 36.65 38.75 41.05 43.55 46.05 48.65

$15,000

n-T

$10,000

Issue 15D-1 2-4 5-8 9-10 11-16 17-20 21-22 23 24-25 26 27-28 29 30-31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70

cco

Age to Which Issue

Table Premium 81 80 79 79 77 75 74 75 74 75 74 74 73 74 74 75 76 76 77 77 78 79 80 81 82 83 83 84 84 85 85 86 87 88 88 88 89 89 89 89 89 90 90 90 90 90 90 90 91 91 91 91

PureLife-plus is permanent life insurance to Attained Age 121 that can never be cancelled as long as you pay the necessary premiums. After the Guaranteed Period, the premiums can be lower, the same, or higher than the Table Premium. See the brochure under ”Permanent Coverage”. PureLifePlus2018-C4ABB5ND9DM

monthly p r e m i u m s PureLife-plus

—

Standard Risk Table Premiums

—

Non-Tobacco

—

Express Issue GUARANTEED

Life Insurance Face Amounts for Monthly Premiums Shown

$10,000

(ALB) 15D-1 2-4 5-8 9-10 11-16 17-20 21-22 23 24-25 26 27-28 29 30-31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70

Face

$16.00

$18.00

$20.00

$24.00

$28.00

$32.00

30,469 29,546 28,677 27,858 26,352 25,658 25,000

42,969 41,667 40,442 39,286 37,163 36,185 35,257 34,375 31,977 30,556 28,646 26,443 25,463 24,123 22,917 21,154 19,643 17,858 16,177 14,946 13,889 12,972 12,062 11,364 10,743 10,037

49,219 47,728 46,324 45,000 42,568 41,448 40,385 39,375 36,628 35,000 32,813 30,289 29,167 27,632 26,250 24,231 22,500 20,455 18,530 17,120 15,910 14,859 13,816 13,017 12,305 11,497 10,715

55,469 53,788 52,206 50,715 47,973 46,711 45,513 44,375 41,280 39,445 36,980 34,135 32,871 31,141 29,584 27,308 25,358 23,052 20,883 19,294 17,930 16,746 15,571 14,670 13,868 12,957 12,075 11,164 10,320

67,969 65,910 63,971 62,143 58,784 57,237 55,770 54,375 50,582 48,334 45,313 41,827 40,278 38,158 36,250 33,462 31,072 28,247 25,589 23,642 21,970 20,519 19,079 17,976 16,993 15,876 14,796 13,680 12,646 11,951 11,329 10,715 10,212

80,469 78,031 75,736 73,572 69,595 67,764 66,026 64,375 59,884 57,223 53,646 49,520 47,686 45,176 42,917 39,616 36,786 33,442 30,295 27,990 26,011 24,293 22,588 21,281 20,118 18,796 17,518 16,195 14,971 14,149 13,412 12,685 12,090 11,445 10,912 10,384

92,969 90,152 87,500 85,000 80,406 78,290 76,283 74,375 69,187 66,112 61,980 57,212 55,093 52,193 49,584 45,770 42,500 38,637 35,000 32,337 30,051 28,067 26,097 24,587 23,243 21,716 20,239 18,711 17,297 16,347 15,495 14,656 13,968 13,223 12,606 11,996 11,312 10,779 10,189

18,750 18,056 17,106 16,250 15,000 13,929 12,663 11,471 10,598

9.25 9.95 10.75 11.45 12.15 12.85 13.65 14.35 15.05 15.95 16.95 18.15 19.45 20.45 21.45 22.55 23.55 24.75 25.85 27.05 28.55 29.85 31.45 33.05 34.75 36.65 38.75 41.05 43.55 46.05 48.65

$12.00

oba

Age

Age to Which

n-T

For

cco

Prem Issue

PERIOD

Coverage is Guaranteed at $40.00

99,343 96,795 94,375 87,791 83,889 78,646 72,597 69,908 66,229 62,917 58,077 53,929 49,026 44,412 41,033 38,132 35,614 33,115 31,199 29,493 27,555 25,681 23,743 21,948 20,742 19,662 18,597 17,724 16,778 15,996 15,222 14,354 13,678 12,929 12,257 11,616 10,974

Table Premium 81 80 79 79 77 75 74 75 74 75 74 74 73 74 74 75 76 76 77 77 78 79 80 81 82 83 83 84 84 85 85 86 87 88 88 88 89 89 89 89 89 90 90 90 90 90 90 90 91 91 91 91

monthly p r e m i u m s PureLife-plus

—

Standard Risk Table Premiums

—

Tobacco

—

Express Issue GUARANTEED

Monthly Premiums for Life Insurance Face Amounts Shown

PERIOD

Age to Which Issue

Coverage is

Age

Guaranteed at

14.15 15.05 16.15 17.55 18.25 19.25 20.05 21.05 21.95 23.25 24.35 25.45 27.05 28.45 29.75 31.15 32.75 34.35 36.05 37.75 39.55 41.85 44.05 46.25 48.45 50.85 53.45 56.25 59.15 62.25 65.55

15.30 15.75 16.80 17.25 18.45 20.10 21.45 23.10 25.20 26.25 27.75 28.95 30.45 31.80 33.75 35.40 37.05 39.45 41.55 43.50 45.60 48.00 50.40 52.95 55.50 58.20 61.65 64.95 68.25 71.55 75.15

$20,000

$25,000

$30,000

$40,000

$50,000

$75,000

$100,000

15.25 16.00 16.75 17.25 17.75 18.25 18.50 21.00 21.75 22.00 22.25 24.00 24.75 26.50 27.25 29.25 32.00 34.25 37.00 40.50 42.25 44.75 46.75 49.25 51.50 54.75 57.50 60.25 64.25 67.75 71.00 74.50 78.50 82.50 86.75 91.00 95.50 101.25 106.75 112.25 117.75 123.75

17.85 18.75 19.65 20.25 20.85 21.45 21.75 24.75 25.65 25.95 26.25 28.35 29.25 31.35 32.25 34.65 37.95 40.65 43.95 48.15 50.25 53.25 55.65 58.65 61.35 65.25 68.55 71.85 76.65 80.85 84.75 88.95 93.75 98.55 103.65 108.75 114.15 121.05 127.65 134.25 140.85 148.05

23.05 24.25 25.45 26.25 27.05 27.85 28.25 32.25 33.45 33.85 34.25 37.05 38.25 41.05 42.25 45.45 49.85 53.45 57.85 63.45 66.25 70.25 73.45 77.45 81.05 86.25 90.65 95.05 101.45 107.05 112.25 117.85 124.25 130.65 137.45 144.25 151.45 160.65 169.45 178.25 187.05 196.65

28.25 29.75 31.25 32.25 33.25 34.25 34.75 39.75 41.25 41.75 42.25 45.75 47.25 50.75 52.25 56.25 61.75 66.25 71.75 78.75 82.25 87.25 91.25 96.25 100.75 107.25 112.75 118.25 126.25 133.25 139.75 146.75 154.75 162.75 171.25 179.75 188.75 200.25 211.25 222.25 233.25 245.25

41.25 43.50 45.75 47.25 48.75 50.25 51.00 58.50 60.75 61.50 62.25 67.50 69.75 75.00 77.25 83.25 91.50 98.25 106.50 117.00 122.25 129.75 135.75 143.25 150.00 159.75

54.25 57.25 60.25 62.25 64.25 66.25 67.25 77.25 80.25 81.25 82.25 89.25 92.25 99.25 102.25 110.25 121.25 130.25 141.25 155.25 162.25 172.25 180.25 190.25 199.25 212.25

$15,000

acc

$10,000

19.65 20.25 21.65 22.25 23.85 26.05 27.85 30.05 32.85 34.25 36.25 37.85 39.85 41.65 44.25 46.45 48.65 51.85 54.65 57.25 60.05 63.25 66.45 69.85 73.25 76.85 81.45 85.85 90.25 94.65 99.45

Tob

Issue 15D-1 2-4 5-8 9-10 11-16 17-20 21-22 23 24-25 26 27-28 29 30-31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70

Table Premium 81 80 79 79 77 71 71 72 71 72 71 71 72 72 72 71 72 72 73 73 74 76 77 78 80 80 81 81 82 82 83 83 83 84 85 85 85 85 86 86 86 86 86 87 87 87 87 88 88 88 88 89

monthly p r e m i u m s PureLife-plus

—

Standard Risk Table Premiums

—

Tobacco

—

Express Issue GUARANTEED

Life Insurance Face Amounts for Monthly Premiums Shown Prem

PERIOD

Age to Which

Issue

For

Coverage is

Age

$10,000

Guaranteed at

(ALB) 15D-1 2-4 5-8 9-10 11-16 17-20 21-22 23 24-25 26 27-28 29 30-31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70

Face

$30.00

$32.00

$35.00

$40.00

$45.00

$50.00

41,827 39,546 37,500 36,250 35,081 33,985 33,462 29,000 27,885 27,532 27,188 25,000 24,167 22,423 21,750 20,139 18,278 16,993 15,648 14,216 13,594 12,795 12,220 11,570 11,041 10,358

49,520 46,819 44,397 42,917 41,533 40,235 39,616 34,334 33,013 32,595 32,188 29,598 28,612 26,547 25,750 23,843 21,639 20,118 18,526 16,831 16,094 15,148 14,467 13,697 13,072 12,262 11,652 11,100 10,384

53,366 50,455 47,845 46,250 44,759 43,360 42,693 37,000 35,577 35,127 34,688 31,897 30,834 28,609 27,750 25,695 23,320 21,680 19,965 18,138 17,344 16,324 15,590 14,761 14,087 13,215 12,557 11,962 11,190 10,592 10,091

57,212 54,091 51,294 49,584 47,984 46,485 45,770 39,667 38,142 37,659 37,188 34,196 33,056 30,671 29,750 27,547 25,000 23,243 21,403 19,445 18,594 17,500 16,714 15,825 15,102 14,167 13,462 12,824 11,996 11,355 10,819 10,295

62,981 59,546 56,466 54,584 52,823 51,172 50,385 43,667 41,988 41,456 40,938 37,644 36,389 33,763 32,750 30,325 27,522 25,586 23,562 21,406 20,469 19,265 18,399 17,421 16,625 15,596 14,820 14,117 13,206 12,500 11,910 11,333 10,738 10,203

72,597 68,637 65,087 62,917 60,888 58,985 58,077 50,334 48,398 47,785 47,188 43,391 41,945 38,918 37,750 34,954 31,723 29,493 27,159 24,674 23,594 22,206 21,208 20,080 19,163 17,977 17,082 16,272 15,222 14,409 13,728 13,063 12,378 11,761 11,169 10,634 10,121

82,212 77,728 73,707 71,250 68,952 66,797 65,770 57,000 54,808 54,114 53,438 49,138 47,500 44,073 42,750 39,584 35,925 33,399 30,756 27,942 26,719 25,148 24,017 22,740 21,701 20,358 19,344 18,427 17,238 16,317 15,546 14,793 14,017 13,318 12,648 12,043 11,462 10,796 10,228

91,827 86,819 82,328 79,584 77,017 74,610 73,462 63,667 61,218 60,444 59,688 54,886 53,056 49,227 47,750 44,213 40,127 37,305 34,353 31,210 29,844 28,089 26,826 25,399 24,239 22,739 21,607 20,582 19,255 18,226 17,364 16,523 15,656 14,876 14,128 13,451 12,802 12,059 11,424 10,853 10,336

acc

$28.00

Tob

14.15 15.05 16.15 17.55 18.25 19.25 20.05 21.05 21.95 23.25 24.35 25.45 27.05 28.45 29.75 31.15 32.75 34.35 36.05 37.75 39.55 41.85 44.05 46.25 48.45 50.85 53.45 56.25 59.15 62.25 65.55

$24.00

Table Premium 81 80 79 79 77 71 71 72 71 72 71 71 72 72 72 71 72 72 73 73 74 76 77 78 80 80 81 81 82 82 83 83 83 84 85 85 85 85 86 86 86 86 86 87 87 87 87 88 88 88 88 89

VOLUNTARY GROUP TERM LIFE and ACCIDENTAL DEATH & DISMEMBERMENTINSURANCE BENEFIT HIGHLIGHTS

City of Lufkin

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

Approximately 50 million

To learn more about Life and AD&D insurance, visit thehartford.com/employeebeneﬁts

households recognize they need more life insurance (40 percent of households).1

COVERAGE INFORMATION APPLICANT

LIFE COVERAGE

AD&D COVERAGE

Employee

Beneﬁt : Increments of $10,000 Maximum: the lesser of 5x earnings or $300,000

AD&D: Included

Spouse

Beneﬁt2: Increments of $5,000. Maximum: the lesser of 50% of your supplemental coverage or $100,000

AD&D: Included

Child(ren)

Beneﬁt: $10,000

AD&D: Included

p y [

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

LOSS FROM ACCIDENT

COVERAGE

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

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

beneﬁt will be reduced by 50% at age 70.

CITY OF LUFKIN SUPP LIFE& ADD BHS_PUBLICATION DATE:

5/28/2019

00095800

PAGE 1 OF 4

PREMIUMS

See the Life Premium Worksheet.3

ASKED & ANSWERED

WHO IS ELIGIBLE? You are eligible if you are an active full time employee who works at least 30 hours per week on a regularly scheduled basis. Your spouse and child(ren) are also eligible for coverage. Any child(ren) must be under age 25. AM I GUARANTEED COVERAGE? If you are currently participating in this coverage you may increase your current coverage by $10,000, not to exceed $100,000, without providing evidence of insurability. If you are electing coverage for the first time, you may elect coverage up to the amount of $100,000. Additional coverage amounts will require evidence of insurability that is satisfactory to The Hartford before the excess can become effective. If you are currently participating in this coverage you may increase your spouse's current coverage by $5,000, not to exceed $30,000 without providing evidence of insurability. If you are electing coverage for the first time, you may elect coverage in $5000 increments up to the amount of $30,000. Additional coverage amounts will require your spouse to provide evidence of insurability that is satisfactory to The Hartford before the excess can become effective. This insurance is guaranteed issue coverage – it is available without having to provide information about your child(ren)’s health. AD&D is available without having to provide information about your or your family’s health. HOW MUCH DOES IT COST AND HOW DO I PAY FOR THIS INSURANCE? Premiums are provided on the Life Premium Worksheet. You have a choice of coverage amounts. You may elect insurance for you only, or for you and your dependent(s). Premiums will be automatically paid through payroll deduction, as authorized by you during the enrollment process. This ensures you don’t have to worry about writing a check or missing a payment. WHEN CAN I ENROLL? You may enroll from 8/15/2019 to 9/30/2019. WHEN DOES THIS INSURANCE BEGIN? The effective date of this coverage is 10/1/2019. You must be actively at work with your employer on the day your coverage takes effect. Your spouse and child(ren) must be performing normal activities and not be confined (at home or in a hospital/care facility), unless already insured with the prior carrier. WHEN DOES THIS INSURANCE END? This insurance will end when you (or your dependent(s)) no longer satisfy the applicable eligibility conditions, premium is unpaid, or the coverage is no longer offered. CAN I KEEP THIS INSURANCE IF I LEAVE MY EMPLOYER OR AM NO LONGER A MEMBER OF THIS GROUP? Yes, you can take this life coverage with you. Coverage may be continued for you and your dependent(s) under a group portability certificate or an individual conversion life certificate. Your spouse may also continue insurance in certain circumstances. The specific terms and qualifying events for conversion and portability are described in the certificate.Conversion and portability are not available for AD&D coverage.

1LIMRA, Facts About Life 2016. Web. 30 June 2017. <https://www.limra.com/uploadedFiles/limra.com/LIMRA_Root/Posts/PR/_Media/PDFs/Facts-of-Life-2016.pdf> 3Rates and/or beneﬁts may be changed. Rates are based on the age of the insured person and increase on the policy anniversary date on or following your birthday

category.

as you enter each new age

Prepare. Protect. Prevail. With The Hartford. ®

CITY OF LUFKIN SUPP LIFE & ADD BHS_PUBLICATION DATE:

52 5/28/2019

00095800

PAGE 2 OF 4

LIMITATIONS & EXCLUSIONS This insurance coverage includes certain limitations and exclusions. The certiﬁcate details all provisions, limitations, and exclusions for this insurance coverage. A copy of the certiﬁcate can be obtained from your employer. GROUP LIFE INSURANCE

GENERAL LIMITATIONS AND EXCLUSIONS •A benefit will not be paid if death occurs by suicide within two years (or as allowed by state law) of purchasing this coverage. •You and your dependent(s) must be citizens or legal residents of the United States, its territories and protectorates. DEPENDENT LIMITATIONS AND EXCLUSIONS •Coverage may only be elected for dependents when you elect and are approved for coverage for yourself. •Coverage may not be elected for a dependent who has employee coverage under this certificate. •Coverage may not be elected for a dependent who is in active full-time military service. •Child(ren) may only be covered as a dependent of one employee. •Infants may receive a reduced benefit prior to the age of six months. 5962a NS 08/16 © 2016.The Hartford Financial Services Group, Inc. All rights reserved. Life Form Series includes GBD-1000, GBD-1100, or state equivalent.

GROUP ACCIDENTAL DEATH & DISMEMBERMENT INSURANCE

GENERAL LIMITATIONS AND EXCLUSIONS •Your benefit will be reduced by 50% at age 70. •This insurance does not cover losses caused by: • Sickness; disease; or any treatment for either • Any infection, except certain ones caused by an accidental cut or wound • Intentionally self-inflicted injury, suicide or suicide attempt • War or act of war, whether declared or not • Injury sustained while in the armed forces of any country or international authority • Injury sustained on aircraft in certain circumstances • Taking prescription or illegal drugs unless prescribed by or administered by a licensed physician • Injury sustained while riding, driving, or testing any motor vehicle for racing • Injury sustained while committing or attempting to commit a felony • Injury sustained while driving while intoxicated •You and your dependent(s) must be citizens or legal residents of the United States, its territories and protectorates. DEPENDENT LIMITATIONS AND EXCLUSIONS •Coverage may only be elected for dependents when you elect and are approved for coverage for yourself. •Coverage may not be elected for a dependent who has employee coverage under this certificate. •Child(ren) may only be covered as a dependent of one employee. DEFINITIONS •Loss means, with regard to hands and feet, actual severance through or above wrist or ankle joints; with regard to sight, speech or hearing, entire and irrecoverable loss thereof; with regard to thumb and index finger, actual severance through or above the metacarpophalangeal joints; with regard to movement, complete and irreversible paralysis of such limbs. •Injury means bodily injury resulting directly from an accident, independent of all other causes, which occurs while you or your dependent(s) have coverage. 5962c NS 08/16 © 2016.The Hartford Financial Services Group, Inc. All rights reserved. Accident Form Series includes GBD-1000, GBD-1300, or state equivalent. Prepare. Protect. Prevail. With The Hartford. ®

The Hartford® is The Hartford Financial Services Group, Inc. and its subsidiaries, including issuing companies Hartford Life Insurance Company and Hartford Life and Accident Insurance Company. Home Office is Hartford, CT. This Benefit Highlights document explains the general purpose of the insurance described, but in no way changes or affects the policy as actually issued. In the event of a discrepancy between this document and the policy, the terms of the policy apply. Benefits are subject to state availability. Policy terms and conditions vary by state. Complete details are in the Certificate of Insurance issued to each insured individual and the Master Policy as issued to the policyholder.

53 CITY OF LUFKIN LIMITATIONS & EXCLUSIONS_PUBLICATION DATE: 5/28/2019

00095800

PAGE 3 OF 4

Premium Worksheet Rates and/or beneﬁts can change. Rates are based on the employee’s age and increase as you enter each new age category. VOLUNTARY TERM LIFE AND ACCIDENTAL DEATH & DISMEMBERMENT (AD&D) INSURANCE Monthly Premium Amount (Cost per Pay Period – 12/Year)QQ20, 23, 24 26x, 27, 29x Beneﬁt $10,000 $20,000 $30,000 $40,000 $50,000 $60,000 $70,000 $80,000 $90,000 $100,000 $110,000 $120,000 $130,000 $140,000 $150,000 $160,000 $170,000 $180,000 $190,000 $200,000 $210,000 $220,000 $230,000 $240,000 $250,000 $260,000 $270,000 $280,000 $290,000 $300,000

Under 25 $1.10 $2.20 $3.30 $4.40 $5.50 $6.60 $7.70 $8.80 $9.90 $11.00 $12.10 $13.20 $14.30 $15.40 $16.50 $17.60 $18.70 $19.80 $20.90 $22.00 $23.10 $24.20 $25.30 $26.40 $27.50 $28.60 $29.70 $30.80 $31.90 $33.00

25-29 $1.20 $2.40 $3.60 $4.80 $6.00 $7.20 $8.40 $9.60 $10.80 $12.00 $13.20 $14.40 $15.60 $16.80 $18.00 $19.20 $20.40 $21.60 $22.80 $24.00 $25.20 $26.40 $27.60 $28.80 $30.00 $31.20 $32.40 $33.60 $34.80 $36.00

30-34 $1.20 $2.40 $3.60 $4.80 $6.00 $7.20 $8.40 $9.60 $10.80 $12.00 $13.20 $14.40 $15.60 $16.80 $18.00 $19.20 $20.40 $21.60 $22.80 $24.00 $25.20 $26.40 $27.60 $28.80 $30.00 $31.20 $32.40 $33.60 $34.80 $36.00

35-39 $1.60 $3.20 $4.80 $6.40 $8.00 $9.60 $11.20 $12.80 $14.40 $16.00 $17.60 $19.20 $20.80 $22.40 $24.00 $25.60 $27.20 $28.80 $30.40 $32.00 $33.60 $35.20 $36.80 $38.40 $40.00 $41.60 $43.20 $44.80 $46.40 $48.00

40-44 $2.30 $4.60 $6.90 $9.20 $11.50 $13.80 $16.10 $18.40 $20.70 $23.00 $25.30 $27.60 $29.90 $32.20 $34.50 $36.80 $39.10 $41.40 $43.70 $46.00 $48.30 $50.60 $52.90 $55.20 $57.50 $59.80 $62.10 $64.40 $66.70 $69.00

45-49 $3.30 $6.60 $9.90 $13.20 $16.50 $19.80 $23.10 $26.40 $29.70 $33.00 $36.30 $39.60 $42.90 $46.20 $49.50 $52.80 $56.10 $59.40 $62.70 $66.00 $69.30 $72.60 $75.90 $79.20 $82.50 $85.80 $89.10 $92.40 $95.70 $99.00

50-54 $5.30 $10.60 $15.90 $21.20 $26.50 $31.80 $37.10 $42.40 $47.70 $53.00 $58.30 $63.60 $68.90 $74.20 $79.50 $84.80 $90.10 $95.40 $100.70 $106.00 $111.30 $116.60 $121.90 $127.20 $132.50 $137.80 $143.10 $148.40 $153.70 $159.00

55-59 $7.80 $15.60 $23.40 $31.20 $39.00 $46.80 $54.60 $62.40 $70.20 $78.00 $85.80 $93.60 $101.40 $109.20 $117.00 $124.80 $132.60 $140.40 $148.20 $156.00 $163.80 $171.60 $179.40 $187.20 $195.00 $202.80 $210.60 $218.40 $226.20 $234.00

60-64 $11.50 $23.00 $34.50 $46.00 $57.50 $69.00 $80.50 $92.00 $103.50 $115.00 $126.50 $138.00 $149.50 $161.00 $172.50 $184.00 $195.50 $207.00 $218.50 $230.00 $241.50 $253.00 $264.50 $276.00 $287.50 $299.00 $310.50 $322.00 $333.50 $345.00

65-69 $16.60 $33.20 $49.80 $66.40 $83.00 $99.60 $116.20 $132.80 $149.40 $166.00 $182.60 $199.20 $215.80 $232.40 $249.00 $265.60 $282.20 $298.80 $315.40 $332.00 $348.60 $365.20 $381.80 $398.40 $415.00 $431.60 $448.20 $464.80 $481.40 $498.00

70-74 $27.80 $55.60 $83.40 $111.20 $139.00 $166.80 $194.60 $222.40 $250.20 $278.00 $305.80 $333.60 $361.40 $389.20 $417.00 $444.80 $472.60 $500.40 $528.20 $556.00 $583.80 $611.60 $639.40 $667.20 $695.00 $722.80 $750.60 $778.40 $806.20 $834.00

SPOUSE VOLUNTARY TERM LIFE LIFE AND ACCIDENTAL DEATH & DISMEMBERMENT (AD&D) INSURANCE Monthly Premium Amount (Cost per Pay Period – 12/Year) Age $5,000 $10,000 $15,000 $20,000 $25,000 $30,000 $35,000 $40,000 $45,000 $50,000

Under 25 $0.55 $1.10 $1.65 $2.20 $2.75 $3.30 $3.85 $4.40 $4.95 $5.50

25-29 $0.60 $1.20 $1.80 $2.40 $3.00 $3.60 $4.20 $4.80 $5.40 $6.00

30-34 $0.60 $1.20 $1.80 $2.40 $3.00 $3.60 $4.20 $4.80 $5.40 $6.00

35-39 $0.80 $1.60 $2.40 $3.20 $4.00 $4.80 $5.60 $6.40 $7.20 $8.00

40-44 $1.15 $2.30 $3.45 $4.60 $5.75 $6.90 $8.05 $9.20 $10.35 $11.50

45-49 $1.65 $3.30 $4.95 $6.60 $8.25 $9.90 $11.55 $13.20 $14.85 $16.50

PAGE54 1 OF 2

50-54 $2.65 $5.30 $7.95 $10.60 $13.25 $15.90 $18.55 $21.20 $23.85 $26.50

55-59 $3.90 $7.80 $11.70 $15.60 $19.50 $23.40 $27.30 $31.20 $35.10 $39.00

60-64 $5.75 $11.50 $17.25 $23.00 $28.75 $34.50 $40.25 $46.00 $51.75 $57.50

65-69 $8.30 $16.60 $24.90 $33.20 $41.50 $49.80 $58.10 $66.40 $74.70 $83.00

70-74 $13.90 $27.80 $41.70 $55.60 $69.50 $83.40 $97.30 $111.20 $125.10 $139.00

75+ $74.90 $149.80 $224.70 $299.60 $374.50 $449.40 $524.30 $599.20 $674.10 $749.00 $823.90 $898.80 $973.70 $1,048.60 $1,123.50 $1,198.40 $1,273.30 $1,348.20 $1,423.10 $1,498.00 $1,572.90 $1,647.80 $1,722.70 $1,797.60 $1,872.50 $1,947.40 $2,022.30 $2,097.20 $2,172.10 $2,247.00

75+ $37.45 $74.90 $112.35 $149.80 $187.25 $224.70 $262.15 $299.60 $337.05 $374.50

CREATION DATE: 5/16/2019 CITY OF LUFKIN/00095800

$55,000 $60,000 $65,000 $70,000 $75,000 $80,000 $85,000 $90,000 $95,000 $100,000

$6.05 $6.60 $7.15 $7.70 $8.25 $8.80 $9.35 $9.90 $10.45 $11.00

$6.60 $7.20 $7.80 $8.40 $9.00 $9.60 $10.20 $10.80 $11.40 $12.00

$8.80 $9.60 $10.40 $11.20 $12.00 $12.80 $13.60 $14.40 $15.20 $16.00

$12.65 $13.80 $14.95 $16.10 $17.25 $18.40 $19.55 $20.70 $21.85 $23.00

$18.15 $19.80 $21.45 $23.10 $24.75 $26.40 $28.05 $29.70 $31.35 $33.00

$29.15 $31.80 $34.45 $37.10 $39.75 $42.40 $45.05 $47.70 $50.35 $53.00

$42.90 $46.80 $50.70 $54.60 $58.50 $62.40 $66.30 $70.20 $74.10 $78.00

$63.25 $69.00 $74.75 $80.50 $86.25 $92.00 $97.75 $103.50 $109.25 $115.00

$91.30 $99.60 $107.90 $116.20 $124.50 $132.80 $141.10 $149.40 $157.70 $166.00

$152.90 $166.80 $180.70 $194.60 $208.50 $222.40 $236.30 $250.20 $264.10 $278.00

$411.95 $449.40 $486.85 $524.30 $561.75 $599.20 $636.65 $674.10 $711.55 $749.00

CHILD(REN) VOLUNTARY TERM LIFE AND ACCIDENTAL DEATH & DISMEMBERMENT (AD&D) INSURANCE Monthly Premium Amount (Cost per Pay Period – 12/Year)QQ89 Beneﬁt Amount

Cost For Each Child

$10,000

$1.40

Number of Covered Children

Cost For All Children

Prepare. Protect. Prevail. With The Hartford. ® The Hartford® is The Hartford Financial Services Group, Inc. and its subsidiaries, including issuing companies Hartford Life Insurance Company and Hartford Life and Accident Insurance Company. Home Office is Hartford, CT. This document explains the general purpose of the insurance described, but in no way changes or affects the policy as actually issued. In the event of a discrepancy between this document and the policy, the terms of the policy apply. Benefits are subject to state availability. Policy terms and conditions vary by state. Complete details are in the Certificate of Insurance issued to each insured individual and the Master Policy as issued to the policyholder.

PAGE55 2 OF 2

CREATION DATE: 5/16/2019 CITY OF LUFKIN/00095800

New Health Insurance Marketplace Coverage Options and Your Health Coverage

Form Approved OMB No. 1210-0149 (expires 6-30-2023)

PART A: General Information When key parts of the health care law take effect in 2014, there will be a new way to buy health insurance: the Health Insurance Marketplace. To assist you as you evaluate options for you and your family, this notice provides some basic information about the new Marketplace.

What is the Health Insurance Marketplace? The Marketplace is designed to help you find health insurance that meets your needs and fits your budget. The Marketplace offers "one-stop shopping" to find and compare private health insurance options. You may also be eligible for a new kind of tax credit that lowers your monthly premium right away. Open enrollment for health insurance coverage through the Marketplace begins in October 2013 for coverage starting as early as January 1, 2014.

Can I Save Money on my Health Insurance Premiums in the Marketplace? You may qualify to save money and lower your monthly premium, but only if your employer does not offer coverage, or offers coverage that doesn't meet certain standards. The savings on your premium that you're eligible for depends on your household income.

Does Employer Health Coverage Affect Eligibility for Premium Savings through the Marketplace? Yes. If you have an offer of health coverage from your employer that meets certain standards, you will not be eligible for a tax credit through the Marketplace and may wish to enroll in your employer's health plan. However, you may be eligible for a tax credit that lowers your monthly premium, or a reduction in certain cost-sharing if your employer does not offer coverage to you at all or does not offer coverage that meets certain standards. If the cost of a plan from your employer that would cover you (and not any other members of your family) is more than 9.5% of your household income for the year, or if the coverage your employer provides does not meet the "minimum value" standard set by the Affordable Care Act, you may be eligible for a tax credit.1

Note: If you purchase a health plan through the Marketplace instead of accepting health coverage offered by your employer, then you may lose the employer contribution (if any) to the employer-offered coverage. Also, this employer contribution -as well as your employee contribution to employer-offered coverage- is often excluded from income for Federal and State income tax purposes. Your payments for coverage through the Marketplace are made on an after-tax basis.

How Can I Get More Information? The Marketplace can help you evaluate your coverage options, including your eligibility for coverage through the Marketplace and its cost. Please visit HealthCare.gov for more information, including an online application for health insurance coverage and contact information for a Health Insurance Marketplace in your area.

1 An employer-sponsored health plan meets the "minimum value standard" if the plan's share of the total allowed benefit costs covered by the plan is no less than 60 percent of such costs.

PART B: Information About Health Coverage Offered by Your Employer This section contains information about any health coverage offered by your employer. If you decide to complete an application for coverage in the Marketplace, you will be asked to provide this information. This information is numbered to correspond to the Marketplace application. 4. Employer Identification Number (EIN)

3. Employer name

75-6000591

City of Lufkin

6. Employer phone number

5. Employer address

936-633-0274

300 E. Shepherd 7. City

8. State TX.

Lufkin

9. ZIP code 75902

10. Who can we contact at this job? Brittany Semien 11. Phone number (if different from above) 12. Email address bsemien@cityoflufkin.com

You are not eligible for health insurance coverage through this employer. You and your family may be able to obtain health coverage through the Marketplace, with a new kind of tax credit that lowers your monthly premiums and with assistance for out-of-pocket costs.

Model COBRA Continuation Coverage General Notice Instructions The Department of Labor has developed a model Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA) continuation coverage general notice that plans may use to provide the general notice. To use this model general notice properly, the Plan Administrator must fill in the blanks with the appropriate plan information. The Department considers use of the model general notice to be good faith compliance with the general notice content requirements of COBRA. The use of the model notices isn’t required. The model notices are provided to help facilitate compliance with the applicable notice requirements. NOTE: Plans do not need to include this instruction page with the model general notice. Paperwork Reduction Act Statement According to the Paperwork Reduction Act of 1995 (Pub. L. 104-13) (PRA), no persons are required to respond to a collection of information unless such collection displays a valid Office of Management and Budget (OMB) control number. The Department notes that a Federal agency cannot conduct or sponsor a collection of information unless it is approved by OMB under the PRA, and displays a currently valid OMB control number, and the public is not required to respond to a collection of information unless it displays a currently valid OMB control number. See 44 U.S.C. 3507. Also, notwithstanding any other provisions of law, no person shall be subject to penalty for failing to comply with a collection of information if the collection of information does not display a currently valid OMB control number. See 44 U.S.C. 3512. The public reporting burden for this collection of information is estimated to average approximately four minutes per respondent. Interested parties are encouraged to send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the U.S. Department of Labor, Office of Policy and Research, Attention: PRA Clearance Officer, 200 Constitution Avenue, N.W., Room N-5718, Washington, DC 20210 or email ebsa.opr@dol.gov and reference the OMB Control Number 1210-0123.

Model General Notice of COBRA Continuation Coverage Rights (For use by single-employer group health plans) ** Continuation Coverage Rights Under COBRA** Introduction You’re getting 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 [choose and enter appropriate information: must pay or aren’t required to 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.”

[If the Plan provides retiree health coverage, add the following paragraph:] 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 [enter name of employer sponsoring the Plan], 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; [add if Plan provides retiree health coverage: 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 [or enter longer period permitted under the terms of the Plan] after the qualifying event occurs. You must provide this notice to: [Enter name of appropriate party]. [Add description of any additional Plan procedures for this notice, including a description of any required information or documentation.]

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. [Add description of any additional Plan procedures for this notice, including a description of any required information or documentation, the name of the appropriate party to whom notice must be sent, and the time period for giving notice.]

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, Medicare, Medicaid, Children’s Health Insurance Program (CHIP), 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.

Can I enroll in Medicare instead of COBRA continuation coverage after my group health plan coverage ends? In general, if you don’t enroll in Medicare Part A or B when you are first eligible because you are still employed, after the Medicare initial enrollment period, you have an 8-month special enrollment period1 to sign up for Medicare Part A or B, beginning on the earlier of • •

The month after your employment ends; or The month after group health plan coverage based on current employment ends.

If you don’t enroll in Medicare and elect COBRA continuation coverage instead, you may have to pay a Part B late enrollment penalty and you may have a gap in coverage if you decide you want Part B later. If you elect COBRA continuation coverage and later enroll in Medicare Part A or B before the COBRA continuation coverage ends, the Plan may terminate your continuation coverage. However, if Medicare Part A or B is effective on or before the date of the COBRA election, COBRA coverage may not be discontinued on account of Medicare entitlement, even if you enroll in the other part of Medicare after the date of the election of COBRA coverage. If you are enrolled in both COBRA continuation coverage and Medicare, Medicare will generally pay first (primary payer) and COBRA continuation coverage will pay second. Certain plans may pay as if secondary to Medicare, even if you are not enrolled in Medicare. For more information visit https://www.medicare.gov/medicare-and-you.

https://www.medicare.gov/sign-up-change-plans/how-do-i-get-parts-a-b/part-a-part-b-sign-up-periods. 61

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 [Enter name of the Plan and name (or position), address and phone number of party or parties from whom information about the Plan and COBRA continuation coverage can be obtained on request.]

the advanced financial group 936.634.3378 www.theadvancedfinancialgroup.com 63