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EMPLOYEE BENEFITS GUIDE 2025 PLAN YEAR:

JULY 1, 2025 - JUNE 30, 2026

CHARLOTTESVILLE CITY SCHOOLS

WWW.PIERCEGROUPBENEFITS.COM

EMPLOYEE SERVICES: 800-387-5955

TABLE OF CONTENTS

EMPLOYEE BENEFITS GUIDE TABLE OF CONTENTS Welcome to Charlottesville City Schools’ comprehensive benefits program. This guide highlights the benefits offered to all eligible employees for the plan year listed below. Benefits described in this guide are voluntary, employee-paid benefits unless otherwise noted.

ENROLLMENT DATES: April 9, 2025 - April 30, 2025 PLAN YEAR & EFFECTIVE DATES: July 1, 2025 - June 30, 2026

Click on the video below to help you prepare for annual enrollment and learn about the benefits available to you!

Important Contact Information............................... 3 Eligibility Requirements......................................... 4 Overview Of Benefits............................................. 5 Important Notices................................................. 6 Mid-Year Events..................................................... 7 Enrollment Information.......................................... 9 Health Insurance................................................... 10 Dental Insurance................................................... 18 Dental Rates......................................................... 21 Vision Insurance.................................................... 22 Vision Rates.......................................................... 25 Health Savings Account......................................... 26 The HSA Store....................................................... 31 Flexible Spending Account..................................... 32 Limited-Purpose Flexible Spending Account........... 34 The FSA Store....................................................... 35 Dependent Care Account....................................... 36 Employee Assistance Program............................... 38 Cancer Benefits..................................................... 40 Critical Illness Benefits.......................................... 50 Short-Term Disability Benefits................................ 61 Accident Benefits.................................................. 73 Medical Bridge Benefits......................................... 79 Term Life Insurance............................................... 87 Whole Life Insurance............................................. 91 Authorization For Colonial Life Insurance Form....... 96 Additional Benefits................................................ 97 Required Health Care Notices................................ 98 COBRA Continuation Of Coverage.......................... 103 Privacy Notices..................................................... 105 Continuation Of Coverage...................................... 106

IMPORTANT NOTE & DISCLAIMER This is neither an insurance contract nor a Summary Plan Description and only the actual policy provisions will prevail.

CHARLOTTESVILLE CITY SCHOOLS

2025 Benefits Plan

July 1, 2025 - June 30, 2026

All information in this guide, including premiums quoted, is subject to change. All policy descriptions are for informational purposes only. Your actual policies may be different than those in this guide. Rev: 3/18/2025

IMPORTANT CONTACT INFORMATION Carrier

Phone/Fax

Website

Health Insurance

Anthem Health

P: 833-388-1400

www.anthem.com

Health Savings Account

Inspira Financial

P: 844-729-3539

www.inspirafinancial.com

Flexible Spending Accounts

Flex Facts

P: 877-943-2287 F: 877-747-8564

www.FlexFacts.com

Dental Insurance

Delta Dental of VA

P: 800-237-6060

www.deltadentalVA.com

Vision Insurance

EyeMed Vision

P: 866-939-3633

www.eyemed.com

Employee Assistance Program

UVA FEAP

P: 434-243-2643

feap@virginia.edu

uvafeap.com

Student Loan Assistance Program

GradFin

P: 844-472-3346

www.gradfin.com

To View Your Benefits Online

Pierce Group Benefits

P: 800-387-5955 F: 984-225-2605

service@ piercegroupbenefits.com

www.PierceGroupBenefits.com/ CharlottesvilleCitySchools

www.coloniallife.com

Customer Service & Wellness Screenings

Supplemental Benefits

Colonial Life

P: 800-325-4368 F: 800-880-9325 TDD For Hearing Impaired Customers

800-798-4040

Under certain qualifying events, employees and dependents may have the opportunity to continue coverage for 18-36 months under the COBRA Act. 3

ELIGIBILITY REQUIREMENTS CURRENT EMPLOYEE? ANNUAL ENROLLMENT DATES: April 9, 2025 - April 30, 2025

PLAN YEAR & EFFECTIVE DATES: July 1, 2025 - June 30, 2026

ELIGIBILITY • Employees must work in a full-time equivalent position of .5 or greater to participate in benefits.

NEW HIRE? Congratulations on your new employment! Your employment means more than just a paycheck. Your employer also provides eligible employees with a valuable benefits package. Above you will find eligibility requirements and below you will find information about how to enroll in these benefits as a new employee. All Benefits - Please call PGB’s Employee Services within 30 days of your date of hire and a PGB Benefits Representative will help you enroll in benefits. The Employee Services number is located in the contact section of this guide. Be sure to also review your group’s custom benefits website, that allows for easy, year-round access to benefit information, live chat support, benefit explainer videos, plan certificates and documents, and carrier contacts and forms. www.PierceGroupBenefits.com/CharlottesvilleCitySchools

OVERVIEW OF BENEFITS POST – TAX BENEFITS

PRE – TAX BENEFITS

Disability Benefits Colonial Life

Health Insurance Anthem Health

Health Savings Account Inspira Financial

Critical Illness Benefits Colonial Life

- Individual Maximum: $4,300/year Max -Family Maximum: $8,550/year Max HSA plans can only be established in conjunction with a qualified High-Deductible Health Plan (HDHP). Employer contributes $1,500 per year to eligible employees accounts.

Life Insurance Colonial Life - Term Life Insurance - Whole Life Insurance

Flexible Spending Accounts Flex Facts

ADDITIONAL BENEFITS

- Medical Reimbursement: $3,300/year Max - Dependent Care Reimbursement: $5,000/year Max - Limited Medical Reimbursement: $3,300/year Max

*You will need to re-enroll in the Flexible Spending Accounts if you want them to continue next year. If you do not re-enroll, your contribution will stop effective June 30, 2025.

Employee Assistance Program UVA FEAP (Employer-Paid Benefit)

Dental Insurance Delta Dental of VA

Student Loan Assistance Program GradFin

Vision Insurance EyeMed Vision

Cancer Benefits Colonial Life

Accident Benefits Colonial Life

Medical Bridge Benefits Colonial Life 5

IMPORTANT NOTICES When do my benefits start? The plan year for Colonial Life Insurance Products, Anthem Health, Inspira Financial Health Savings Account, Flex Facts Flexible Spending Accounts, Delta Dental of VA, and Eye Med Vision runs from July 1, 2025, through June 30, 2026. Please Note: Health Insurance benefits are based on the Calendar Year, running from January 1st through December 31st. Health benefits and deductibles will reset every January 1st. When do my deductions start? Deductions for Colonial Life Insurance Products, Anthem Health, Inspira Financial Health Savings Account, Flex Facts Flexible Spending Accounts, Delta Dental of VA, and Eye Med Vision start July 2025 for enrolled 12-month employees and August 2025 for enrolled 10-month employees. Why have my Accident or Medical Bridge benefits not started yet? The Health Screening Rider on the Colonial Accident and Colonial Medical Bridge plan has a 30-day waiting period for new enrollees. Coverage, therefore, will not begin until July 31, 2025. What is an EAP? Your employer offers an Employee Assistance Program (EAP) for you and your eligible family members. An EAP is an employer-sponsored benefit that offers confidential support and resources for personal or work-related challenges and concerns. Please see the EAP pages of this benefit guide for more details and contact information. How do Flexible Spending Account (FSA) funds work, and do my FSA funds have to be used by a specific deadline? Flexible Spending Account expenses must be incurred during the plan year to be eligible for reimbursement. After the plan year ends, an employee has 90 days to submit claims for incurred qualified spending account expenses (or 90 days after employment termination date). If employment is terminated before the plan year ends, the spending account also ends. Failure to use all allotted funds in the FSA account will result in a “Use It or Lose It” scenario. Your plan includes a grace period which is an additional 2.5 months (running July 1, 2026, through September 15, 2026), during which you can incur eligible expenses that can be reimbursed. Therefore, you have from July 1, 2025, through September 15, 2026, to incur qualified expenses eligible for reimbursement. If you do not incur qualified expenses by September 15, 2026, and/or file by September 30, 2026, any contributions are forfeited under the “Use It or Lose It” rule. My spouse is enrolled in an Health Savings Account (HSA), am I eligible for an FSA? As a married couple, one spouse cannot be enrolled in a Medical Reimbursement FSA at the same time the other opens or contributes to an HSA. How do Dependent Care Account (DCA) funds work and when do they need to be used? Dependent Care Accounts are like FSA accounts and allow you to request reimbursement up to your current balance. However, you cannot receive more reimbursement than what has been deducted from your pay. Any remaining funds in your DCA account must be utilized before the deadline. Failure to use all allotted funds in the DCA account will result in a “Use It or Lose It” scenario. When will I get my card? If you will be receiving a new debit card, whether you are a new participant or to replace your expired card, please be aware that it may take up to 30 days following your plan effective date for your card to arrive. Your card will be delivered by mail in a plain white envelope. During this time you may use manual claim forms for eligible expenses. Please note that your debit card is good through the expiration date printed on the card. I want to sign my family up for benefits as well, what information will I need? If signing up for any coverage on your spouse and/or children, please have their dates of birth and social security numbers available when speaking with the Benefits Representative. What does Pre-Tax vs. Post-Tax Change? Pre-Tax benefits take funds directly from your paycheck to cover benefits before going through State and Federal taxing process. Post-Tax collects funds for benefits after taxes have been taken out. Please be aware there are certain coverages that may be subject to federal and state tax when premium is paid by pretax deduction or employee contribution. Can I change my benefit elections outside of the enrollment period? Elections made during this enrollment period CANNOT BE CHANGED AFTER THE ENROLLMENT PERIOD unless there is a family status change, otherwise known as a qualifying life event (Mid-Year Events), as defined by the Internal Revenue Code. Examples of Mid-Year Events can be found in the chart on the next page. Once a Mid-Year Event has occurred, an employee has 30 days to notify PGB’s VA Employee Services at 1-800-387-5955 to request a change in elections. I have a pre-existing condition. Will I still be covered? Some policies may include a pre-existing condition clause. Please read your policy carefully for full details. 6

MID-YEAR EVENTS The benefit elections you make during Annual Enrollment or as a New Hire will remain in effect for the entire plan year. You will not be able to change or revoke your elections once they have been made unless a Mid-Year Event (status change) occurs. The summary of events that allow an employee to make benefit changes and instructions for processing those life event changes can be reviewed in the chart below.

Mid-Year Event

Action Required

Result If Action Is Not Taken

New Hire

Make elections within 30 days of hire date. Documentation is required.

You and your dependents are not eligible until the next Annual Enrollment period.

Marriage

Add your new spouse to your elections within 30 days of the marriage date. A copy of the marriage certificate must be presented.

Your spouse is not eligible until the next Annual Enrollment period.

Divorce

Remove the former spouse within 30 days of the divorce. Proof of the divorce will be required. A copy of the divorce decree must be presented.

Benefits are not available for the divorced spouse and will be recouped if paid erroneously.

Enroll the new dependent in your elections within 30 days of the birth or adoption date, even if you already have family coverage. A copy of the birth certificate, mother’s copy of birth certificate, or hospital discharge papers must be presented. Once you receive the child’s Social Security Number, don’t forget to update your child’s insurance information record.

The new dependent will not be covered until the next Annual Enrollment period.

Remove or update dependent elections within 30 days of the dependent aging out. For more information and assistance, please call PGB Employee Services at 800-387-5955.

Coverage for the dependent will end at the time of the dependent aging out and the policyholder must remove/update the dependent elections in order for the change to be reflected in the employee’s deductions.

Death of a Spouse or Dependent

Remove the dependent from your elections within 30 days from the date of death. Death certificate must be presented.

You could pay a higher premium than required and you may be overpaying for coverage required.

Change in Spouse’s Employment or Coverage

Add or drop benefits from your elections within 30 days of the event date. A letter from the employer or insurance company must be presented.

You will not be able to make changes until the next Annual Enrollment period.

Birth or Adoption of a Child

Dependent Aging Out

The examples included in this chart are not all-inclusive. Please speak to a Benefits Representative to learn more. 7

MID-YEAR EVENTS Mid-Year Event

Action Required

Result If Action Is Not Taken

Part-Time to Full-Time or Vice Versa

Change your elections within 30 days from the employment status change to receive COBRA information or to enroll in benefits as a full-time employee. Documentation from the employer must be provided.

Benefits may not be available to you or your dependents if you wait to enroll in COBRA. Full-time employees will have to wait until the next Annual Enrollment period.

Transferring Employers

If you are transferring from one PGB client to another, some benefits may be eligible for transfer. Please call PGB Employee Services at 800-387-5955 for more information and assistance.

You may lose the opportunity to transfer benefits.

Loss of Government or Education Sponsored Health Coverage

If you, your spouse, or a dependent loses coverage under any group health coverage sponsored by a governmental or educational institution, you may be eligible to add additional coverage for eligible benefits.

You and your dependents are not eligible until the next Annual Enrollment period.

Entitlement to Medicare or Medicaid

If you, your spouse, or dependent becomes entitled to or loses coverage under Medicare or Medicaid, you may be able to change coverage under the accident or health plan.

You and your dependents are not eligible until the next Annual Enrollment period.

Non-FMLA Leave

An employee taking a leave of absence, other than under the Family & Medical Leave Act, may not be eligible to re-enter the Flexible Benefits program until next plan year. Please contact your Benefit Administrator for more information.

You and your dependents are not eligible until the next Annual Enrollment period.

Retiring

Your individual supplemental/voluntary policies through Colonial Life are portable! To move them from payroll deduction to direct billing, please complete and submit the Payment Method Change Form to Colonial Life within 30 days of retiring. You are also eligible for post-employment Dental, Vision, and Telemedicine benefits through PGB. Please visit: www.piercegroupbenefits.com/ individualcoverage or call our Employee Services at 800-387-5955 for more information and assistance.

If you do not transfer your policies from payroll deduction to direct billing, Colonial Life will terminate your policies resulting in a loss of coverage.

The examples included in this chart are not all-inclusive. Please speak to a Benefits Representative to learn more. 8

ENROLLMENT INFORMATION IN-PERSON During your annual enrollment period, a PGB Benefits Representative will be available by appointment to meet with you one-on-one to help you evaluate your benefits based on your individual and family needs, answer any questions you may have, and assist you in the enrollment process.

ANNUAL ENROLLMENT PERIOD:

APRIL 9, 2025 - APRIL 30, 2025 BENEFIT ELECTION OPTIONS YOU CAN MAKE THE FOLLOWING BENEFIT ELECTIONS DURING THE ANNUAL ENROLLMENT PERIOD: • • • • • •

Enroll in, change, or cancel Health Insurance.+ Enroll in, change, or cancel Health Savings Accounts.+ Enroll/Re-Enroll in Flexible Spending Accounts.+ Enroll in, change, or cancel Dental Insurance.+ Enroll in, change, or cancel Vision Insurance.+ Enroll in, change, or cancel Colonial coverage. +You will need to re-enroll in Health Insurance, Health Savings Account, Flexible Spending Accounts, Dental Insurance, and Vision Insurance if you want them to continue this year.

IMPORTANT: Benefits will NOT automatically roll over from the current plan year. If you wish to remain covered, elect new coverage, waive coverage, or change coverage in any CCS insurance coverage, you MUST login to BenSelect during Open Enrollment to make your elections for the new plan year. We strongly encourage you to schedule an appointment to meet with a Pierce Group Benefits Counselor during Open Enrollment. This would allow you a one-to-one meeting to discuss your individual benefit needs and provide you with assistance through the BenSelect enrollment process.

ACCESS YOUR BENEFIT OPTIONS WHENEVER, WHEREVER You can view details about what benefits your employer offers, view educational videos about all of your benefits, download forms, chat with one of our knowledgeable Benefits Representatives, and more on your personalized benefits website. To view your custom benefits website, visit: www.PierceGroupBenefits.com/CharlottesvilleCitySchools 9

Click on the video below to learn more about Health Insurance!

HEALTH INSURANCE

Charlottesville City Schools

Comparison of Benefits for Health Insurance Plan Options (effective 7/1/25-6/30/26)

In-Network Benefits Deductible

(per calendar year)

Coinsurance Out-of-Pocket Maximum (per calendar year)

Routine Preventive Care Primary Care Office Visit Specialist Office Visit Urgent Care Provider Visit Spinal Manipulation Therapy

(limited to 30 visits per calendar year)

Diagnostic Laboratory Diagnostic X-ray Diagnostic Complex Imaging

(if not performed as part of physician office visit & billed by physician)

Inpatient Facility Outpatient Facility Outpatient Hospital Expenses Emergency Room Prescription Copays Prescription Out-of-Pocket Maximum (per calendar year)

Out-of-Network Benefits Deductible

(per calendar year)

Coinsurance Out-of-Pocket Maximum (per calendar year)

Core KeyCare Plan

Enhanced KeyCare Plus Plan

HDHP KeyCare Plan w/ HSA

$1,000 Individual/$2,000 Family 20%

$0 20%

$3,300 Individual/$6,600 Family 20%

$3,500 Individual/$7,000 Family $0 $30 copay (deductible waived) $30 copay (deductible waived) $30 copay (deductible waived)

$3,000 Individual/$6,000 Family $0 $20 copay $40 copay $40 copay

$5,500 Individual/$11,000 Family $0 20% after deductible met 20% after deductible met 20% after deductible met

20% after deductible met 20% after deductible met 20% after deductible met

$40 copay 20% 20%

20% after deductible met 20% after deductible met 20% after deductible met

20% after deductible met 20% after deductible met 20% after deductible met 20% after deductible met 20% after deductible met $10/$30/$50

20% $400 copay + 20% $100 copay + 20% 20% $100 copay + 20% $10/$30/$50

20% after deductible met 20% after deductible met 20% after deductible met 20% after deductible met 20% after deductible met $10/$30/$50 after deductible met

$2,850 Individual/$5,700 Family

$3,350 Individual/$6,700 Family

Included w/ Medical OPM

$1,500 Individual/$3,000 Family 40% after deductible met

$500 Individual/$1,000 Family 30% after deductible met

$3, 00 Individual/$6, 00 Family 20% after deductible met

$5,500 Individual/$11,000 Family

$4,500 Individual/$9,000 Family

$5,500 Individual/$11,000 Family

Wellbeing Solutions Supporting your whole health matters

We want to support your whole health the best way possible. That’s why your health plan includes Wellbeing Solutions, a suite of programs to help you with everyday health and your overall well-being. Use the SydneySM Health mobile app and anthem.com anytime to access Wellbeing Solutions programs and resources that meet your healthcare needs.

Making your well-being a priority Explore Wellbeing Solutions programs on the Sydney Health app

Proactive support MyHealth Check-in. By taking a short health assessment, you will receive personalized health tips and resources to support your needs. We will offer details on programs that can help you lower health risks, reach your personal goals, and prevent future health problems.

improve your quality of life. Tap into our knowledge hub, featuring tools, articles, and webinars on topics like suicide awareness and support, autism, attention deficit hyperactivity disorder (ADHD), and post-traumatic stress disorder (PTSD). We’re here to help guide you on the path to better mental health and well-being.

MyHealth Advantage. We provide you with a confidential health summary that includes reminders for checkups, tests, and exams; lists of claims and prescriptions; and general health tips.

Emotional Wellbeing Resources. Learn effective ways to develop resilience, reduce stress, and practice mindfulness through online programs and personalized coaching. Digital tools help you identify thoughts and behavior patterns that affect your emotional well-being.

24/7 NurseLine. Talk to a trained, registered nurse without leaving your home. Convenient, 24/7 care means you can quickly get the answers to common health concerns.

Autism Spectrum Disorder Program. Receive support for a covered family member with an autism spectrum disorder. Our licensed behavior analysts can help you navigate the healthcare system and address any unique family challenges. We focus on the whole family and work with all of you to help you understand services and access care.

Mental health resources Behavioral Health Advantage (BHA). If you’re trying to manage a behavioral health condition or cope with substance use disorder, you don’t have to face it alone. Our behavioral health case managers are licensed mental health professionals. They offer caring support for you and your family, including 24/7 drug and alcohol assistance, to

Condition-based support Building Healthy Families. Whether you’re planning for a family, are pregnant, or are postpartum, you can access digital tools and educational resources to support the needs of your growing family.

Concierge Care. This program pairs you with a personal health advocate to provide coaching and digital resources on health conditions, such as type 2 diabetes and heart failure, as well as when you are being discharged from an inpatient setting.

ConditionCare. Receive one-on-one, digital support from a healthcare professional for a chronic condition, like asthma or diabetes, to help you reach your health goals.

Case Management. After an illness or hospital stay, you can receive one-on-one support and care coordination from our team of medical professionals. They partner with you and your family to help guide you through the healthcare system and make the most of your benefits. Their goal is to understand your needs from all angles and help you get the best care possible.

Cancer Care. If you or a family member is facing a cancer diagnosis or have started treatment, the Cancer Care Navigator program can provide one-on-one guidance and digital support when it matters most.

Connect with Sydney Health Sydney Health offers useful health and wellness tips and personalized action plans that can help you reach your unique well-being goals. Use Sydney Health for a convenient way to find care and details about your health plan coverage along with Wellbeing Solutions benefits. Download, open, register, and/or sign into the Sydney Health mobile app. 1. Go to homepage > Scroll down > Choose Personalize Your Care (for web and mobile). 2. Browse the wellness programs included in your plan. Scan this QR code with your smartphone to download the Sydney Health app.

We care about you With Wellbeing Solutions, you can work toward your health goals, knowing you are supported and cared for at every step. If you have any questions, call Member Services or visit anthem.com.

Sydney Health is offered through an arrangement with Carelon Digital Platforms, a separatecompany offering mobileapplication services on behalf of your health plan. Care lon He alth, Inc is a se parate company providing care manage me nt se rvice s on be half of Anthem Blue Cross and Blue Shield Anthem BlueCross and BlueShield is thetradenameof: In Colorado: Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc. In Connecticut: Anthem Health Plans, Inc. In Indiana: Anthem InsuranceCompanies, Inc. In Georgia: BlueCross BlueShield HealthcarePlan of Georgia, Inc. and Community CareHealth Plan of Georgia, Inc. In Kentucky: Anthem Health Plans of Kentucky, Inc. In Maine: Anthem Health Plans of Maine, Inc. In Missouri (excluding 30 counties in theKansas City area): RightCHOICE® Managed Care, Inc. (RIT), Healthy Alliance® LifeInsuranceCompany (HALIC), and HMO Missouri, Inc. RIT and certain affiliates administer non-HMO benefits underwritten by HALIC and HMO benefits underwritten by HMO Missouri, Inc. RIT and certain affiliates only provideadministrativeservices for self-funded plans and do not underwritebenefits. In Nevada: Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc., dba HMO Nevada. In New Hampshire: Anthem Health Plans of New Hampshire, Inc. HMO plans are administered by Anthem Health Plans of New Hampshire, Inc. and underwritten by Matthew Thornton Health Plan, Inc. In 17 southeastern counties of New York: Anthem HealthChoice Assurance, Inc., and Anthem HealthChoice HMO, Inc. In these same counties Anthem Blue Cross and Blue Shield HP is the trade name of Anthem HP. LLC. In Ohio: Community Insurance Company. In Virginia: Anthem Health Plans of Virginia, Inc. trades as Anthem Blue Cross and BlueShield, and its affiliateHealthKeepers, Inc. trades as Anthem HealthKeepers providing HMO coverage, and their servicearea is all of Virginia except for theCity of Fairfax, theTown of Vienna, and thearea east of StateRoute123. In Wisconsin: BlueCross BlueShield of Wisconsin (BCBSWI), underwrites or administers PPO and indemnity policies and underwrites theout-of-network benefits in POS policies offered by CompcareHealth Services InsuranceCorporation (Compcare) or Wisconsin CollaborativeInsuranceCorporation (WCIC). Compcareunderwrites or administers HMO or POS policies; WCIC underwrites or administers Well Priority HMO or POS policies. Independent licensees of the Blue Cross and Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc. 1053690MUMENABS VPOD 05/24

The Sydney Health mobile app makes healthcare easier Access personalized health and wellness information wherever you are

Use Sydney Health to keep track of your health and benefits — all in one place. With a few taps, you can quickly access your plan details, Member Services, virtual care, and wellness resources. Sydney Health stays one step ahead — moving your health forward by building a world of wellness around you. SM

Find Care

Community Resources

Search for doctors, hospitals, and other healthcare professionals in your plan’s network and compare costs. You can filter providers by what is most important to you, such as gender, languages spoken, or location. You’ll be matched with the best results based on your personal needs.

This resource center helps you connect with organizations offering no-cost and reduced-cost programs to help with challenges such as food, transportation, and child care.

My Health Dashboard

See a full picture of your family’s health in one secure place. Use a single profile to view, download, and share information such as health histories and electronic medical records directly from your smartphone or computer.

Use My Health Dashboard to find news on health topics that interest you, health and wellness tips, and personalized action plans that can help you reach your goals. It also offers a customized experience just for you, such as syncing your fitness tracker and scanning and tracking your meals.

Chat If you have questions about your benefits or need information, Sydney Health can help you quickly find what you’re looking for and connect you to an Anthem representative.

Download the Sydney Health app today Use the app anytime to: 

My Health Records

¿Prefieres obtener información en español? Tienes opciones. Si tu teléfono móvil ya está configurado en español, la aplicación Sydney Health también estará en español. Si no es así, selecciona el menú dentro de la aplicación Sydney Health y elige el idioma de la aplicación. También puedes visitar espanol.anthem.com.



Find care and compare costs. See what’s covered and check claims.



View and use digital ID cards.



Check your plan progress.



Fill prescriptions. Scan the QR code to download the Sydney Health app.

You can also set up an account at anthem.com/register to access most of the same features from your computer.

Virtual Care Connect directly to care from the convenience of home. Assess your symptoms quickly using the Symptom Checker or talk to a doctor via chat or video session. In addition to using a telehealth service, you can receive in-person or virtual care from your own doctor or another healthcare provider in your plan’s network. If you receive care from a doctor or healthcare provider not in your plan’s network, your share of the costs may be higher. You may also receive a bill for any charges not covered by your health plan. Sydney Health is offered through an arrangement with Carelon Digital Platforms, a separate company offering mobile application services on behalf of your health plan. ©2023 The Virtual Primary Care experience is offered through an arrangement with Hydrogen Health. Anthem Blue Cross and Blue Shield is the trade name of: In Colorado: Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc. Copies of Colorado network access plans are available on request from member services or can be obtained by going to anthem.com/co/networkaccess. In Connecticut: Anthem Health Plans, Inc. In Georgia: Blue Cross Blue Shield Healthcare Plan of Georgia, Inc. In Indiana: Anthem Insurance Companies, Inc. In Kentucky: Anthem Health Plans of Kentucky, Inc. In Maine: Anthem Health Plans of Maine, Inc. In Missouri (excluding 30 counties in the Kansas City area): RightCHOICE® Managed Care, Inc. (RIT), Healthy Alliance® Life Insurance Company (HALIC), and HMO Missouri, Inc. RIT and certain affiliates administer non-HMO benefits underwritten by HALIC and HMO benefits underwritten by HMO Missouri, Inc. RIT and certain affiliates only provide administrative services for self-funded plans and do not underwrite benefits. In Nevada: Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc., dba HMO Nevada. In New Hampshire: Anthem Health Plans of New Hampshire, Inc. HMO plans are administered by Anthem Health Plans of New Hampshire, Inc. and underwritten by Matthew Thornton Health Plan, Inc. In Ohio: Community Insurance Company. In Virginia: Anthem Health Plans of Virginia, Inc. trades as Anthem Blue Cross and Blue Shield in Virginia, and its service area is all of Virginia except for the City of Fairfax, the Town of Vienna, and the area east of State Route 123. In Wisconsin: Blue Cross Blue Shield of Wisconsin (BCBSWI), underwrites or administers PPO and indemnity policies and underwrites the out of network benefits in POS policies offered by Compcare Health Services Insurance Corporation (Compcare) or Wisconsin Collaborative Insurance Corporation (WCIC). Compcare underwrites or administers HMO or POS policies; WCIC underwrites or administers Well Priority HMO or POS policies. Independent licensees of the Blue Cross and Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc. 116947MUMENABS VPOD BV Rev. 12/22

Expanding your virtual care options Find complete care support, on your time, through the Sydney Health app

 Download our

Sydney Health mobile app today.

Visit with a doctor at your convenience Accessing the care you need, when you need it, matters. That’s why our SydneySM Health mobile app connects you to a team of doctors ready to help you on your time. There are two secure ways to find low or no-additional cost care through our app:

Set up your account right away and it will be ready to use when you need it.

1 Chat with a doctor 24/7 without an appointment ◦ Urgent care support for health issues, such as allergies, a cold, or the flu. ◦ New prescriptions1 for concerns such as a cough or a sinus infection.

2 Schedule a virtual primary care appointment ◦ Routine care, including virtual annual preventive care (wellness) visit and prescription refills.1,2,3,4 ◦ Personalized care plans for chronic conditions, such as asthma or diabetes.

Assess your symptoms with the Symptom Checker When you’re sick, you can use the Symptom Checker on Sydney Health to answer a few questions about how you’re feeling. That information is run against millions of medical data points to provide care advice tailored to you.

Save money and time with virtual care Sydney Health brings care to you anywhere, anytime. The Symptom Checker is always free to use, while virtual primary care visits and on-demand urgent care through the app are available at low or no-additional cost.

% resolve of virtual visits

the person’s need.5

1 Virtual annual preventive care (wellness) visits through the Sydney Health app are available starting September 2022. The virtual annual preventive care (wellness) visit is covered in full unless the employer has a limit or cap under their benefit plan. 2 Virtual primary care medical services provided by Preventive Medical Associates P.C. through an arrangement with Hydrogen Health, which provides the virtual care platform. 3 Eligible employees are those who have not yet had an annual preventive care (wellness) visit during the plan year (either virtual or in-person) whose group benefit plan covers a virtual primary care exam. If an employer group has a cap on the number of preventive care (wellness) visits that are covered in full and the employee has exceeded the cap but would like to have another preventive care (wellness) visit, they may be responsible for copays and other out-of-pocket costs for the visit. Employees should consult their benefit plan and/or contact Member Services if they have any questions. 4 Your doctor will determine if a prescription is needed at time of visit. 5 K Health analysis of Q4 2020 visit depositions. Sydney Health is offered through an arrangement with Carelon Digital Platforms, a separate company offering mobile application services on behalf of your health plan. ©2020-2022 The Virtual Primary Care experience is offered through an arrangement with Hydrogen Health. In addition to using a telehealth service, you can receive in-person or virtual care from your own doctor or another healthcare professional in your plan’s network. If you receive care from a doctor or healthcare professional not in your plan’s network, your share of the costs may be higher. You may also receive a bill for any charges not covered by your health plan. Anthem Blue Cross and Blue Shield is the trade name of: In Colorado: Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc. In Connecticut: Anthem Health Plans, Inc. In Georgia: Blue Cross Blue Shield Healthcare Plan of Georgia, Inc. In Indiana: Anthem Insurance Companies, Inc. In Kentucky: Anthem Health Plans of Kentucky, Inc. In Maine: Anthem Health Plans of Maine, Inc. In Missouri (excluding 30 counties in the Kansas City area): RightCHOICE® Managed Care, Inc. (RIT), Healthy Alliance® Life Insurance Company (HALIC), and HMO Missouri, Inc. RIT and certain affiliates administer non-HMO benefits underwritten by HALIC and HMO benefits underwritten by HMO Missouri, Inc. RIT and certain affiliates only provide administrative services for self-funded plans and do not underwrite benefits. In Nevada: Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc., dba HMO Nevada. In New Hampshire: Anthem Health Plans of New Hampshire, Inc. HMO plans are administered by Anthem Health Plans of New Hampshire, Inc. and underwritten by Matthew Thornton Health Plan, Inc. In Ohio: Community Insurance Company. In Virginia: Anthem Health Plans of Virginia, Inc. trades as Anthem Blue Cross and Blue Shield in Virginia, and its service area is all of Virginia except for the City of Fairfax, the Town of Vienna, and the area east of State Route 123. In Wisconsin: Blue Cross Blue Shield of Wisconsin (BCBSWI), underwrites or administers PPO and indemnity policies and underwrites the out of network benefits in POS policies offered by Compcare Health Services Insurance Corporation (Compcare) or Wisconsin Collaborative Insurance Corporation (WCIC). Compcare underwrites or administers HMO or POS policies; WCIC underwrites or administers Well Priority HMO or POS policies. Independent licensees of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc. 4579509MUMENABS VPOD BV Rev. 06/22

Charlottesville City Schools

Health Insurance Rates for Full-Time Employees (effective 7/1/2025 - 6/30/2026)

Employee Employee + Child Employee + Children Employee + Spouse Employee + Family Retiree

Core KeyCare Plan $1,000/$2,000 Ded $3,500/$7,000 OPM $10/$30/$50 Rx

Employer Contribution (Monthly)

Employee Contribution (Monthly)

Payroll Deduction Amount (24 Pays)

Payroll Deduction Amount (20 Pays)

$791.94 $1,187.94 $1,656.76 $1,504.72 $2,138.28 $791.94

$744.42 $1,021.62 $1,349.80 $1,243.37 $1,686.86 $333.33

$47.52 $166.32 $306.96 $261.35 $451.42 $458.61

$23.76 $83.16 $153.48 $130.68 $225.71 n/a

$28.51 $99.79 $184.18 $156.81 $270.85 n/a Payroll Deduction Amount (20 Pays)

Enhanced KeyCare Plus Plan $0 Ded $3,000/$6,000 OPM $10/$30/$50 Rx

Employer Contribution (Monthly)

Employee Contribution (Monthly)

Payroll Deduction Amount (24 Pays)

$921.20 $1,381.78 $1,927.14 $1,750.29 $2,487.26 $921.20

$797.32 $1,079.12 $1,412.73 $1,304.54 $1,755.37 $333.33

$123.88 $302.66 $514.41 $445.75 $731.89 $587.87

$61.94 $151.33 $257.21 $222.88 $365.95 n/a

$74.33 $181.60 $308.65 $267.45 $439.13 n/a Payroll Deduction Amount (20 Pays) $0.00 $64.41 $71.57 $78.73 $143.14 n/a

HDHP KeyCare Plan w/ HSA $3,200/$6,400 Ded $5,500/$11,000 OPM

Employer Contribution (Monthly)

Employee Contribution (Monthly)

Payroll Deduction Amount (24 Pays)

$591.56 $1,128.33 $1,187.97 $1,247.61 $1,784.38 $591.56

$591.56 $1,020.98 $1,068.69 $1,116.40 $1,545.82 $333.33

$0.00 $107.35 $119.28 $131.21 $238.56 $258.23

$0.00 $53.68 $59.64 $65.61 $119.28 n/a

Charlottesville City Schools

Health Insurance Rates for Part-Time Employees (effective 7/1/2025 - 6/30/2026)

Employee Employee + Child Employee + Children Employee + Spouse Employee + Family

Core KeyCare Plan $1,000/$2,000 Ded $3,500/$7,000 OPM $10/$30/$50 Rx

Employer Contribution (Monthly)

Employee Contribution (Monthly)

Payroll Deduction Amount (24 Pays)

Payroll Deduction Amount (20 Pays)

$791.94 $1,187.94 $1,656.76 $1,504.72 $2,138.28

$673.15 $910.75 $1,192.04 $1,100.82 $1,480.95

$118.79 $277.19 $464.72 $403.90 $657.33

$59.40 $138.60 $232.36 $201.95 $328.66

$71.27 $166.31 $278.83 $242.34 $394.40

Enhanced KeyCare Plus Plan $0 Ded $3,000/$6,000 OPM $10/$30/$50 Rx

Employer Contribution (Monthly)

Employee Contribution (Monthly)

Payroll Deduction Amount (24 Pays)

Payroll Deduction Amount (20 Pays)

$921.20 $1,381.78 $1,927.14 $1,750.29 $2,487.26

$709.65 $942.75 $1,218.69 $1,129.20 $1,502.10

$211.55 $439.03 $708.45 $621.09 $985.16

$105.78 $219.52 $354.23 $310.55 $492.58

$126.93 $263.42 $425.07 $372.65 $591.10 Payroll Deduction Amount (20 Pays) $35.49 $132.11 $142.85 $153.58 $250.20

HDHP KeyCare Plan w/ HSA $3,200/$6,400 Ded $5,500/$11,000 OPM

Employer Contribution (Monthly)

Employee Contribution (Monthly)

Payroll Deduction Amount (24 Pays)

$591.56 $1,128.33 $1,187.97 $1,247.61 $1,784.38

$532.40 $908.14 $949.89 $991.64 $1,367.38

$59.16 $220.19 $238.08 $255.97 $417.00

$29.58 $110.09 $119.04 $127.99 $208.50

Click on the video below to learn more about Dental Insurance!

DENTAL INSURANCE



Charlottesville City Schools

Dental Insurance Rates for Full-Time and Part-Time Employees (effective 7/1/2025 - 6/30/2026)

Delta Dental PPO plus Premier Plan Employee Employee + Child Employee + Children Employee + Spouse Employee + Family

Employee Contribution (Monthly) $40.72 $71.27 $76.95 $71.27 $126.21

Payroll Deduction Amount (24 Pays) $20.36 $35.64 $38.48 $35.64 $63.11

Payroll Deduction Amount (20 Pays) $24.43 $42.76 $46.17 $42.76 $75.73

Click on the video below to learn more about Vision Insurance!

VISION INSURANCE

Charlottesville City Schools SUMMARY OF BENEFITS

Additional discounts

40% Complete pair of prescription eyeglasses

OFF

20% 20%

OFF Non-prescription sunglasses

Vision Care Services _____________________________

In-Network Member Cost _________________________________________

Out-of-Network Reimbursement _________________

Exam With Dilation as Necessary

$10 Co-pay

Up to $35

Retinal Imaging

Up to $39

N/A

Frames

$0 Co-pay; $130 allowance; 20% off balance over $130

Up to $65

Standard Plastic Lenses Single Vision Bifocal Trifocal Standard Progressive Lens Premium Progressive Lens Lenticular

$10 Co-pay $10 Co-pay $10 Co-pay $65 $65, 80% of charge less $110 allowance $10 Co-pay

Up to $25 Up to $40 Up to $55 Up to $40 Up to $40 Up to $55

Lens Options (paid by the member and added to the base price of the lens) UV Treatment $15 Tint (Solid and Gradient) $15 Standard Plastic Scratch Coating $15 Standard Polycarbonate $40 Standard Polycarbonate - Kids under 19 $40 Standard Anti-Reflective Coating $45 Other Add-Ons and Services 20% off retail price

N/A N/A N/A N/A N/A N/A N/A

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

Up to $55 10% off retail

N/A N/A

OFF Remaining balance beyond plan coverage

Contact Lenses Conventional Disposable Medically Necessary

$0 Co-pay; $135 allowance; 15% off balance over $135 $0 Co-pay; $135 allowance; plus balance over $135 $0 Co-pay, Paid-in-Full

Up to $108 Up to $108 Up to $210

These discounts are for in-network providers only

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

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

N/A

Hearing Care Hearing Health Care from Amplifon Hearing Network

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

N/A

Frequency Examination Lenses or Contact Lenses Frame

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

Take a sneak peek before enrolling • You’re on the ACCESS Network • For a complete list of in-network providers near you, use our Enhanced Provider Locator on www.eyemed.com or call 1-866-723-0596. • For Lasik providers, call 1-877-5LASER6.

Benefits are not provided from services or materials arising from: 1) Orthoptic or vision training, subnormal vision aids and any associated supplemental testing; Aniseikonic lenses; 2) Medical and/or surgical treatment of the eye, eyes or supporting structures; 3) Any eye or Vision Examination, or any corrective eyewear required by a Policyholder as a condition of employment; Safety eyewear; 4) Services provided as a result of any Workers’ Compensation law, or similar legislation, or required by any governmental agency or program whether federal, state or subdivisions thereof; 5) Plano (non-prescription) lenses; 6) Non-prescription sunglasses; 7) Two pair of glasses in lieu of bifocals; 8) Services or materials provided by any other group benefit plan providing vision care 9) Services rendered after the date an Insured Person ceases to be covered under the Policy, except when Vision Materials ordered before coverage ended are delivered, and the services rendered to the Insured Person are within 31 days from the date of such order. 10) Lost or broken lenses, frames, glasses, or contact lenses will not be replaced except in the next Benefit Frequency when Vision Materials would next become available. Benefits may not be combined with any discount, promotional offering, or other group benefit plans. Standard/Premium Progressive lens not covered-fund as a Bifocal lens. Standard Progressive lens covered-fund Premium Progressive as a Standard. Benefit allowance provides no remaining balance for future use within the same benefit year. Fees charged for a non-insured benefit must be paid in full to the Provider. Such fees or materials are not covered. AH2015

BLM2015

What’s in it for me? Options. It’s simple really. We’re dedicated to helping you see clearly — and that’s why we’ve built a network that gives you lots of choices and flexibility. You can choose from thousands of independent and retail providers to find the one that best fits your needs and schedule. No matter which one you choose, our plan is designed to be easy-to-use and help you access the care you need. Welcome to EyeMed.

Benefits Snapshot

With EyeMed

Out-of-Network Reimbursement

Exam with dilation as necessary (Once every 12 months)

$10 Co-pay

Up to $35

Frames (Once every 12 months)

$0 Co-pay; $130 allowance; 20% off balance over $130

Up to $65

Single Vision Lenses (Once every 12 months)

$10 Co-pay

Up to $25

$0 Co-pay; $135 allowance; plus balance over $135

Up to $108

Or Contacts (Once every 12 months)

And now it’s time for the breakdown . . . Here’s an example of what you might pay for a pair of glasses with us vs. what you’d pay without vision coverage. So, let’s say you get an eye exam and choose a frame that costs $163 with single vision lenses that have UV and scratch protection. Now let’s see the difference...

81%

SAVINGS with us*

With EyeMed

Without Insurance**

Exam $10 Co-pay

Exam

$106

Frame $163

Frame

$163

-$130 allowance $33 -$6.60 (20% discount off balance) $26.40

Lens

Total

Lens

$10 Co-pay

$78

$15 UV treatment add-on

$23 UV treatment add-on

+$15 Scratch coating add-on

+$25 Scratch coating add-on

$40

$126

$76.40

Total

$395

Download the EyeMed Members App

It’s the easy way to view your ID card, see benefit details and find a provider near you.

*This is a snapshot of your benefits. Actual savings will depend on provider, frame and lens selections. **Based on industry averages.

Charlottesville City Schools

Vision Insurance Rates for Full-Time and Part-Time Employees (effective 7/1/2025 - 6/30/2026)

EyeMed Vision Plan Employee Employee + Child Employee + Children Employee + Spouse Employee + Family

Employee Contribution (Monthly) $9.27 $18.41 $18.41 $17.48 $27.00

Payroll Deduction Amount (24 Pays) $4.64 $9.21 $9.21 $8.74 $13.50

Payroll Deduction Amount (20 Pays) $5.56 $11.05 $11.05 $10.49 $16.20

Click on the video below to learn more about Health Savings Accounts!

HEALTH SAVINGS ACCOUNT

HEALTH SAVINGS ACCOUNT (HSA)

Save now — and for your future If you’re on a high-deductible health plan (HDHP), you can use an HSA to pay your required deductible with pretax funds. With an HSA, you may be able to contribute up to $4,300* per individual or $8,550* per family (pretax) annually. If you are 55 or older, you can contribute an extra $1,000.

Adding an HSA to your health plan can help grow your savings after meeting immediate health care expenses.

Triple tax benefit Your contributions are tax-free, and remain completely tax-free when used for qualified health care expenses.

Check HSA eligibility You’re eligible if you’re enrolled in a qualified high-deductible health plan, with a few exceptions. They include: • Other health plan coverage that pays out-of-pocket expenses before you meet your plan deductible, such as Medicare or TriCare coverage • A general-purpose health care flexible spending account or health reimbursement arrangement in the same year • Veterans Affairs medical benefits used in the last three months, unless the hospital care or medical services were for a service-connected disability • Someone claiming you as a dependent on their tax return

Use your HSA to save

Invest tax-free You can invest your HSA funds in an investment account, where your money may grow tax-free.**

Take it with you Your HSA isn’t tied to an employer, health plan, or retirement. If you have an HSA elsewhere, you can transfer the balance to your new one. And your unused funds roll over from year to year.

Choose your way to pay Once funds are available in your HSA, Inspira makes it easy to pay for your eligible expenses.

Pay with your Inspira Card™ Helpful HSA tips 1.

Check IRS contribution limits and eligible expense items on your employer’s plan document or at inspirafinancial.com.

2. Access the record of your HSA expense payments on the Inspira website.

3. If you use your HSA for ineligible expenses, you’ll need to pay income taxes. Plus, a 20% penalty tax on that amount, unless you’re age 65 or older or disabled at the time.

When you use it, your expense is automatically paid from your account.

Pay yourself back Pay for eligible expenses with cash, a check, or your personal credit card. Then withdraw funds from your HSA to pay yourself back and have your payment deposited directly into your checking or savings account.

Pay expenses online Use our digital tools to set up easy repeat payments.

Use the Inspira Mobile™ app It’s the easiest way to manage your account and view alerts; make payments, withdrawals, and deposits; use our barcode scanner to see if an item is an eligible expense. An HSA allows tax-free payment of medical expenses, many overthe-counter products, and prescriptions, as well as vision and dental expenses. Find a list of which expenses may not be covered on the Inspira website.

Realize the savings potential of an HSA For more information visit inspirafinancial.com or scan the QR code.

The maximum contribution limits are subject to change annually. 2025 IRS limits included. Please note that not all states provide favorable income tax treatment for HSAs.

Inspira Financial Health, Inc. does not provide legal, tax, or financial advice. Please contact a professional for advice on eligibility, tax treatment, and other restrictions. Inspira and Inspira Financial are trademarks of Inspira Financial Trust, LLC. This material is for informational purposes only. It is not an offer of coverage and it does not constitute a contract. Health savings accounts (HSAs) are individual accounts administered by Inspira Financial Health. There may be fees associated with your HSA. HSAs are subject to eligibility requirements and restrictions. State taxes may apply. In case of a conflict between your plan documents and the information in this material, the plan documents will govern. Eligible expenses may vary from employer to employer. Please refer to your employer’s Summary Plan Description (“SPD”) for more information about your covered benefits. Information is believed to be accurate as of the production date; however, it is subject to change. HBI-103 (06/24) | ©2024 Inspira Financial

HEALTH SAVINGS ACCOUNT (HSA)

Invest in your future with your Inspira health savings account As an Inspira HSA customer, you have the opportunity to potentially grow your HSA balance by investing in a variety of mutual funds. It’s a fact — you can make tax-free contributions and tax-free withdrawals for eligible health care expenses. And any growth that occurs will also be tax free.1 Use your HSA to help expand your ability to save for the future.

Get ready to invest your HSA With a minimum balance in your HSA (typically $1,000), you may choose to start investing your HSA dollars. This opens the door to benefits such as: • Access to a diversified group of mutual funds, each professionally managed by a third-party investment adviser. • Investment choices that earn top Morningstar® star ratings with an average of 4+ stars out of 5. Morningstar is a leading investment research firm.2 • Seamless investment capabilities with no transaction fees for trading. • Move money from your investment account back to your cash account if you need those funds for health care.

Just 27% of working Americans know HSAs can be used as an investment vehicle.3

Easy online management From the Inspira website, you can:

1 2

Transfer funds to and from your HSA. Use the "auto-invest" feature to control recurring transfers. Schedule transfers for each week, month, or quarter.

your investment account information, like investment 3 View balances, elections, and recent transactions. Use the Inspira Mobile™ app for even easier access.

Manage your investment account — keep your portfolio asset allocation where you want it by using the rebalance feature. You can choose a one-time adjustment or set a rule for future re-allocation trades.

Make your HSA work harder for your future For more information, visit inspirafinancial.com or scan the QR code.

Please note that not all states provide favorable income tax treatment for HSAs. A 5-star rating is the highest while a 1-star rating is the lowest; rating is based on an average of 27 funds. Morningstar, Inc., Morningstar, the Morningstar logo and Morningstar.com are registered trademarks of Morningstar, Inc. 3 Investor's Business Daily. Health Savings Accounts: From Simple Savings To Investment Powerhouse. November 2023. Note: Standard text messaging and other rates from your wireless carrier still apply. 1

Inspira Financial Health, Inc. does not provide legal, tax or financial advice. Please contact a professional for advice on eligibility, tax treatment, and other restrictions. Inspira and Inspira Financial are trademarks of Inspira Financial Trust, LLC. This material is for informational purposes only. It is not an offer of coverage and it does not constitute a contract. Health savings accounts (HSAs) are individual accounts administered by Inspira Financial Health. There may be fees associated with your HSA. HSAs are subject to eligibility requirements and restrictions. State taxes may apply. In case of a conflict between your plan documents and the information in this material, the plan documents will govern. Eligible expenses may vary from employer to employer. Please refer to your employer’s Summary Plan Description (“SPD”) for more information about your covered benefits. Information is believed to be accurate as of the production date; however, it is subject to change. Investment services are offered through an independent, third-party registered investment advisor. The HSA investment account is an optional, self-directed service, and Inspira Financial Health does not provide investment advice. By transferring funds into an HSA investment account, you will be exposed to a number of risks, including the loss of principal, and such funds are not FDIC or NCUA insured, or guaranteed by Inspira Financial Health. You should always read the prospectus for the funds you intend on purchasing. The prospectus describes the funds, investment objectives and strategies, their fees and expenses, and the risks inherent to investing in each fund. Investing through the Inspira Financial Health platform is subject to the terms and conditions of the Health Savings Account Custodial Agreement and the Investment Agreement. System response and account access times may vary due to a variety of factors, including trading volumes, market conditions, system performance, and other factors. HBI-142 (07/24) | ©2024 Inspira Financial Health, Inc.

THE HSA STORE Save even more with your HSA through our partnership.

$20 OFF *Limit one per customer

Get $20 off any order of $150 with code PBG20HSA

Shop Now

Resources Available Through The HSA Store • The largest selection of guaranteed HSA-eligible products • Phone and live chat support available 24 hours a day / 7 days a week

Eligibility List

HSA Calculator

Search comprehensive list of eligible products and services.

Estimate how much you can save with an HSA.

Learning Center

Savings Center

Easy tips and resources for utilizing an HSA.

Your funds go further with the HSA Store rewards program.

• Fast and free shipping on orders over $50 • Use your HSA card or any other major credit card for purchases

Your Health, Your Funds, Your Choice Take control of your health and wellness with guaranteed HSA-eligible essentials. Pierce Group Benefits partners with the HSA store to provide one convenient location for Heath Savings Account holders. 31

Click or Scan to Shop Now

Click on the video below to learn more about Flexible Spending Accounts!

FLEXIBLE SPENDING ACCOUNT

Plan Year: 7/1/2025-6/30/2026

Flexible Spending Account Plan Enrollment Materials

No matter which health insurance plan you enroll in this year, you will likely have out-of-pocket costs. Save up to 30% on qualifying out-of-pocket expenses by setting aside pre-tax dollars from your paycheck with a flex account! Dependent Care Account (DCA)

Medical FSA

Medical

Pharmacy

Dental

Vision

Over-theCounter

Childcare Expenses

How does it work? It's simple.

Choose your annual election for each flex plan, based on your anticipated expenses.

Your annual election is deducted pre-tax from your paycheck in equal amounts during the plan year.

Swipe your card for eligible expenses or submit a claim for reimbursement.

This lowers your taxable income! 33

Questions? Contact us at info@flexfacts.com or 877-943-2287

Medical FSA

Save up to $990 on medical expenses this year! Participating in an FSA is like receiving a 30% discount from your medical providers.

How does an FSA work?

Spending your FSA funds

A medical FSA is a flexible spending account that allows you to set aside pre-tax dollars for eligible medical, dental, and vision expenses for you and your dependents.

Choose an annual election amount, up to $3,300*. This amount will be deducted from your paychecks in equal installments throughout the year. Your full election will be available for spending on the first day of the plan year!

Swipe your Flex Facts debit card to pay for eligible expenses or pay with your personal funds and submit a claim for reimbursement.

Why should I enroll in an FSA?

Common eligible expenses

Almost everyone has some level of out of pocket medical costs. If you expect to incur medical expenses, you’ll want to take advantage of the savings this plan offers. Money contributed to a healthcare FSA is free from federal and most state taxes. On average, participants enjoy a 30% tax savings on their annual contribution, saving up to $990 per year!

Limited Purpose FSA for HSA participants

. . ..

You can't contribute to an HSA and full purpose FSA within the same plan year. Instead, you can contribute to a limited purpose FSA, which covers dental and vision expenses. This will help you preserve your HSA funds for other purposes, including saving for the future.

Helpful hints... Your election can only be changed during the plan year if you experience a qualifying event. Save your receipts. You may need itemized invoices to verify card swipes or for claim reimbursements. If your employment terminates, your account will be terminated. You will have an additional 2.5 month grace period to spend your FSA funds after the plan ends. Be sure to spend your funds by then, as unspent funds will be forfeited.

• • • • • • • • • •

Copays, deductible, coinsurance Doctor office visits, lab work, x-rays Hospital charges Dental and orthodontia Vision exams, glasses, contact lenses, laser vision correction Physical therapy Chiropractic care Medical supplies and first aid kits Rx and over-the-counter meds And much more... Visit http://fsastore.com/ FlexfactsEL for full list.

Download our app Search 'Flex Facts' on the App Store or Google Play. *based on 2025 IRS Contribution Limit.

Please note: Your employer may limit the maximum annual limit to a lesser amount.

Questions? Contact us at info@flexfacts.com or 877-943-2287

THE FSA STORE Save even more with your FSA through our partnership.

$20 OFF *Limit one per customer

Get $20 off any order of $150 with code PBG20FSA

Shop Now

Resources Available Through The FSA Store • The largest selection of guaranteed FSA-eligible products • Phone and live chat support available 24 hours a day / 7 days a week

Eligibility List

FSA Calculator

Search comprehensive list of eligible products and services.

Estimate how much you can save with an FSA.

Learning Center

Savings Center

Easy tips and resources for utilizing an FSA.

Your funds go further with the FSA Store rewards program.

• Fast and free shipping on orders over $50 • Use your FSA card or any other major credit card for purchases

Your Health, Your Funds, Your Choice Take control of your health and wellness with guaranteed FSA-eligible essentials. Pierce Group Benefits partners with the FSA store to provide one convenient location for Flexible Spending Account holders. 35

Click or Scan to Shop Now

Click on the video below to learn more about Dependent Care Accounts!

DEPENDENT CARE ACCOUNT

Dependent Care FSA

Save up to $1,500 on dependent care expenses this year! Participating in a dependent care FSA is like receiving a 30% discount from your care providers.

How does a DCA work?

Spending your funds

A dependent care FSA (DCA) is a flexible spending account that allows you to set aside pre-tax dollars for dependent care expenses that allow you to work or look for work. This includes daycares, babysitters and before/after school care.

Choose an annual election amount, up to $5,000/family. This amount will be deducted from your paychecks in equal installments throughout the year.

Qualifying Dependents* • Your qualifying child under age 13

Why should I enroll in an DCA?

Child and dependent care is a large expense for many families. If you pay for care of dependents in order to work, you’ll want to take advantage of the savings this plan offers. Money contributed to a dependent care FSA (DCA) is free from federal and most state taxes. On average, participants enjoy a 30% tax savings on their annual contribution, saving up to $1,500 per year!

. . . ..

Swipe your Flex Facts debit card to pay for eligible expenses or pay with your personal funds and submit a claim for reimbursement.

Helpful hints... Funds will be made available in your DCA account, as deductions are taken each payroll. Your election can only be changed during the plan year if you experience a qualifying event. Save your receipts. You may need itemized invoices to verify card swipes or for claim reimbursements. If your employment terminates, your account will be terminated. You will have an additional 2.5 month grace period to spend your DCA funds after the plan ends. Be sure to spend your funds by then, as unspent funds will be forfeited.

• Your spouse or qualifying adult child or relative who is physically or mentally incapable of self-care

Eligible Expenses • Before school or after school care for children 12 and younger • Custodial care for adult dependents • Licensed day care centers • Nanny / Au Pair • Nursery Schools or preschools • Late Pick-up fees • Summer or Holiday day camps A full list of eligible expenses can be found at www.flexfacts.com.

Download our app Search 'Flex Facts' on the App Store or Google Play.

*additional restrictions may apply. See Internal Revenue Code Section 152.

Questions? Contact us at info@flexfacts.com or 877-943-2287

Click on the video below to learn more about Employee Assistance Programs!

EMPLOYEE ASSISTANCE PROGRAM

FEAP IS HERE FOR YOU Short-Term, Confidential Services for Both Personal and Professional Concerns Counseling, Assessments, Referrals, & Resources

39 Charlottesville, VA 22908 1300 Jefferson Park Avenue, call: 434.243.2643 visit: uvafeap.com

Click on the video below to learn more about Cancer Benefits!

CANCER BENEFITS

Cancer Insurance How would cancer impact your way of life? Hopefully, you and your family will never face cancer. If you do, a financial safety net can help you and your loved ones focus on what matters most — recovery. If you were diagnosed with cancer, you could have expenses that medical insurance doesn’t cover. In addition to your regular, ongoing bills, you could have indirect treatment and recovery costs, such as child care and home health care services.

Help when you need it most Cancer coverage from Colonial Life & Accident Insurance Company can help protect the lifestyle you’ve worked so hard to build. It provides benefits you can use to help cover: ■ Loss of income ■ Out-of-network treatment ■ Lodging and meals ■ Deductibles and co-pays

CANCER ASSIST

One family’s journey

DOCTOR’S SCREENING

Paul and Kim were preparing for their second child when they learned Paul had cancer. They quickly realized their medical insurance wouldn’t cover everything. Thankfully, Kim’s job enabled her to have a cancer insurance policy on Paul to help them with expenses.

SECOND OPINION

SURGERY

Wellness benefit

Travel expenses

Out-of-pocket costs

Paul’s wellness benefit helped pay for the screening that discovered his cancer.

When the couple traveled several hundred miles from their home to a top cancer hospital, they used the policy’s lodging and transportation benefits to help with expenses.

The policy’s benefits helped with deductibles and co-pays related to Paul’s surgery and hospital stay.

For illustrative purposes only

With cancer insurance: ■ Coverage options are available for you

and your eligible dependents. ■ Benefits are paid directly to you, unless

you specify otherwise. ■ You’re paid regardless of any insurance

you may have with other companies. ■ You can take coverage with you, even if you

change jobs or retire.

ONLY of ALL

CANCERS are

hereditary.

American Cancer Society, Cancer Facts & Figures, 2013

Cancer insurance provides benefits to help with cancer expenses — from diagnosis to recovery.

TREATMENT

RECOVERY

Experimental care

Follow-up evaluations

Paul used his plan’s benefits to help pay for experimental treatments not covered by his medical insurance.

Paul has been cancer-free for more than four years. His cancer policy provides a benefit for periodic scans to help ensure the cancer stays in check.

Our cancer insurance offers more than 30 benefits that can help you with costs that may not be covered by your medical insurance. Treatment benefits

(inpatient or outpatient)

Surgery benefits ■ Surgical procedures

■ Radiation/chemotherapy

■ Anesthesia

■ Anti-nausea medication

■ Reconstructive surgery

■ Medical imaging studies

■ Outpatient surgical center

■ Supportive or protective care drugs

■ Prosthetic device/artificial limb

and colony stimulating factors ■ Second medical opinion

Travel benefits

■ Blood/plasma/platelets/

■ Transportation

immunoglobulins ■ Bone marrow or peripheral stem

■ Companion transportation ■ Lodging

LIFETIME RISK OF DEVELOPING CANCER

MEN 1 in 2

cell donation ■ Bone marrow or peripheral stem

cell transplant ■ Egg(s) extraction or harvesting/

sperm collection and storage ■ Experimental treatment ■ Hair/external breast/voice

box prosthesis ■ Home health care services ■ Hospice (initial or daily care)

Inpatient benefits ■ Hospital confinement ■ Private full-time nursing services ■ Skilled nursing care facility ■ Ambulance ■ Air ambulance

Additional benefits WOMEN

■ Family care

1 in 3

■ Cancer vaccine ■ Bone marrow donor screening ■ Skin cancer initial diagnosis ■ Waiver of premium

American Cancer Society, Cancer Facts & Figures, 2013

Optional riders For an additional cost, you may have the option of purchasing additional riders for even more financial protection against cancer. Talk with your benefits counselor to find out which of these riders are available for you to purchase. ■ Diagnosis of cancer rider — Pays a one-time, lump-sum benefit for the

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initial diagnosis of cancer. You may choose a benefit amount in $1,000 increments between $1,000 and $10,000. If your dependent child is diagnosed with cancer, we will pay two and a half times ($2,500 - $25,000) the chosen benefit amount. ■ Diagnosis of cancer progressive payment rider — Provides a lump-sum

payment of $50 for each month the rider has been in force and before cancer is first diagnosed. ■ Specified disease hospital confinement rider — Pays $300 per day if

you or a covered family member is confined to a hospital for treatment for one of the 34 specified diseases covered under the rider.

If cancer impacts your life, you should be able to focus on getting better — not on how you’ll pay your bills. Talk with your Colonial Life benefits counselor about how cancer insurance can help provide financial security for you and your family.

PRE-EXISTING CONDITION LIMITATION We will not pay benefits for the diagnosis of internal cancer or skin cancer that is a pre-existing condition, nor will we pay benefits for the treatment of internal cancer or skin cancer that is a pre-existing condition unless the covered person has satisfied the six-month pre-existing condition limitation period shown on the Policy Schedule. Pre-existing condition means a condition for which a covered person was diagnosed prior to the effective date of this policy, and for which medical advice or treatment was recommended by or received from a doctor within six months immediately preceding the effective date of this policy. EXCLUSIONS We will not pay benefits for cancer or skin cancer: ■ If the diagnosis or treatment of cancer is received outside of the territorial limits of the United States and its possessions; or ■ For other conditions or diseases, except losses due directly from cancer. The policy and its riders may have additional exclusions and limitations. For cost and complete details of the coverage, see your Colonial Life benefits counselor. Coverage may vary by state and may not be available in all states. Applicable to policy form CanAssist-VA and rider forms R-CanAssistIndx-VA, R-CanAssistProg-VA and R-CanAssistSpDis-VA. ©2016 Colonial Life & Accident Insurance Company, Columbia, SC | Colonial Life insurance products are by Colonial Life & Accident Insurance Company, for which Colonial Life is the marketing brand.

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Cancer Insurance Level 4 Benefits BENEFIT DESCRIPTION

Cancer insurance helps provide financial protection through a variety of benefits. These benefits are not only for you but also for your covered family members.

BENEFIT AMOUNT

Air ambulance . . . .............................................................................. $2,000 per trip

Transportation to or from a hospital or medical facility [max. of two trips per confinement]

Ambulance . . . . . . ............................................................................... $250 per trip Transportation to or from a hospital or medical facility [max. of two trips per confinement]

Anesthesia

Administered during a surgical procedure for cancer treatment ■ General anesthesia ......................................................................... 25% of surgical procedures benefit ■ Local anesthesia............................................................................ $50 per procedure

Anti-nausea medication ..................................................................... $60 per day administered or Doctor-prescribed medication for radiation or chemotherapy [$240 monthly max.]

per prescription filled

Blood/plasma/platelets/immunoglobulins .............................................. $250 per day A transfusion required during cancer treatment [$10,000 calendar year max.]

Bone marrow donor screening ............................................................. $50 Testing in connection with being a potential donor [once per lifetime]

Bone marrow or peripheral stem cell donation ......................................... $1,000 Receiving another person’s bone marrow or stem cells for a transplant [once per lifetime]

Bone marrow or peripheral stem cell transplant ....................................... $10,000 per transplant

Transplant you receive in connection with cancer treatment [max. of two bone marrow transplant benefits per lifetime]

Cancer vaccine. . . .............................................................................. $50 An FDA-approved vaccine for the prevention of cancer [once per lifetime]

Companion transportation ................................................................. $0.50 per mile

Companion travels by plane, train or bus to accompany a covered cancer patient more than 50 miles one way for treatment [up to $1,500 per round trip]

Egg(s) extraction or harvesting/sperm collection and storage

Extracted/harvested or collected before chemotherapy or radiation [once per lifetime] ■ Egg(s) extraction or harvesting/sperm collection ......................................... $1,500 ■ Egg(s) or sperm storage (cryopreservation) ............................................... $500

Experimental treatment ..................................................................... $300 per day Hospital, medical or surgical care for cancer [$15,000 lifetime max.]

For more information, talk with your benefits counselor.

Family care . . . . . . ............................................................................... $60 per day Inpatient or outpatient treatment for a covered dependent child [$3,000 calendar year max.]

Hair/external breast/voice box prosthesis ............................................... $500 per calendar year Prosthesis needed as a direct result of cancer

Home health care services .................................................................. $175 per day Examples include physical therapy, occupational therapy, speech therapy and audiology; prosthesis and orthopedic appliances; rental or purchase of durable medical equipment [up to 100 days per covered person per lifetime]

Hospice (initial or daily care)

An initial, one-time benefit and a daily benefit for treatment [$15,000 lifetime max. for both] ■ Initial hospice care [once per lifetime] ..................................................... $1,000 ■ Daily hospice care .......................................................................... $50 per day

CANCER ASSIST – LEVEL 4

BENEFIT DESCRIPTION

BENEFIT AMOUNT

Hospital confinement

Hospital stay (including intensive care) required for cancer treatment ■ 30 days or less . . ........................................................................................ $350 per day ■ 31 days or more ........................................................................................ $700 per day

Lodging . . . . . . . . . . . . ......................................................................................... $80 per day Hotel/motel expenses when being treated for cancer more than 50 miles from home [70-day calendar year max.]

Medical imaging studies ................................................................................. $225 per study

Specific studies for cancer treatment [$450 calendar year max.]

Outpatient surgical center .............................................................................. $400 per day Surgery at an outpatient center for cancer treatment [$1,200 calendar year max.]

Private full-time nursing services ...................................................................... $150 per day Services while hospital confined other than those regularly furnished by the hospital

Prosthetic device/artificial limb ........................................................................ $3,000 per device or limb A surgical implant needed because of cancer surgery [payable one per site, $6,000 lifetime max.]

Radiation/chemotherapy

[per day with a max. of one per calendar week] ■ Injected chemotherapy by medical personnel ........................................................ $1,000 ■ Radiation delivered by medical personnel ............................................................ $1,000 [per day with a max. of one per calendar month] ■ Self-injected . . . ......................................................................................... $400 ■ Pump . . . . . . . . . . ......................................................................................... $400 ■ Topical . . . . . . . . . . ........................................................................................ $400 ■ Oral hormonal [1-24 months] .......................................................................... $400 ■ Oral hormonal [25+ months] ........................................................................... $350 ■ Oral non-hormonal ..................................................................................... $400

Reconstructive surgery .................................................................................. $60 per surgical unit

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A surgery to reconstruct anatomic defects that result from cancer treatment [min. $350 per procedure, up to $3,000, including 25% for general anesthesia]

Second medical opinion ................................................................................. $300

A second physician’s opinion on cancer surgery or treatment [once per lifetime]

Skilled nursing care facility ............................................................................. $175 per day Confinement to a covered facility after hospital release [up to 100 days per covered person per lifetime]

Skin cancer diagnosis .................................................................................... $600 A skin cancer diagnosis while the policy is in force [once per lifetime]

Supportive or protective care drugs and colony stimulating factors ........................... $200 per day Doctor-prescribed drugs to enhance or modify radiation/chemotherapy treatments [$1,600 calendar year max.]

Surgical procedures ...................................................................................... $70 per surgical unit Inpatient or outpatient surgery for cancer treatment [min. $350 per procedure, up to $6,000]

Transportation . . . . ........................................................................................ $0.50 per mile

Travel expenses when being treated for cancer more than 50 miles from home [up to $1,500 per round trip]

Waiver of premium ....................................................................................... Is available No premiums due if the named insured is disabled longer than 90 consecutive days

The policy has limitations and exclusions that may affect benefits payable. Most benefits require that a charge be incurred. Coverage may vary by state and may not be available in all states. For cost and complete details, see your benefits counselor. This chart highlights the benefits of policy forms CanAssist-NJ and CanAssist-VA. This chart is not complete without form 101505-NJ or 101481-VA.

©2016 Colonial Life & Accident Insurance Company, Columbia, SC | Colonial Life insurance products are underwritten by Colonial Life & Accident Insurance Company, for which Colonial Life is the marketing brand.

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Individual Cancer Insurance Description of Benefits THE POLICY PROVIDES LIMITED BENEFITS. For cost and complete details of the coverage, see your Colonial Life benefits counselor. Coverage may vary by state and may not be available in all states. Coverage is dependent on answers to health questions. Applicable to policy forms CanAssist-VA and rider forms R-CanAssistIndx-VA, R-CanAssistProg-VA and R-CanAssistSpDis-VA. Cancer Insurance Benefits Level 1 Level 2 Level 3 Level 4 Air Ambulance, per trip $2,000 $2,000 $2,000 $2,000 Maximum trips per confinement 2 2 2 2 Ambulance, per trip $250 $250 $250 $250 Maximum trips per confinement 2 2 2 2 Anesthesia, General 25% of Surgical Procedures Benefit Anesthesia, Local, per procedure $25 $30 $40 $50 Anti-Nausea Medication, per day $25 $40 $50 $60 Maximum per month $100 $160 $200 $240 Blood/Plasma/Platelets/Immunoglobulins, per day $150 $150 $175 $250 Maximum per year $10,000 $10,000 $10,000 $10,000 Bone Marrow or Peripheral Stem Cell Donation, per lifetime $500 $500 $750 $1,000 Bone Marrow or Peripheral Stem Cell Transplant, per transplant $3,500 $4,000 $7,000 $10,000 Maximum transplants per lifetime 2 2 2 2 Companion Transportation, per mile $0.50 $0.50 $0.50 $0.50 Maximum per round trip $1,000 $1,000 $1,200 $1,500 Egg(s) Extraction or Harvesting or Sperm Collection, per lifetime $500 $700 $1,000 $1,500 Egg(s) or Sperm Storage, per lifetime $175 $200 $350 $500 Experimental Treatment, per day $200 $250 $300 $300 Maximum per lifetime $10,000 $12,500 $15,000 $15,000 Family Care, per day $30 $40 $50 $60 Maximum per year $1,500 $2,000 $2,500 $3,000 Hair/External Breast/Voice Box Prosthesis, per year $200 $200 $350 $500 Home Health Care Services, per day $50 $75 $125 $175 Benefit payable for at least and not more than 100 days per covered person per lifetime Hospice, Initial, per lifetime $1,000 $1,000 $1,000 $1,000 Hospice, Daily $50 $50 $50 $50 Maximum combined Initial and Daily per lifetime $15,000 $15,000 $15,000 $15,000 Hospital Confinement, 30 days or less, per day $100 $150 $250 $350 Hospital Confinement, 31 days or more, per day $200 $300 $500 $700 Benefit payable for up to 365 days per covered person per calendar year. Lodging, per day $50 $50 $75 $80 Maximum days per year 70 70 70 70 Medical Imaging Studies, per study $75 $125 $175 $225 Maximum per year $150 $250 $350 $450 Outpatient Surgical Center, per day $100 $200 $300 $400 Maximum per year $300 $600 $900 $1,200 Private Full-time Nursing Services, per day $50 $75 $125 $150 Prosthetic Device/Artificial Limb, per device or limb $1,000 $1,500 $2,000 $3,000 Maximum per lifetime $2,000 $3,000 $4,000 $6,000

Cancer Insurance Benefits Level 1 Level 2 Level 3 Level 4 Radiation/Chemotherapy Benefit payable period can exceed but will not be less than 365 days per covered person per lifetime Injected chemotherapy by medical personnel, per day with a $250 $500 $750 $1,000 maximum of one per calendar week Radiation delivered by medical personnel, per day with a $250 $500 $750 $1,000 maximum of one per calendar week Self-Injected Chemotherapy, per day with a maximum of one per $150 $200 $300 $400 calendar month Pump Chemotherapy, per day with a maximum of one per $150 $200 $300 $400 calendar month Topical Chemotherapy, per day with a maximum of one per $150 $200 $300 $400 calendar month Oral Hormonal Chemotherapy (1-24 months), per day with a $150 $200 $300 $400 maximum of one per calendar month Oral Hormonal Chemotherapy (25+ months), per day with a $100 $150 $250 $350 maximum of one per calendar month Oral Non-Hormonal Chemotherapy, per day with a maximum of $150 $200 $300 $400 one per calendar month Reconstructive Surgery, per surgical unit $40 $40 $60 $60 Minimum per procedure $100 $150 $250 $350 Maximum per procedure, including 25% for general anesthesia $2,500 $2,500 $3,000 $3,000 Second Medical Opinion, per lifetime $150 $200 $300 $300 Skilled Nursing Care Facility, per day, up to days confined $50 $75 $125 $175 Benefit payable for at least and not more than 100 days per covered person per lifetime Skin Cancer Initial Diagnosis $300 $300 $400 $600 Supportive/Protective Care Drugs/Colony Stimulating Factors, per day $50 $100 $150 $200 Maximum per year $400 $800 $1,200 $1,600 Surgical Procedures $40 $50 $60 $70 Minimum per procedure $100 $150 $250 $350 Maximum per procedure $2,500 $3,000 $5,000 $6,000 Transportation $0.50 $0.50 $0.50 $0.50 Maximum per round trip $1,000 $1,000 $1,200 $1,500 Waiver of Premium Yes Yes Yes Yes Policy-Wellness Benefits Bone Marrow Donor Screening, per lifetime $50 $50 $50 $50 Cancer Vaccine, per lifetime $50 $50 $50 $50 One amount per account: $0, $25, $50, Part 1: Cancer Wellness/Health Screening, per year $75 or $100 Part 2: Cancer Wellness/Health Screening, per year Same as Part 1 Additional Riders may be available at an additional cost What is not covered by the policy Pre-Existing Condition Limitation We will not pay benefits for the diagnosis of internal cancer or skin cancer that is a pre-existing condition nor will we pay benefits for the treatment of internal cancer or skin cancer that is a pre-existing condition, unless the covered person has satisfied the six-month pre-existing condition limitation period. Pre-existing condition means a condition for which a covered person was diagnosed prior to the effective date of the policy and for which medical advice or treatment was recommended by or received from a doctor within six months immediately preceding the effective date of the policy. We will not pay benefits for cancer or skin cancer: � If the diagnosis or treatment of cancer is received outside of the territorial limits of the United States and its possessions; or � For other conditions or diseases, except losses due directly from cancer. Underwritten by Colonial Life & Accident Insurance Company, Columbia, SC ©2018 Colonial Life & Accident Insurance Company. All rights reserved. Colonial Life is a registered trademark and marketing brand of Colonial Life & Accident Insurance Company. ADR1962-2018

CANCER BENEFIT PREMIUMS LEVEL 1 - Composite Rates Employee

Employee/Spouse

One-Parent Family

Two-Parent Family

Level 1 with $100 Cancer Wellness/Health Screening 10-Pay Premium

$21.72

$34.32

$21.90

$34.50

12-Pay Premium

$18.10

$28.60

$18.25

$28.75

One-Parent Family

Two-Parent Family

LEVEL 2 - Composite Rates Employee

Employee/Spouse

Level 2 with $100 Cancer Wellness/Health Screening 10-Pay Premium

$25.98

$40.62

$26.34

$40.98

12-Pay Premium

$21.65

$33.85

$21.95

$34.15

One-Parent Family

Two-Parent Family

LEVEL 3 - Composite Rates Employee

Employee/Spouse

Level 3 with $100 Cancer Wellness/Health Screening 10-Pay Premium

$31.98

$53.28

$32.52

$53.82

12-Pay Premium

$26.65

$44.40

$27.10

$44.85

One-Parent Family

Two-Parent Family

LEVEL 4 - Composite Rates Employee

Employee/Spouse

Level 4 with $100 Cancer Wellness/Health Screening 10-Pay Premium

$42.72

$71.28

$43.44

$72.00

12-Pay Premium

$35.60

$59.40

$36.20

$60.00

One-Parent Family

Two-Parent Family

OPTIONAL RIDERS Employee

Employee/Spouse

Specified Disease Hospital Confinement Rider 10-Pay Premium

$1.50

$2.10

$1.50

$2.10

12-Pay Premium

$1.25

$1.75

$1.25

$1.75

Initial Diagnosis of Cancer Rider (per $1,000) 10-Pay Premium

$1.80

$3.00

$1.92

$3.12

12-Pay Premium

$1.50

$2.50

$1.60

$2.60

Initial Diagnosis of Cancer Progressive Payment Rider 10-Pay Premium

$9.36

$20.46

$9.36

$20.46

12-Pay Premium

$7.80

$17.05

$7.80

$17.05

Sample rates only. Multiple choices and options available and rates may vary.

Click on the video below to learn more about Critical Illness Benefits!

CRITICAL ILLNESS BENEFITS

Group Critical Illness Insurance Plan 1

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

An unexpected moment changes life forever

Coverage amount: ____________________________

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

Critical illness benefit

HOW CHRIS’S COVERAGE HELPED

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

For illustrative purposes only.

COVERED CONDITION¹

PERCENTAGE OF APPLICABLE COVERAGE AMOUNT

Benign brain tumor

100%

Coma

100%

End stage renal (kidney) failure

100%

Heart attack (myocardial infarction)

100%

Loss of hearing

100%

Loss of sight

100%

Loss of speech

100%

Major organ failure requiring transplant

100%

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

100%

Permanent paralysis due to a covered accident

100%

Stroke

100%

Sudden cardiac arrest

100%

Coronary artery disease

25%

GCI6000 – PLAN 1 – CRITICAL ILLNESS

KEY BENEFITS

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

For more information, talk with your benefits counselor.

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

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

Additional covered conditions for dependent children PERCENTAGE OF APPLICABLE COVERAGE AMOUNT

COVERED CONDITION¹

Cerebral palsy

100%

Cleft lip or palate

100%

Cystic fibrosis

100%

Down syndrome

100%

Spina bifida

100%

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

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

EXCLUSIONS AND LIMITATIONS FOR CRITICAL ILLNESS

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

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PRE-EXISTING CONDITION LIMITATION

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

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Group Critical Illness Insurance Plan 2

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

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

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

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

Special needs daycare

Coverage amount: ____________________________

Critical illness and cancer benefits COVERED CRITICAL ILLNESS CONDITION¹

Benign brain tumor

100%

Coma

100%

End stage renal (kidney) failure

100%

Heart attack (myocardial infarction)

100%

Loss of hearing

100%

Loss of sight

100%

Loss of speech

100%

Major organ failure requiring transplant

100%

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

100%

Permanent paralysis due to a covered accident

100%

Stroke

100%

Sudden cardiac arrest

100%

Coronary artery disease

25%

COVERED CANCER CONDITION¹ For illustrative purposes only.

PERCENTAGE OF APPLICABLE COVERAGE AMOUNT

Invasive cancer (including all breast cancer)

100%

Non-invasive cancer

25%

Skin cancer initial diagnosis ............................................................ $400 per lifetime 53

GCI6000 – PLAN 2 – CRITICAL ILLNESS AND CANCER

KEY BENEFITS

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

Additional covered conditions for dependent children PERCENTAGE OF APPLICABLE COVERAGE AMOUNT

COVERED CONDITION¹

Cerebral palsy

100%

Cleft lip or palate

100%

Cystic fibrosis

100%

Down syndrome

100%

Spina bifida

100%

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

For more information, talk with your benefits counselor.

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

EXCLUSIONS AND LIMITATIONS FOR CRITICAL ILLNESS

EXCLUSIONS AND LIMITATIONS FOR CANCER

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

PRE-EXISTING CONDITION LIMITATION

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

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Group Critical Illness Insurance First Diagnosis Building Benefit Rider

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

First diagnosis building benefit Payable once per covered person per lifetime

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

For more information, talk with your benefits counselor.

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

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

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Group Critical Illness Insurance Infectious Diseases Rider

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

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

PERCENTAGE OF APPLICABLE COVERAGE AMOUNT

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

For more information, talk with your benefits counselor.

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Antibiotic resistant bacteria (including MRSA)

50%

Cerebrospinal meningitis (bacterial)

50%

Diphtheria

50%

Encephalitis

50%

Legionnaires’ disease

50%

Lyme disease

50%

Malaria

50%

Necrotizing fasciitis

50%

Osteomyelitis

50%

Poliomyelitis

50%

Rabies

50%

Sepsis

50%

Tetanus

50%

Tuberculosis

50%

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

25%

GCI6000 – INFECTIOUS DISEASES RIDER

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

EXCLUSIONS AND LIMITATIONS FOR INFECTIOUS DISEASES RIDER

ColonialLife.com

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

PRE-EXISTING CONDITION LIMITATION

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

5-20 | 387523

Group Critical Illness Insurance Progressive Diseases Rider

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

COVERED PROGRESSIVE DISEASE¹

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

For more information, talk with your benefits counselor.

ColonialLife.com

Amyotrophic Lateral Sclerosis (ALS)

25%

Dementia (including Alzheimer’s disease)

25%

Huntington’s disease

25%

Lupus

25%

Multiple sclerosis (MS)

25%

Muscular dystrophy

25%

Myasthenia gravis (MG)

25%

Parkinson’s disease

25%

Systemic sclerosis (scleroderma)

25%

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

EXCLUSIONS AND LIMITATIONS FOR PROGRESSIVE DISEASES RIDER

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

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

GCI6000 – PROGRESSIVE DISEASES RIDER | 5-20 | 387594

CRITICAL ILLNESS BENEFIT PREMIUMS Plan 1 - Critical Illness Rates illustrated per unit. Named Insured unit value = $1000

Issue Age

Deduction

Named Insured

Employee & Spouse

One-Parent Family

Two Parent Family

Non-Tobacco 17-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74

10-Pay Premium

$0.26

$0.37

$0.26

$0.37

12-Pay Premium

$0.22

$0.31

$0.22

$0.31

10-Pay Premium

$0.36

$0.52

$0.36

$0.52

12-Pay Premium

$0.30

$0.43

$0.30

$0.43

10-Pay Premium

$0.46

$0.66

$0.46

$0.66

12-Pay Premium

$0.38

$0.55

$0.38

$0.55

10-Pay Premium

$0.68

$1.02

$0.68

$1.02

12-Pay Premium

$0.57

$0.85

$0.57

$0.85

10-Pay Premium

$0.92

$1.37

$0.92

$1.37

12-Pay Premium

$0.77

$1.14

$0.77

$1.14

10-Pay Premium

$1.30

$1.98

$1.30

$1.98

12-Pay Premium

$1.08

$1.65

$1.08

$1.65

10-Pay Premium

$1.73

$2.68

$1.73

$2.68

12-Pay Premium

$1.44

$2.23

$1.44

$2.23

10-Pay Premium

$2.28

$3.53

$2.28

$3.53

12-Pay Premium

$1.90

$2.94

$1.90

$2.94

10-Pay Premium

$3.12

$4.82

$3.12

$4.82

12-Pay Premium

$2.60

$4.02

$2.60

$4.02

10-Pay Premium

$3.41

$5.26

$3.41

$5.26

12-Pay Premium

$2.84

$4.38

$2.84

$4.38

10-Pay Premium

$3.92

$6.05

$3.92

$6.05

12-Pay Premium

$3.27

$5.04

$3.27

$5.04

One-Parent Family $7.98 $6.65

Two Parent Family $12.42 $10.35

Wellbeing Assistance Benefit Rates by wellbeing amount = 1 unit Welbeing Amount $100

10-Pay Premium 12-Pay Premium

Named Insured $7.98 $6.65

Employee & Spouse $12.42 $10.35

Sample rates only. Multiple choices and options available and rates may vary.

CRITICAL ILLNESS BENEFIT PREMIUMS Plan 2 - Critical Illness & Cancer Benefits Rates illustrated per unit. Named Insured unit value = $1000

Issue Age

Deduction

Named Insured

Employee & Spouse

One-Parent Family

Two Parent Family

Non-Tobacco 17-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74

10-Pay Premium

$0.48

$0.68

$0.48

$0.68

12-Pay Premium

$0.40

$0.57

$0.40

$0.57

10-Pay Premium

$0.68

$1.00

$0.68

$1.00

12-Pay Premium

$0.57

$0.83

$0.57

$0.83

10-Pay Premium

$0.90

$1.31

$0.90

$1.31

12-Pay Premium

$0.75

$1.09

$0.75

$1.09

10-Pay Premium

$1.38

$2.04

$1.38

$2.04

12-Pay Premium

$1.15

$1.70

$1.15

$1.70

10-Pay Premium

$1.86

$2.76

$1.86

$2.76

12-Pay Premium

$1.55

$2.30

$1.55

$2.30

10-Pay Premium

$2.65

$3.98

$2.65

$3.98

12-Pay Premium

$2.21

$3.32

$2.21

$3.32

10-Pay Premium

$3.43

$5.21

$3.43

$5.21

12-Pay Premium

$2.86

$4.34

$2.86

$4.34

10-Pay Premium

$4.51

$6.85

$4.51

$6.85

12-Pay Premium

$3.76

$5.71

$3.76

$5.71

10-Pay Premium

$6.16

$9.35

$6.16

$9.35

12-Pay Premium

$5.13

$7.79

$5.13

$7.79

10-Pay Premium

$7.55

$11.48

$7.55

$11.48

12-Pay Premium

$6.29

$9.57

$6.29

$9.57

10-Pay Premium

$7.55

$11.48

$7.55

$11.48

12-Pay Premium

$6.29

$9.57

$6.29

$9.57

One-Parent Family $7.98 $6.65

Two Parent Family $12.42 $10.35

Wellbeing Assistance Benefit Rates by wellbeing amount = 1 unit Wellbeing Amount $100

10-Pay Premium 12-Pay Premium

Named Insured $7.98 $6.65

Employee & Spouse $12.42 $10.35

Sample rates only. Multiple choices and options available and rates may vary.

Click on the video below to learn more about Short-Term Disability Benefits!

SHORT-TERM DISABILITY BENEFITS

Educator Disability Income Insurance

How long could you afford to go without a paycheck? Help protect your paycheck with Colonial Life’s short-term disability insurance. You use your paycheck mainly to pay for your home, your car, groceries, medical bills and utilities. What if you couldn’t go to work due to an accident or sickness? Monthly Expenses:

$_________________

$_________________ Total $_________________

My Coverage Worksheet (For use with your Colonial Life Benefits Counselor) Who’s being covered?

You only You and your spouse You and your dependent children You, your spouse and your dependent children

How much coverage do I need? On-Job Accident/On-Job Sickness $______________ Off-Job Accident/Off-Job Sickness $______________ Select One Benefit Period Option:

On-Job

Off-Job

First 3 months

$_____________/month

Next 9 months

$_____________/month

First 6 months

$_____________/month

Next 6 months

$_____________/month

= Total Disability

Educator Disability 1.0-VA

Option A Option B = Partial Disability Up to 3 months

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

After a Sickness: ___________ days

How much will it cost? Your cost will vary based on the level of coverage you select. 62

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

Medical Fees for Accidents Only Doctor’s Office or Urgent Care Facility Visit (Once per covered accident) ..................................................................$75 X-Ray and Other Diagnostic Imaging (Once per covered accident) .............................................................................$75 Emergency Room Visit (Once per covered accident) ...................................................................................................... $150

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

Benefits begin on the first day of confinement in a hospital for a covered accident or sickness. Up to 3 months .................................................................................................................... $1,200/month ($40/day) The Hospital Confinement benefit increases to $6,000/month ($200/day) when the Total Disability benefit ends at age 70

Accidental Death and Dismemberment Benefits Benefits payable for death or dismemberment. l l

Accidental Death .............................................................................................................................................................. $25,000 Loss of a Finger or Toe Single Dismemberment ................................................................................................................................................. $750 Double Dismemberment ............................................................................................................................................$1,500 Loss of a Hand, Foot or Sight of an Eye Single Dismemberment ..............................................................................................................................................$7,500 Double Dismemberment ......................................................................................................................................... $15,000 Accidental Death Common Carrier ........................................................................................................................... $50,000

Complete Fractures Complete Fractures requiring closed reduction Hip, Thigh ....................................................................................................................................................................................$1,500 Vertebrae ....................................................................................................................................................................................... 1,350 Pelvis ............................................................................................................................................................................................... 1,200 Skull (depressed) ......................................................................................................................................................................... 1,125 Leg .......................................................................................................................................................................................................900 Foot, Ankle, Kneecap .....................................................................................................................................................................750 Forearm, Hand, Wrist .....................................................................................................................................................................750 Lower Jaw ..........................................................................................................................................................................................600 Shoulder Blade, Collarbone ........................................................................................................................................................600 Skull (simple) ....................................................................................................................................................................................525 Upper Arm, Upper Jaw .................................................................................................................................................................525 Facial Bones ......................................................................................................................................................................................450 Vertebral Processes ........................................................................................................................................................................300 Coccyx, Rib, Finger, Toe ................................................................................................................................................................120 63

Complete Dislocations Complete Dislocations requiring closed reduction with anesthesia Hip ..................................................................................................................................................................................................$1,350 Knee .....................................................................................................................................................................................................975 Collarbone - sternoclavicular ......................................................................................................................................................750 Shoulder ............................................................................................................................................................................................750 Collarbone - acromioclavicular separation ............................................................................................................................675 Ankle, Foot ........................................................................................................................................................................................600 Hand ....................................................................................................................................................................................................525 Lower Jaw ..........................................................................................................................................................................................450 Wrist ....................................................................................................................................................................................................375 Elbow ..................................................................................................................................................................................................300 One Finger, Toe ................................................................................................................................................................................120 For a fracture or dislocation requiring an open reduction, your benefit would be 11/2 times the amount shown.

Additional Features l

Waiver of Premium

Worldwide Coverage

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

Medical Fees for Accidents Only Doctor’s Office or Urgent Care Facility Visit (Once per covered accident) ..........................................................$75 X-Ray and Other Diagnostic Imaging (Once per covered accident) .....................................................................$75 Emergency Room Visit (Once per covered accident) .............................................................................................. $150

Hospital Confinement Benefit for Accident or Sickness l

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

Accidental Death and Dismemberment Benefits l

Accidental Death .................................................................................................................................... Spouse $10,000 Child(ren) $5,000 Loss of a Finger or Toe Single Dismemberment ...........................................................................................................................................$75 Double Dismemberment ..................................................................................................................................... $150

Loss of a Hand, Foot or Sight of an Eye Single Dismemberment ........................................................................................................................................ $750 Double Dismemberment ..................................................................................................................................$1,500

Accidental Death Common Carrier .................................................................................................Spouse $20,000 Child(ren) $10,000

Here are some

Colonial Life’s frequently asked questions about disability insurance: Will my disability income payment be reduced if I have other insurance?

What if I change employers?

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

If you change jobs or leave your employer, you can take your coverage with you at no additional cost. Your coverage is guaranteed renewable for life as long as you continue to pay your premiums when they are due.

When am I considered totally disabled?

Can my premium change? You may choose the amount of coverage to meet your needs (subject to your income). You can elect more or less coverage which will change your premium. Colonial Life can change your premium only if we change it on all policies of this kind in the state where your policy was issued.

Totally disabled means you are: l

Unable to perform the material and substantial duties of your job; Not, in fact, engaged in any employment or occupation for wage or profit for which you are qualified by reason of education, training or experience; and

What is a covered accident or a covered sickness?

Under the regular and appropriate care of a doctor.

A covered accident is an accident. A covered sickness means an illness, infection, disease or any other abnormal physical condition, not caused by an injury.

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

A covered accident or covered sickness: l Occurs after the effective date of the policy; l Occurs while the policy is in force; l Is of a type listed on the Policy Schedule; and l Is not excluded by name or specific description in the policy. EXCLUSIONS We will not pay benefits for injuries received in accidents or sicknesses which are caused by or are the result of: alcoholism or drug addiction; flying; giving birth within the first nine months after the effective date of the policy; felonies or illegal occupations; having a pre-existing condition as described and limited by the policy; psychiatric or psychological condition; committing or trying to commit suicide or injuring yourself intentionally; being exposed to war or any act of war or serving in the armed forces of any country or authority.

When do disability benefits end? The Total Disability Benefit will end on the policy anniversary date on or after your 70th birthday. The Hospital Confinement benefit increases when the Total Disability Benefit ends. A pre-existing condition is when you have a sickness or physical condition for which you were treated, had medical testing, received medical advice, or had taken medication within 12 months testing, or before the effective date of your policy. If you become disabled because of a pre-existing condition, Colonial Life will not pay for any disability period if it begins during the first 12 months the policy is in force. Colonial Life 1200 Colonial Life Boulevard Columbia, South Carolina 29210 coloniallife.com 6/11

©2011 Colonial Life & Accident Insurance Company. Colonial Life products are underwritten by Colonial Life & Accident Insurance Life products underwritten Colonial Life & Accident Company, for Colonial which Colonial Life are is the marketingbybrand. Insurance Company, for which Colonial Life is the marketing brand.

Colonial Life and Making benefits count are registered service marks of Colonial Life &71381-1 Accident Insurance Company. 100252 65

Educator Disability 1.0-VA

For cost and complete details, see your Colonial Life benefits counselor. Applicable to policy form ED DIS 1.0-VA. Coverage may vary by state and may not be available in all states. This is not an insurance contract and only the actual policy provisions will control.

What is a pre-existing condition?

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SHORT-TERM DISABILITY PREMIUMS Benefit Period Option A: 3 Month/9 Month Plan Plan 1: On- & Off-Job Coverage

Teacher, Principal, T.A., Clerical, Café Manager Monthly premium Premiums are for base plan and disability benefits

Benefit Amount

Elimination Period

First 3 months

Next 9 Months

Units

0/7

0/14

14/14

0/30

30/30

400

200

$18.40

$16.00

$15.00

$14.80

$12.80

600

300

$24.30

$20.70

$19.20

$18.90

$15.90

800

400

$30.20

$25.40

$23.40

$23.00

$19.00

1000

500

$36.10

$30.10

$27.60

$27.10

$22.10

1200

600

$42.00

$34.80

$31.80

$31.20

$25.20

1400

700

$47.90

$39.50

$36.00

$35.30

$28.30

1600

800

$53.80

$44.20

$40.20

$39.40

$31.40

1800

900

$59.70

$48.90

$44.40

$43.50

$34.50

2000

1000

$65.60

$53.60

$48.60

$47.60

$37.60

2200

1100

$71.50

$58.30

$52.80

$51.70

$40.70

2400

1200

$77.40

$63.00

$57.00

$55.80

$43.80

2600

1300

$83.30

$67.70

$61.20

$59.90

$46.90

2800

1400

$89.20

$72.40

$65.40

$64.00

$50.00

3000

1500

$95.10

$77.10

$69.60

$68.10

$53.10

3200

1600

$101.00

$81.80

$73.80

$72.20

$56.20

3400

1700

$106.90

$86.50

$78.00

$76.30

$59.30

3600

1800

$112.80

$91.20

$82.20

$80.40

$62.40

3800

1900

$118.70

$95.90

$86.40

$84.50

$65.50

4000

2000

$124.60

$100.60

$90.60

$88.60

$68.60

4200

2100

$130.50

$105.30

$94.80

$92.70

$71.70

4400

2200

$136.40

$110.00

$99.00

$96.80

$74.80

4600

2300

$142.30

$114.70

$103.20

$100.90

$77.90

4800

2400

$148.20

$119.40

$107.40

$105.00

$81.00

5000

2500

$154.10

$124.10

$111.60

$109.10

$84.10

Spouse and Dependent Premiums Rider

Monthly Premium

Spouse Accident & Sickness Benefit Coverage

$5.50

Child(ren) Accident & Sickness Benefit Coverage

$7.50

Sample rates only. Multiple choices and options available and rates may vary.

SHORT-TERM DISABILITY PREMIUMS Benefit Period Option A: 3 Month/9 Month Plan Plan 1: On- & Off-Job Coverage

Café Staff, Custodian Super, Custodian Staff, Maintaince Super, Maintenance Staff Monthly premium Premiums are for base plan and disability benefits

Benefit Amount

Elimination Period

First 3 months

Next 9 Months

Units

0/7

0/14

14/14

0/30

30/30

400

200

$23.60

$21.40

$19.40

$18.80

$16.00

600

300

$32.10

$28.80

$25.80

$24.90

$20.70

800

400

$40.60

$36.20

$32.20

$31.00

$25.40

1000

500

$49.10

$43.60

$38.60

$37.10

$30.10

1200

600

$57.60

$51.00

$45.00

$43.20

$34.80

1400

700

$66.10

$58.40

$51.40

$49.30

$39.50

1600

800

$74.60

$65.80

$57.80

$55.40

$44.20

1800

900

$83.10

$73.20

$64.20

$61.50

$48.90

2000

1000

$91.60

$80.60

$70.60

$67.60

$53.60

2200

1100

$100.10

$88.00

$77.00

$73.70

$58.30

2400

1200

$108.60

$95.40

$83.40

$79.80

$63.00

2600

1300

$117.10

$102.80

$89.80

$85.90

$67.70

2800

1400

$125.60

$110.20

$96.20

$92.00

$72.40

3000

1500

$134.10

$117.60

$102.60

$98.10

$77.10

3200

1600

$142.60

$125.00

$109.00

$104.20

$81.80

3400

1700

$151.10

$132.40

$115.40

$110.30

$86.50

3600

1800

$159.60

$139.80

$121.80

$116.40

$91.20

3800

1900

$168.10

$147.20

$128.20

$122.50

$95.90

4000

2000

$176.60

$154.60

$134.60

$128.60

$100.60

4200

2100

$185.10

$162.00

$141.00

$134.70

$105.30

4400

2200

$193.60

$169.40

$147.40

$140.80

$110.00

4600

2300

$202.10

$176.80

$153.80

$146.90

$114.70

4800

2400

$210.60

$184.20

$160.20

$153.00

$119.40

5000

2500

$219.10

$191.60

$166.60

$159.10

$124.10

Spouse and Dependent Premiums Rider

Monthly Premium

Spouse Accident & Sickness Benefit Coverage

$5.50

Child(ren) Accident & Sickness Benefit Coverage

$7.50

Sample rates only. Multiple choices and options available and rates may vary.

SHORT-TERM DISABILITY PREMIUMS Benefit Period Option A: 3 Month/9 Month Plan Plan 1: On- & Off-Job Coverage

Bus Driver, Mechanic Monthly premium Premiums are for base plan and disability benefits

Benefit Amount

Elimination Period

First 3 months

Next 9 Months

Units

0/7

0/14

14/14

0/30

30/30

400

200

$27.00

$23.60

$21.80

$21.60

$17.80

600

300

$37.20

$32.10

$29.40

$29.10

$23.40

800

400

$47.40

$40.60

$37.00

$36.60

$29.00

1000

500

$57.60

$49.10

$44.60

$44.10

$34.60

1200

600

$67.80

$57.60

$52.20

$51.60

$40.20

1400

700

$78.00

$66.10

$59.80

$59.10

$45.80

1600

800

$88.20

$74.60

$67.40

$66.60

$51.40

1800

900

$98.40

$83.10

$75.00

$74.10

$57.00

2000

1000

$108.60

$91.60

$82.60

$81.60

$62.60

2200

1100

$118.80

$100.10

$90.20

$89.10

$68.20

2400

1200

$129.00

$108.60

$97.80

$96.60

$73.80

2600

1300

$139.20

$117.10

$105.40

$104.10

$79.40

2800

1400

$149.40

$125.60

$113.00

$111.60

$85.00

3000

1500

$159.60

$134.10

$120.60

$119.10

$90.60

3200

1600

$169.80

$142.60

$128.20

$126.60

$96.20

3400

1700

$180.00

$151.10

$135.80

$134.10

$101.80

3600

1800

$190.20

$159.60

$143.40

$141.60

$107.40

3800

1900

$200.40

$168.10

$151.00

$149.10

$113.00

4000

2000

$210.60

$176.60

$158.60

$156.60

$118.60

4200

2100

$220.80

$185.10

$166.20

$164.10

$124.20

4400

2200

$231.00

$193.60

$173.80

$171.60

$129.80

4600

2300

$241.20

$202.10

$181.40

$179.10

$135.40

4800

2400

$251.40

$210.60

$189.00

$186.60

$141.00

5000

2500

$261.60

$219.10

$196.60

$194.10

$146.60

Spouse and Dependent Premiums Rider

Monthly Premium

Spouse Accident & Sickness Benefit Coverage

$5.50

Child(ren) Accident & Sickness Benefit Coverage

$7.50

Sample rates only. Multiple choices and options available and rates may vary.

SHORT-TERM DISABILITY PREMIUMS Benefit Period Option A: 3 Month/9 Month Plan Plan 2: Off-Job Coverage

Teacher, Principal, T.A., Clerical, Café Manager Monthly premium Premiums are for base plan and disability benefits Benefit Amount

Elimination Period

First 3 months

Next 9 Months

Units

0/7

0/14

14/14

0/30

30/30

400

200

$14.45

$12.05

$10.85

$10.05

$9.25

600

300

$19.35

$15.75

$13.95

$12.75

$11.55

800

400

$24.25

$19.45

$17.05

$15.45

$13.85

1000

500

$29.15

$23.15

$20.15

$18.15

$16.15

1200

600

$34.05

$26.85

$23.25

$20.85

$18.45

1400

700

$38.95

$30.55

$26.35

$23.55

$20.75

1600

800

$43.85

$34.25

$29.45

$26.25

$23.05

1800

900

$48.75

$37.95

$32.55

$28.95

$25.35

2000

1000

$53.65

$41.65

$35.65

$31.65

$27.65

2200

1100

$58.55

$45.35

$38.75

$34.35

$29.95

2400

1200

$63.45

$49.05

$41.85

$37.05

$32.25

2600

1300

$68.35

$52.75

$44.95

$39.75

$34.55

2800

1400

$73.25

$56.45

$48.05

$42.45

$36.85

3000

1500

$78.15

$60.15

$51.15

$45.15

$39.15

3200

1600

$83.05

$63.85

$54.25

$47.85

$41.45

3400

1700

$87.95

$67.55

$57.35

$50.55

$43.75

3600

1800

$92.85

$71.25

$60.45

$53.25

$46.05

3800

1900

$97.75

$74.95

$63.55

$55.95

$48.35

4000

2000

$102.65

$78.65

$66.65

$58.65

$50.65

4200

2100

$107.55

$82.35

$69.75

$61.35

$52.95

4400

2200

$112.45

$86.05

$72.85

$64.05

$55.25

4600

2300

$117.35

$89.75

$75.95

$66.75

$57.55

4800

2400

$122.25

$93.45

$79.05

$69.45

$59.85

5000

2500

$127.15

$97.15

$82.15

$72.15

$62.15

Spouse and Dependent Premiums Rider

Monthly Premium

Spouse Accident & Sickness Benefit Coverage

$5.50

Child(ren) Accident & Sickness Benefit Coverage

$7.50

Sample rates only. Multiple choices and options available and rates may vary.

SHORT-TERM DISABILITY PREMIUMS Benefit Period Option A: 3 Month/9 Month Plan Plan 2: Off-Job Coverage

Café Staff, Custodian Super, Custodian Staff, Maintaince Super, Maintenance Staff Monthly premium Premiums are for base plan and disability benefits Benefit Amount

Elimination Period

First 3 months

Next 9 Months

Units

0/7

0/14

14/14

0/30

30/30

400

200

$19.65

$16.05

$14.45

$12.85

$11.65

600

300

$27.15

$21.75

$19.35

$16.95

$15.15

800

400

$34.65

$27.45

$24.25

$21.05

$18.65

1000

500

$42.15

$33.15

$29.15

$25.15

$22.15

1200

600

$49.65

$38.85

$34.05

$29.25

$25.65

1400

700

$57.15

$44.55

$38.95

$33.35

$29.15

1600

800

$64.65

$50.25

$43.85

$37.45

$32.65

1800

900

$72.15

$55.95

$48.75

$41.55

$36.15

2000

1000

$79.65

$61.65

$53.65

$45.65

$39.65

2200

1100

$87.15

$67.35

$58.55

$49.75

$43.15

2400

1200

$94.65

$73.05

$63.45

$53.85

$46.65

2600

1300

$102.15

$78.75

$68.35

$57.95

$50.15

2800

1400

$109.65

$84.45

$73.25

$62.05

$53.65

3000

1500

$117.15

$90.15

$78.15

$66.15

$57.15

3200

1600

$124.65

$95.85

$83.05

$70.25

$60.65

3400

1700

$132.15

$101.55

$87.95

$74.35

$64.15

3600

1800

$139.65

$107.25

$92.85

$78.45

$67.65

3800

1900

$147.15

$112.95

$97.75

$82.55

$71.15

4000

2000

$154.65

$118.65

$102.65

$86.65

$74.65

4200

2100

$162.15

$124.35

$107.55

$90.75

$78.15

4400

2200

$169.65

$130.05

$112.45

$94.85

$81.65

4600

2300

$177.15

$135.75

$117.35

$98.95

$85.15

4800

2400

$184.65

$141.45

$122.25

$103.05

$88.65

5000

2500

$192.15

$147.15

$127.15

$107.15

$92.15

Spouse and Dependent Premiums Rider

Monthly Premium

Spouse Accident & Sickness Benefit Coverage

$5.50

Child(ren) Accident & Sickness Benefit Coverage

$7.50

Sample rates only. Multiple choices and options available and rates may vary.

SHORT-TERM DISABILITY PREMIUMS Benefit Period Option A: 3 Month/9 Month Plan Plan 2: Off-Job Coverage

Bus Driver, Mechanic Monthly premium Premiums are for base plan and disability benefits Benefit Amount

Elimination Period

First 3 months

Next 9 Months

Units

0/7

0/14

14/14

0/30

30/30

400

200

$22.25

$17.45

$16.05

$14.25

$12.65

600

300

$31.05

$23.85

$21.75

$19.05

$16.65

800

400

$39.85

$30.25

$27.45

$23.85

$20.65

1000

500

$48.65

$36.65

$33.15

$28.65

$24.65

1200

600

$57.45

$43.05

$38.85

$33.45

$28.65

1400

700

$66.25

$49.45

$44.55

$38.25

$32.65

1600

800

$75.05

$55.85

$50.25

$43.05

$36.65

1800

900

$83.85

$62.25

$55.95

$47.85

$40.65

2000

1000

$92.65

$68.65

$61.65

$52.65

$44.65

2200

1100

$101.45

$75.05

$67.35

$57.45

$48.65

2400

1200

$110.25

$81.45

$73.05

$62.25

$52.65

2600

1300

$119.05

$87.85

$78.75

$67.05

$56.65

2800

1400

$127.85

$94.25

$84.45

$71.85

$60.65

3000

1500

$136.65

$100.65

$90.15

$76.65

$64.65

3200

1600

$145.45

$107.05

$95.85

$81.45

$68.65

3400

1700

$154.25

$113.45

$101.55

$86.25

$72.65

3600

1800

$163.05

$119.85

$107.25

$91.05

$76.65

3800

1900

$171.85

$126.25

$112.95

$95.85

$80.65

4000

2000

$180.65

$132.65

$118.65

$100.65

$84.65

4200

2100

$189.45

$139.05

$124.35

$105.45

$88.65

4400

2200

$198.25

$145.45

$130.05

$110.25

$92.65

4600

2300

$207.05

$151.85

$135.75

$115.05

$96.65

4800

2400

$215.85

$158.25

$141.45

$119.85

$100.65

5000

2500

$224.65

$164.65

$147.15

$124.65

$104.65

Spouse and Dependent Premiums Rider

Monthly Premium

Spouse Accident & Sickness Benefit Coverage

$5.50

Child(ren) Accident & Sickness Benefit Coverage

$7.50

Sample rates only. Multiple choices and options available and rates may vary.

Click on the video below to learn more about Accident Benefits!

ACCIDENT BENEFITS

Accident Insurance

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

Sports-related accidental injury Broken bone Burn Concussion Laceration

Back or knee injuries

l l l l

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

Accident 1.0-Preferred with Health Screening Benefit-VA

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

What additional features are included? l

Worldwide coverage

Portable

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

Compliant with Healthcare Spending Account (HSA) guidelines

Can my premium change?

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

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

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

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

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

Initial Care l

Accident Emergency Treatment........... $125

Ambulance .......................................$200

X-ray Benefit ...................................................$30

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

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

Non-Surgical

Surgical

$2,200 $1,100 $880 $550 $330 $330 $110 $110

$4,400 $2,200 $1,760 $1,100 $660 $660 $220 $220

Non-Surgical

Surgical

$2,750 $1,100 $1,650 $825 $385 $385 $385 $330 $330 $330 $275 $220 $110

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

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

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

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

Concussion ......................................................................................................................................................... $60

l l

Emergency Dental Work .......................................$75 Extraction, $300 Crown, Implant, or Denture Lacerations (based on size) ...........................................................................................................$30 to $500

Requires Surgery l

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

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

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

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

Surgical Care l

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

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

Surgery (arthroscopic or exploratory) ....................................................................................................$200

Blood/Plasma/Platelets ................................................................................................................................$300 75

Transportation/Lodging Assistance If injured, covered person must travel more than 50 miles from residence to receive special treatment and confinement in a hospital. l l

Transportation .............................................................................$500 per round trip up to 3 round trips Lodging (family member or companion) ...............................................$125 per night up to 30 days for a hotel/motel lodging costs

Accident Hospital Care l

Hospital Admission* ........................................................................................................ $1,000 per accident

Hospital ICU Admission* ................................................................................................ $2,000 per accident * We will pay either the Hospital Admission or Hospital Intensive Care Unit (ICU) Admission, but not both. l.

Hospital Confinement ......................................................... $225 per day up to 365 days per accident

Hospital ICU Confinement ...................................................$450 per day up to 15 days per accident

Accident Follow-Up Care l l

Accident Follow-Up Doctor Visit .......................................................... $50 (up to 3 visits per accident) Medical Imaging Study ......................................................................................................$150 per accident (limit 1 per covered accident and 1 per calendar year)

Occupational or Physical Therapy ..................................................... $25 per treatment up to 10 days

Appliances .......................................................................................... $100 (such as wheelchair, crutches)

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

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

Accidental Dismemberment l

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

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

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

Loss of one hand and one foot

Loss of the sight of both eyes

Loss of both hands or both feet

Loss of the hearing of both ears

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

Loss of the ability to speak

Loss or loss of use of both arms or both legs Named Insured ................ $25,000

Spouse ..............$25,000

Child(ren) .........$12,500

365-day elimination period. Amounts reduced for covered persons age 65 and over. Payable once per lifetime for each covered person.

Accidental Death Accidental Death

Common Carrier

Named Insured

$25,000

$100,000

Spouse

$25,000

$100,000

Child(ren)

$5,000

$20,000

Health Screening Benefit

l $50 per covered person per calendar year

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

Tests include: l.

Blood test for triglycerides

Hemoccult stool analysis

Bone marrow testing

Mammography

Breast ultrasound

Pap smear

CA 15-3 (blood test for breast cancer)

PSA (blood test for prostate cancer)

CA125 (blood test for ovarian cancer)

Carotid doppler

Serum cholesterol test to determine level of HDL and LDL

Serum protein electrophoresis (blood test for myeloma)

Stress test on a bicycle or treadmill

Skin cancer biopsy

Thermography

ThinPrep pap test

Virtual colonoscopy

l. CEA (blood test for colon cancer) l.

Chest x-ray

Colonoscopy

Echocardiogram (ECHO)

Electrocardiogram (EKG, ECG)

Fasting blood glucose test

Flexible sigmoidoscopy

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

Spouse Only

One-Parent Family, with Spouse

Employee & Spouse Two-Parent Family

When are covered accident benefits available? (check one) On and Off -Job Benefits

Off -Job Only Benefits

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

Colonial Life 1200 Colonial Life Boulevard Columbia, South Carolina 29210 coloniallife.com 10/11

©2011 Colonial Life & Accident Insurance Company. Colonial Life products are underwritten by Colonial Life & Accident Insurance Company, for which Colonial Life is the marketing brand. Colonial Life and Making benefits count are registered service marks of Colonial Life & Accident Insurance Company.

74231-2

Accident 1.0-Preferred with Health Screening Benefit-VA

One-Parent Family, with Employee

One Child Only

ACCIDENT BENEFIT PREMIUMS Preferred with HealthScreening - On/Off-Job Accident Coverage 10-Pay Premium

12-Pay Premium

Named Insured

$25.38

$21.15

Employee & Spouse

$34.76

$28.97

One-Parent Family

$39.20

$32.67

Two-Parent Family

$48.58

$40.48

Preferred with HealthScreening - Off-Job Only Accident Coverage 10-Pay Premium

12-Pay Premium

Named Insured

$21.50

$17.92

Employee & Spouse

$28.75

$23.96

One-Parent Family

$31.87

$26.56

Two-Parent Family

$39.13

$32.61

Sample rates only. Multiple choices and options available and rates may vary.

Click on the video below to learn more about Medical Bridge Benefits!

MEDICAL BRIDGE BENEFITS

Hospital Confinement Indemnity Insurance Plan 1 Our Individual Medical BridgeSM insurance can help with medical costs that your health insurance may not cover. These benefits are available for you, your spouse and eligible dependent children.

Hospital confinement ..................................................................... $__________________ Maximum of one benefit per covered person per calendar year

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

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

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

Health savings account (HSA) compatible

For more information, talk with your benefits counselor.

ColonialLife.com

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

THIS POLICY PROVIDES LIMITED BENEFITS. EXCLUSIONS We will not pay benefits for losses which are caused by: alcoholism or drug addiction, dental procedures, elective procedures and cosmetic surgery, felonies or illegal occupations, pregnancy of a dependent child, psychiatric or psychological conditions, suicide or injuries which any covered person intentionally does to himself or herself, war, or giving birth within the first nine months after the effective date of the policy. We will not pay benefits for hospital confinement of a newborn who is neither injured nor sick. We will not pay benefits for loss during the first 12 months after the effective date due to a pre-existing condition. A pre-existing condition is a sickness or physical condition for which a covered person was treated, had medical testing, received medical advice or had taken medication within the 12 months before the effective date of the policy. For cost and complete details, see your Colonial Life benefits counselor. Applicable to policy number IMB7000 (including state abbreviations where used, for example: IMB7000-TX). Coverage may vary by state and may not be available in all states. This is not an insurance contract and only the actual policy provisions will control. ©2016 Colonial Life & Accident Insurance Company, Columbia, SC | Colonial Life insurance products are underwritten by Colonial Life & Accident Insurance Company, for which Colonial Life is the marketing brand.

IMB7000 – PLAN 1 | 5-16 | 101576-1

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

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

Waiver of premium

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

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

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

For more information, talk with your benefits counselor.

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

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

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

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

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

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

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

Tier 1 outpatient surgical procedures Breast

Gynecological

Cardiac

Liver

Digestive

Musculoskeletal system

– Axillary node dissection – Breast capsulotomy – Lumpectomy

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

– Pacemaker insertion

– Paracentesis

– Colonoscopy – Fistulotomy – Hemorrhoidectomy – Lysis of adhesions

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

Skin

– Laparoscopic hernia repair – Skin grafting

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

Tier 2 outpatient surgical procedures Breast

Gynecological

Cardiac

Musculoskeletal system

– Breast reconstruction – Breast reduction

– Hysterectomy – Myomectomy

– Angioplasty – Cardiac catheterization

Digestive

– Exploratory laparoscopy – Laparoscopic appendectomy – Laparoscopic cholecystectomy

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

Thyroid

– Excision of a mass

Eye

ColonialLife.com

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

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

Urologic

– Lithotripsy

EXCLUSIONS We will not pay benefits for losses which are caused by: alcoholism or drug addiction, dental procedures, elective procedures and cosmetic surgery, felonies or illegal occupations, pregnancy of a dependent child, psychiatric or psychological conditions, suicide or injuries which any covered person intentionally does to himself or herself, war, or giving birth within the first nine months after the effective date of the policy. We will not pay benefits for hospital confinement of a newborn who is neither injured nor sick. We will not pay benefits for loss during the first 12 months after the effective date due to a pre-existing condition. A pre-existing condition is a sickness or physical condition for which a covered person was treated, had medical testing, received medical advice or had taken medication within the 12 months before the effective date of the policy. For cost and complete details, see your Colonial Life benefits counselor. Applicable to policy number IMB7000 (including state abbreviations where used, for example: IMB7000-TX). Coverage may vary by state and may not be available in all states. This is not an insurance contract and only the actual policy provisions will control. ©2016 Colonial Life & Accident Insurance Company, Columbia, SC | Colonial Life insurance products are underwritten by Colonial Life & Accident Insurance Company, for which Colonial Life is the marketing brand.

1-16 | 101581-1

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

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

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

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

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

For more information, talk with your benefits counselor.

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

ColonialLife.com

Waiting period means the first 30 days following any covered person’s policy coverage effective date, during which no benefits are payable. For cost and complete details, see your Colonial Life benefits counselor. Applicable to policy number IMB7000 (including state abbreviations where used, for example: IMB7000-TX). Coverage may vary by state and may not be available in all states. This is not an insurance contract and only the actual policy provisions will control. ©2016 Colonial Life & Accident Insurance Company, Columbia, SC | Colonial Life insurance products are underwritten by Colonial Life & Accident Insurance Company, for which Colonial Life is the marketing brand.

IMB7000 – HEALTH SCREENING BENEFIT | 5-16 | 101579-1

Hospital Confinement Indemnity Insurance Medical Treatment Package

The medical treatment package for Individual Medical BridgeSM coverage can help pay for deductibles, co-payments and other out-of-pocket expenses related to a covered accident or covered sickness. The medical treatment package cannot be paired with Plan 1. Air ambulance ............................................................................................. $1,000 Maximum of one benefit per covered person per calendar year

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

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

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

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

For more information, talk with your benefits counselor.

Maximum of two visits per covered person per calendar year

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

THIS POLICY PROVIDES LIMITED BENEFITS.

ColonialLife.com

IMB7000 – MEDICAL TREATMENT PACKAGE | 9-16 | 101596-VA

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

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

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

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

For more information, talk with your benefits counselor.

EXCLUSIONS

ColonialLife.com

We will not pay benefits for losses which are caused by: alcoholism or drug addiction, dental procedures, elective procedures and cosmetic surgery, felonies or illegal occupations, pregnancy of a dependent child, psychiatric or psychological conditions, suicide or injuries which any covered person intentionally does to himself or herself, war, or giving birth within the first nine months after the effective date of the rider. We will not pay benefits for hospital confinement of a newborn who is neither injured nor sick. We will not pay benefits for loss during the first 12 months after the effective date due to a pre-existing condition. A pre-existing condition is a sickness or physical condition for which a covered person was treated, had medical testing, received medical advice or had taken medication within the 12 months before the effective date of the rider. For cost and complete details, see your Colonial Life benefits counselor. Applicable to rider numbers R-DHC7000 and R-EIC7000 (including state abbreviations where used, for example: R-DHC7000-TX and R-EIC7000-TX). Coverage may vary by state and may not be available in all states. This is not an insurance contract and only the actual policy or rider provisions will control. ©2016 Colonial Life & Accident Insurance Company, Columbia, SC | Colonial Life insurance products are underwritten by Colonial Life & Accident Insurance Company, for which Colonial Life is the marketing brand. IMB7000 – DAILY HOSPITAL CONFINEMENT AND ENHANCED INTENSIVE CARE UNIT CONFINEMENT RIDERS | 6-16 | 101582-1

MEDICAL BRIDGE BENEFIT PREMIUMS INDIVIDUAL MEDICAL BRIDGE Plan 1 Named Insured

Hospital Confinement $100 Health Screening

Ages 17-49 Ages 50-59 Ages 60-64 Ages 65-75

10-Pay Premium 12-Pay Premium 10-Pay Premium 12-Pay Premium 10-Pay Premium 12-Pay Premium 10-Pay Premium 12-Pay Premium

$1,000.00

$1,500.00

$21.84 $18.20 $27.84 $23.20 $35.10 $29.25 $44.22 $36.85

$28.38 $23.65 $36.90 $30.75 $47.52 $39.60 $60.78 $50.65

INDIVIDUAL MEDICAL BRIDGE Plan 3 Named Insured Hospital Confinement Medical Treatment Pkg $100 Health Screening

$1,000.00

$1,500.00

Outpatient Surgical Procedure

Option 1 Tier 1 $500 Tier 2 $1,000 CY Max $1,500

$45.36 $37.80 $57.00 $47.50 $69.84 $58.20 $85.92 $71.60

$51.90 $43.25 $66.06 $55.05 $82.26 $68.55 $102.48 $85.40

Ages 17-49 Ages 50-59 Ages 60-64 Ages 65-75

10-Pay Premium 12-Pay Premium 10-Pay Premium 12-Pay Premium 10-Pay Premium 12-Pay Premium 10-Pay Premium 12-Pay Premium

Sample rates only. Multiple choices and options available and rates may vary.

Click on the video below to learn more about Term Life Insurance!

TERM LIFE INSURANCE

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

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

Talk with your Colonial Life benefits counselor to learn more.

ColonialLife.com

Spouse coverage options

Dependent coverage options

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

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

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

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

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

How much coverage do you need? £ YOU $ ___________________ Select the term period: £ 10-year £ 15-year £ 20-year £ 30-year £ SPOUSE $ ___________________ Select the term period: £ 10-year £ 15-year £ 20-year £ 30-year

Select any optional riders: £ Spouse term life rider $ _____________ face amount for ________-year term period £ Children’s term life rider $ _____________ face amount £ Accidental death benefit rider £ Chronic care accelerated death benefit rider

Optional riders At an additional cost, you can purchase the following riders for even more financial protection.

Spouse term life rider Your spouse may receive a maximum death benefit of $50,000; 10-year and 20-year spouse term riders are available.

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

Accidental death benefit rider The beneficiary may receive an additional benefit if the covered person dies as a result of an accident before age 70. The benefit doubles if the accidental bodily injury occurs while riding as a fare-paying passenger using public transportation, such as ride-sharing services. An additional 25% will be payable if the injury is sustained while driving or riding in a private passenger vehicle and wearing a seatbelt.

Chronic care accelerated death benefit rider If a licensed health care practitioner certifies that you have a chronic illness, you may receive an advance on all or a portion of the death benefit, available in a one-time lump sum or monthly payments.1 A chronic illness means you require substantial supervision due to a severe cognitive impairment or you may be unable to perform at least two of the six Activities of Daily Living.2 Premiums are waived during the benefit period.

Critical illness accelerated death benefit rider

£ Critical illness accelerated death benefit rider

If you suffer a heart attack (myocardial infarction), stroke or end-stage renal (kidney) failure, a $5,000 benefit is payable.1 A subsequent diagnosis benefit is included.

£ Waiver of premium benefit rider

Waiver of premium benefit rider Premiums are waived (for the policy and riders) if you become totally disabled before the policy anniversary following your 65th birthday and you satisfy the six-month elimination period.3

To learn more, talk with your Colonial Life benefits counselor.

1 Any payout would reduce the death benefit. Benefits may be taxable as income. Individuals should consult with their legal or tax counsel when deciding to apply for accelerated benefits. 2 Activities of daily living are bathing, continence, dressing, eating, toileting and transferring. 3 You must resume premium payments once you are no longer disabled.

EXCLUSIONS AND LIMITATIONS If the insured dies by suicide, whether sane or insane, within two years (one year in ND) from the coverage effective date or the date of reinstatement, we will not pay the death benefit. We will terminate this policy and return the premiums paid without interest, minus any loans and loan interest to you.

ColonialLife.com

This information is not intended to be a complete description of the insurance coverage available. The policy or its provisions may vary or be unavailable in some states. The policy has exclusions and limitations which may affect any benefits payable. Applicable to policy forms ICC18-ITL5000/ITL5000 and rider forms ICC18-R-ITL5000-STR/RITL5000- STR, ICC18-R-ITL5000-CTR/R-ITL5000-CTR, ICC18-R-ITL5000-WP/R-ITL5000-WP, ICC18-R-ITL5000-ACCD/RITL5000- ACCD, ICC18-R-ITL5000-CI/R-ITL5000-CI, ICC18-R-ITL5000-CC/R-ITL5000-CC. For cost and complete details of the coverage, call or write your Colonial Life benefits counselor or the company. Underwritten by Colonial Life & Accident Insurance Company, Columbia, SC ©2021 Colonial Life & Accident Insurance Company. All rights reserved. Colonial Life is a registered trademark and marketing brand of Colonial Life & Accident Insurance Company.

9-21 | 101895-2

TERM LIFE INSURANCE PREMIUMS 10-Year Term Base Plan Monthly Non-Tobacco Rates Issue Age 25 30 35 40 45 50 55 60

Pay Premium

$10,000.00

$25,000.00

$50,000.00

$100,000.00

10-Pay Premium 12-Pay Premium 10-Pay Premium 12-Pay Premium 10-Pay Premium 12-Pay Premium 10-Pay Premium 12-Pay Premium 10-Pay Premium 12-Pay Premium 10-Pay Premium 12-Pay Premium 10-Pay Premium 12-Pay Premium 10-Pay Premium 12-Pay Premium

$7.97 $6.64 $8.47 $7.06 $9.08 $7.57 $9.58 $7.98 $11.00 $9.17 $14.06 $11.72 $19.40 $16.17 $28.03 $23.36

$12.72 $10.60 $13.98 $11.65 $15.53 $12.94 $16.75 $13.96 $20.30 $16.92 $27.95 $23.29 $41.33 $34.44 $62.87 $52.39

$12.25 $10.21 $12.25 $10.21 $13.50 $11.25 $16.85 $14.04 $22.34 $18.62 $30.70 $25.58 $43.64 $36.37 $64.75 $53.96

$19.70 $16.42 $19.70 $16.42 $22.20 $18.50 $28.90 $24.08 $39.90 $33.25 $56.59 $47.16 $82.50 $68.75 $124.69 $103.91

20-Year Term Base Plan Monthly Non-Tobacco Rates Issue Age 25 30 35 40 45 50 55 60

Pay Premium

$10,000.00

$25,000.00

$50,000.00

$100,000.00

$8.05 $6.71 $8.54 $7.12 $9.23 $7.69 $9.88 $8.23 $11.62 $9.68 $15.20 $12.67 $21.67 $18.06 $32.21 $26.84

$12.92 $10.77 $14.17 $11.81 $15.88 $13.23 $17.50 $14.58 $21.85 $18.21 $30.83 $25.69 $46.97 $39.14 $73.32 $61.10

$12.65 $10.54 $12.65 $10.54 $13.90 $11.58 $18.50 $15.42 $26.15 $21.79 $37.90 $31.58 $55.60 $46.33 $86.40 $72.00

$20.50 $17.08 $20.50 $17.08 $23.00 $19.17 $32.20 $26.83 $47.50 $39.58 $70.99 $59.16 $106.39 $88.66 $167.99 $139.99

Sample rates only. Multiple choices and options available and rates may vary.

Click on the video below to learn more about Whole Life Insurance!

WHOLE LIFE INSURANCE

Whole Life Plus Insurance*

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

Advantages of Whole Life Plus insurance

Help give your family more peace of mind and coverage for final expenses with Colonial Life Individual Whole Life Plus insurance.

• Permanent life insurance coverage that stays the same through the life of the policy

Benefits and features Choose the age when your premium payments end — Paid-Up at Age 70 or Paid-Up at Age 100 Stand-alone spouse policy available even without buying a policy for yourself

• Premiums will not increase due to changes in health or age.

Ability to keep the policy if you change jobs or retire

• Accumulates cash value based on a nonforfeiture interest rate of 3.75%2

Built-in terminal illness accelerated death benefit that provides up to 75% of the policy’s death benefit (up to $150,000) if you’re diagnosed with a terminal illness1

• Policy loans available, which can be used for emergencies

Immediate $3,000 claim payment that can help your designated beneficiary pay for funeral costs or other expenses

• Benefit for the beneficiary that is typically tax-free

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

Additional coverage options Spouse term rider Cover your spouse with a death benefit up to $50,000, for 10 or 20 years.

Juvenile Whole Life Plus policy Purchase a policy (Paid-Up at Age 70) while children are young and premiums are low — whether or not you buy a policy for yourself. You may also increase the coverage when the child is 18, 21 and 24 without proof of good health.

Children’s term rider

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

You may purchase up to $20,000 in term life insurance coverage for all of your eligible dependent children and pay one premium. The children’s term rider may be added to either your policy or your spouse’s policy — not both. 92

WHOLE LIFE PLUS (IWL5000)

Benefits worksheet

Additional coverage options (Continued)

For use with your benefits counselor

Accelerated death benefit for long term care services rider3

How much coverage do you need?

Talk with your benefits counselor for more details.

 YOU $_______________________

Accidental death benefit rider

Select the option:

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

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

$ ____________________________ Select the option:

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

 Spouse term rider

$ _____________face amount for _________-year term period

 Children’s term rider

$ ______________ face amount

 Accelerated death benefit for long term care services rider

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

 Critical illness accelerated death benefit rider

 Guaranteed purchase option rider

 Waiver of premium benefit rider

To learn more, talk with your benefits counselor.

An additional benefit may be payable if the covered person dies as a result of an accident before age 70, and doubles if the injury occurs while riding as a fare-paying passenger using public transportation. An additional 25% is payable if the injury occurs while driving or riding in a private passenger vehicle and wearing a seatbelt.

Critical illness accelerated death benefit rider If you suffer a heart attack, stroke or end-stage renal (kidney) failure, a $5,000 benefit is payable.1 A subsequent diagnosis benefit is included.

Guaranteed purchase option rider This rider allows you to purchase additional whole life coverage — without having to answer health questions — at three different points in the future. The rider may only be added if you are age 50 or younger when you purchase the policy. You may purchase up to your initial face amount, not to exceed a total combined maximum of $100,000 for all options.

Waiver of premium benefit rider Policy and rider premiums are waived if you become totally disabled before the policy anniversary following your 65th birthday and you satisfy the six-month elimination period. Once you are no longer disabled, premiums will resume.

* Whole Life Plus is a marketing name of the insurance policy filed as “Whole Life Insurance” in most states. 1 Any payout would reduce the death benefit. Benefits may be taxable as income. Individuals should consult with their legal or tax counsel when deciding to apply for accelerated benefits. 2 Accessing the accumulated cash value reduces the death benefit by the amount accessed, unless the loan is repaid. Cash value will be reduced by any outstanding loans against the policy. 3 The rider is not available in all states. This life insurance does not specifically cover funeral goods or services and may not cover the entire cost of your funeral at the time of your death. The beneficiary of this life insurance may use the proceeds for any purpose, unless otherwise directed. EXCLUSIONS AND LIMITATIONS: If the insured dies by suicide, whether sane or insane, within two years (one year in ND) from the coverage effective date or the date of reinstatement, we will not pay the death benefit. We will terminate this policy and return the premiums paid without interest, minus any loans and loan interest to you. This information is not intended to be a complete description of the insurance coverage available. The policy or its provisions may vary or be unavailable in some states. The policy has exclusions and limitations which may affect any benefits payable. Applicable to policy forms ICC19-IWL5000-70/ IWL5000-70, ICC19-IWL5000-100/IWL5000-100, ICC19-IWL5000J/IWL5000J and rider forms ICC23IWL5000-LTC/IWL5000-LTC, ICC19-R-IWL5000-STR/R-IWL5000-STR, ICC19-R-IWL5000-CTR/RIWL5000-CTR, ICC19-R-IWL5000-WP/R-IWL5000-WP, ICC19-R-IWL5000-ACCD/R-IWL5000-ACCD, ICC19-R-IWL5000-CI/R-IWL5000-CI, ICC19-R-IWL5000-CC/R-IWL5000-CC, ICC19-R-IWL5000GPO/R-IWL5000-GPO (including state abbreviations where applicable). For cost and complete details of the coverage, call or write your Colonial Life benefits counselor or the company. Underwritten by Colonial Life & Accident Insurance Company, Columbia, SC. © 2023 Colonial Life & Accident Insurance Company. All rights reserved. Colonial Life is a registered trademark and marketing brand of Colonial Life & Accident Insurance Company.

ColonialLife.com

FOR EMPLOYEES 8-23 | 642298-2

WHOLE LIFE INSURANCE PREMIUMS Adult Base Plan Paid-up to Age 70 Non-Tobacco Rates Issue Age 25 30 35 40 45 50

Pay Premium 10-Pay Premium 12-Pay Premium 10-Pay Premium 12-Pay Premium 10-Pay Premium 12-Pay Premium 10-Pay Premium 12-Pay Premium 10-Pay Premium 12-Pay Premium 10-Pay Premium 12-Pay Premium

$10,000.00 $11.84 $9.87 $14.30 $11.92 $17.95 $14.96 $23.22 $19.35 $30.68 $25.57 $41.84 $34.87

$25,000.00 $29.63 $24.69 $35.75 $29.79 $44.87 $37.39 $58.04 $48.37 $76.72 $63.93 $104.62 $87.18

$50,000.00 $59.24 $49.37 $71.50 $59.58 $89.75 $74.79 $116.10 $96.75 $153.44 $127.87 $209.24 $174.37

$100,000.00 $118.50 $98.75 $142.99 $119.16 $179.50 $149.58 $232.19 $193.49 $306.89 $255.74 $418.49 $348.74

$200,000.00 $236.99 $197.49 $285.98 $238.32 $358.98 $299.15 $464.38 $386.98 $613.78 $511.48 $836.96 $697.47

$100,000.00 $110.40 $92.00 $125.50 $104.58 $150.19 $125.16 $186.10 $155.08 $238.60 $198.83 $301.19 $250.99 $389.39 $324.49 $515.48 $429.57

$200,000.00 $220.79 $183.99 $250.99 $209.16 $300.38 $250.32 $372.18 $310.15 $477.18 $397.65 $602.38 $501.98 $778.76 $648.97 $1,030.96 $859.13

Adult Base Plan Paid-up to Age 100 Non-Tobacco Rates Issue Age 25 30 35 40 45 50 55 60

Pay Premium 10-Pay Premium 12-Pay Premium 10-Pay Premium 12-Pay Premium 10-Pay Premium 12-Pay Premium 10-Pay Premium 12-Pay Premium 10-Pay Premium 12-Pay Premium 10-Pay Premium 12-Pay Premium 10-Pay Premium 12-Pay Premium 10-Pay Premium 12-Pay Premium

$10,000.00 $11.04 $9.20 $12.55 $10.46 $15.02 $12.52 $18.61 $15.51 $23.86 $19.88 $30.12 $25.10 $38.94 $32.45 $51.55 $42.96

$25,000.00 $27.60 $23.00 $31.37 $26.14 $37.55 $31.29 $46.52 $38.77 $59.65 $49.71 $75.30 $62.75 $97.34 $81.12 $128.87 $107.39

$50,000.00 $55.20 $46.00 $62.75 $52.29 $75.10 $62.58 $93.05 $77.54 $119.29 $99.41 $150.59 $125.49 $194.69 $162.24 $257.74 $214.78

Sample rates only. Multiple choices and options available and rates may vary.

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

_____________ (Social Security Number)

___________________ (Signature)

__________________ (Date Signed)

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

________________________________ (Printed name of legal representative)

_____________________________ (Signature of legal representative)

___________ (Date Signed)

ADDITIONAL BENEFITS VIRGINIA RETIREMENT SYSTEM (VRS) LIFE INSURANCE The Virginia Retirement System (VRS) Optional Group Life Insurance program gives you the opportunity to purchase additional insurance at favorable group rates on yourself and family. Optional group life is term insurance. Term insurance generally provides the largest immediate death protection for your premium dollar. The program is administered by the Virginia Retirement System, and is provided under a group policy issued by the Minnesota Life Insurance Company. Questions about your employer paid and optional life insurance coverage can be submitted one of three ways:

By mail: Securian Financial PO Box 1193, Richmond, VA 23218-1193

By calling: 1-800-441-2258

Or by visiting their website: www.varetire.org/myvrs

VIRGINIA ASSOCIATION OF COUNTIES GROUP SELF INSURANCE RISK POOL (VACORP) SHORT AND LONG TERM DISABILITY Group Long Term Disability (LTD) insurance from Anthem Life Insurance Company helps provide financial protection for insured members by promising to pay a monthly benefit in the event of a covered disability. This Group Short Term Disability (STD) program is provided for VRS Hybrid Plan Participants and administered by AnthemLife. This benefit helps provide financial protection for covered members by promising to pay a weekly benefit in the event of a covered disability. Please refer to the plan summary document and your employee handbook for specific plan details, eligibility definitions, limitations, and exclusions. Questions about your VACORP Short and Long Term Disability can be submitted one of two ways: By calling: 1-844-404-2111

Or by visiting their website: www.vacorp.org/coverage/hybrid-disability

REQUIRED HEALTH CARE NOTICES Newborn and Mothers’ Health Protection Act Group health plans and health insurance issuers generally may not, under federal law restrict benefits for any hospital length of stay in connection with childbirth for the mother or newborn child to less than 48 hours following vaginal delivery, or less than 96 hours following a cesarean section. However, federal law generally does not prohibit the mother’s or newborn’s attending provider, after consulting with the mother, from discharging the mother or newborn earlier than 48 hours (or 96 hours as applicable). In any case, plans and issuers may not, under federal law, require that a provider obtain authorization from the plan or the issuer for prescribing a length of stay not in excess of 48 hours (or 96 hours).

Women’s Health and Cancer Rights Act In October 1998, Congress enacted the Women’s Health and Cancer Rights Act of 1998. This notice explains some important provisions of the Act. Please review this information carefully. As specified in the Women’s Health and Cancer Rights Act, a plan participant or beneficiary who elects breast reconstruction in connection with a covered mastectomy is also entitled to the following benefits: 1. All stages of reconstruction of the breast on which the mastectomy has been performed: 2. Surgery and reconstruction of the other breast to produce a symmetrical appearance; and 3. Prostheses and treatment of physical complications of the mastectomy , including lymphedemas. Health plans must provide coverage of mastectomy related benefits in a manner to determine in consultation with the attending physician and the patient. Coverage for breast reconstruction and related services may be subject to deductibles and insurance amounts that are consistent with those that apply to other benefits under the plan.

Premium Assistance Under Medicaid and the Children’s Health Insurance Program (CHIP) If you or your children are eligible for Medicaid or CHIP and you’re eligible for health coverage from your employer, your state may have a premium assistance program that can help pay for coverage, using funds from their Medicaid or CHIP programs. If you or your children aren’t eligible for Medicaid or CHIP, you won’t be eligible for these premium assistance programs but you may be able to buy individual insurance coverage through the Health Insurance Marketplace. For more information, visit www.healthcare.gov. If you or your dependents are already enrolled in Medicaid or CHIP and you live in a State listed below, contact your State Medicaid or CHIP office to find out if premium assistance is available. If you or your dependents are NOT currently enrolled in Medicaid or CHIP, and you think you or any of your dependents might be eligible for either of these programs, contact your State Medicaid or CHIP office or dial 1-877-KIDS NOW or www.insurekidsnow.gov to find out how to apply. If you qualify, ask your state if it has a program that might help you pay the premiums for an employer sponsored plan. If you or your dependents are eligible for premium assistance under Medicaid or CHIP, as well as eligible under your employer plan, your employer must allow you to enroll in your employer plan if you aren’t already enrolled. This is called a “special enrollment” opportunity, and you must request coverage within 60 days of being determined eligible for premium assistance. If you have questions about enrolling in your employer plan, contact the Department of Labor at www.askebsa.dol.gov or call 1-866-444-EBSA (3272).

REQUIRED HEALTH CARE NOTICES ALABAMA - MEDICAID Website: myalhipp.com Phone: 1-855-692-5447

ALASKA - MEDICAID

GEORGIA - MEDICAID Website: medicaid.georgia.gov/health-insurance premium-payment-program-hipp Phone: 678-564-1162, ext. 2131

INDIANA - MEDICAID

The AK Health Insurance Premium Payment Program Website: myakhipp.com Phone: 1-866-251-4861 Email: CustomerService@MyAKHIPP.com Medicaid Eligibility: dhss.alaska.gov/dpa/Pages/ medicaid/default.aspx

Healthy Indiana Plan for Low-Income Adults 19-64 Website: www.in.gov/fssa/hip Phone: 1-877-438-4479 All other Medicaid Website: www.in.gov/medicaid Phone: 1-800-457-4584

ARKANSAS - MEDICAID

IOWA - MEDICAID AND CHIP (HAWKI)

Website: myarhipp.com Phone: 1-855-MyARHIPP (855-692-7447)

CALIFORNIA - MEDICAID Website: www.dhcs.ca.gov/services/Pages/ TPLRD_CAU_cont.aspx Phone: 916-440-5676

COLORADO - HEALTH FIRST COLORADO (MEDICAID) & CHILD HEALTH PLAN PLUS (CHP+)

Medicaid Website: dhs.iowa.gov/ime/members Medicaid Phone: 1-800-338-8366 Hawki Website: dhs.iowa.gov/Hawki Hawki Phone: 1-800-257-8563

KANSAS - MEDICAID Website: www.kdheks.gov/hcf/default.htm Phone: 1-800-792-4884

KENTUCKY - MEDICAID

Health First Colorado Website: www.healthfirstcolorado.com Health First Colorado Member Contact Center: 1-800-221-3943/State Relay 711 CHP+: www.colorado.gov/pacific/hcpf/childhealth-plan-plus CHP+ Customer Service: 1-800-359-1991/State Relay 711 Health Insurance Buy-In Program (HIBI): www.colorado.gov/pacific/hcpf/health-insurancebuy-program HIBI Customer Service: 1-855-692-6442

Kentucky Integrated Health Insurance Premium Payment Program (KI-HIPP) Website: chfs.ky.gov/agencies/dms/member/Pages/kihipp.aspx Phone: 1-855-459-6328 Email: KIHIPP.PROGRAM@ky.gov KCHIP Website: kidshealth.ky.gov/Pages/index.aspx Phone: 1-877-524-4718 Kentucky Medicaid Website: chfs.ky.gov

FLORIDA - MEDICAID

Website: www.medicaid.la.gov or www.ldh.la.gov/lahipp Phone: 1-888-342-6207 (Medicaid hotline) or 1-855-618-5488 (LaHIPP)

Website: www.flmedicaidtplrecovery.com/flmedicaidtplrecovery.com/hipp/index.html Phone: 1-877-357-3268

LOUISIANA - MEDICAID

REQUIRED HEALTH CARE NOTICES MAINE - MEDICAID Website: www.maine.gov/dhhs/ofi/public assistance/index.html Phone: 1-800-442-6003 TTY: Maine Relay 711

MASSACHUSETTS - MEDICAID AND CHIP Website: www.mass.gov/eohhs/gov/departments/ masshealth Phone: 1-800-862-4840

MINNESOTA - MEDICAID Website: mn.gov/dhs/people-we-serve/children-and-families/health-care/health-care-programs/programs-and-services/medical-assistance.jsp [Under ELIGIBILITY tab, see “What if I have other health insurance?”] Phone: 1-800-657-3739

KANSAS - MEDICAID Website: www.kdheks.gov/hcf/default.htm Phone: 1-800-792-4884

MISSOURI - MEDICAID Website: www.dss.mo.gov/mhd/participants/ pages/hipp.htm Phone: 573-751-2005

MONTANA - MEDICAID Website: dphhs.mt.gov/MontanaHealthcarePrograms/HIPP Phone: 1-800-694-3084

NEBRASKA - MEDICAID Website: www.ACCESSNebraska.ne.gov Phone: 1-855-632-7633 Lincoln: 402-473-7000 Omaha: 402-595-1178

NEVADA - MEDICAID Medicaid Website: dhcfp.nv.gov Medicaid Phone: 1-800-992-0900

NEW HAMPSHIRE - MEDICAID Website: www.dhhs.nh.gov/oii/hipp.htm Phone: 603-271-5218 Toll free number for the HIPP program: 1-800-852-3345, ext. 5218

NEW JERSEY - MEDICAID AND CHIP Medicaid Website: www.state.nj.us/humanservices/dmahs/clients/medicaid Medicaid Phone: 609-631-2392 CHIP Website: www.njfamilycare.org/index.html CHIP Phone: 1-800-701-0710

NEW YORK - MEDICAID Website: www.health.ny.gov/health_care/ medicaid Phone: 1-800-541-2831

NORTH CAROLINA - MEDICAID Website: medicaid.ncdhhs.gov Phone: 919-855-4100

NORTH DAKOTA - MEDICAID Website: www.nd.gov/dhs/services/medicalserv/medicaid Phone: 1-844-854-4825

OKLAHOMA - MEDICAID & CHIP Website: www.insureoklahoma.org Phone: 1-888-365-3742

OREGON - MEDICAID & CHIP Website: healthcare.oregon.gov/Pages/index.aspx Phone: 1-800-699-9075

REQUIRED HEALTH CARE NOTICES PENNSYLVANIA - MEDICAID Website: www.dhs.pa.gov/providers/Providers/ Pages/Medical/HIPP-Program.aspx Phone: 1-800-692-7462

RHODE ISLAND - MEDICAID AND CHIP Website: www.eohhs.ri.gov Phone: 1-855-697-4347 or 401-462-0311 (Direct RIte Share Line)

SOUTH CAROLINA - MEDICAID Website: www.scdhhs.gov Phone: 1-888-549-0820

SOUTH DAKOTA - MEDICAID Website: dss.sd.gov Phone: 1-888-828-0059

TEXAS - MEDICAID Website: gethipptexas.com Phone: 1-800-440-0493

UTAH - MEDICAID Medicaid Website: medicaid.utah.gov CHIP Website: health.utah.gov/chip Phone: 1-877-543-7669

VERMONT - MEDICAID Website: www.greenmountaincare.org Phone: 1-800-250-8427

VIRGINIA - MEDICAID AND CHIP Website: www.coverva.org/hipp Medicaid Phone: 1-800-432-5924 CHIP Phone: 1-855-242-8282

WASHINGTON - MEDICAID Website: www.hca.wa.gov Phone: 1-800-562-3022

WEST VIRGINIA - MEDICAID Website: mywvhipp.com Toll-free phone: 1-855-MyWVHIPP (1-855-699-8447)

WISCONSIN - MEDICAID AND CHIP Website: www.dhs.wisconsin.gov/badgercareplus/p-10095.htm Phone: 1-800-362-3002

WYOMING - MEDICAID Website: wyequalitycare.acs-inc.com Phone: 307-777-7531

REQUIRED HEALTH CARE NOTICES To see if any other states have added a premium assistance program since July 31, 2020, or for more information on special enrollment rights, contact either: U.S. Department of Labor Employee Benefits Security Administration www.dol.gov/agencies/ebsa 1-866-444-EBSA (3272)

U.S. Department of Health and Human Services Centers for Medicare & Medicaid Services www.cms.hhs.gov 1-877-267-2323, Menu Option 4, Ext. 61565

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 seven 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, Employee Benefits Security Administration, 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 1210-0137.

COBRA CONTINUATION OF COVERAGE INTRODUCTION: You’re getting this notice because you recently gained coverage under a group 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.

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.”

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.

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 Charlottesville City Schools 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.

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.

When is COBRA continuation coverage available?

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

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; • The employee’s becoming entitled to Medicare benefits (under Part A, Part B, or both). For all other qualifying events (divorce or legal separation of the employee and spouse or a dependent child’s losing eligibility for coverage as a dependent child), you must notify the Plan Administrator within 60 days after the qualifying event occurs. You must provide this notice to: Laura Floyd at Charlottesville City Schools. Applicable documentation will be required i.e. court order, certificate of coverage etc. 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,

103

COBRA CONTINUATION OF COVERAGE or a second qualifying event during the initial period of coverage, may permit a beneficiary to receive a maximum of 36 months of coverage.

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.

There are also ways in which this 18-month period of COBRA continuation coverage can be extended:

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.

Disability extension of 18-month period of COBRA continuation coverage: If you or anyone in your family covered under the Plan is determined by Social Security to be disabled and you notify the Plan Administrator in a timely fashion, you and your entire family may be entitled to get up to an additional 11 months of COBRA continuation coverage, for a maximum of 29 months. The disability would have to have started at some time before the 60th day of COBRA continuation coverage and must last at least until the end of the 18-month period of COBRA continuation coverage. Second qualifying event extension of 18-month period of continuation coverage: If your family experiences another qualifying event during the 18 months of COBRA continuation coverage, the spouse and dependent children in your family can get up to 18 additional months of COBRA continuation coverage, for a maximum of 36 months, if the Plan is properly notified about the second qualifying event. This extension may be available to the spouse and any dependent children getting COBRA continuation coverage if the employee or former employee dies; becomes entitled to Medicare benefits (under Part A, Part B, or both); gets divorced or legally separated; or if the dependent child stops being eligible under the Plan as a dependent child. This extension is only available if the second qualifying event would have caused the spouse or dependent child to lose coverage under the Plan had the first qualifying event not occurred. Are there other coverage options besides COBRA Continuation Coverage?: Yes. Instead of enrolling in COBRA continuation coverage, there may be other coverage options for you and your family through the Health Insurance Marketplace, 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 period to sign up for Medicare Part A or B, beginning on the earlier of

For more information visit https://www.medicare.gov/medicare-and-you. 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 knowabout 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 Charlottesville City Schools FBA 1562 Dairy Road Charlottesville, VA 22903 Ph: 432-245-2400 Health, Dental, & Vision COBRA Administrator: Flexible Benefits Administrators, Inc. 800-437-3539 PO Box 2070 Viriginia Beach, VA 23450

• 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

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PRIVACY NOTICES Non Public Information (NPI) We collect Non Public Information (NPI) about our customers to provide them with insurance products and services. This may include telephone number, address, date of birth, occupation, income and health history. We may receive NPI from your applications and forms. medical providers, other insurers, employers, insurance support organizations, and service providers. We share the types of NPI described above primarily with people who perform insurance, business, and professional services for us, such as helping us pay claims and detect fraud. We may share NPI with medical providers for insurance and treatment purposes. We may share NPI with an insurance support organization. The organization may retain the NPI and disclose it to others for whom it performs services. In certain cases, we may share NPI with group policy holders for reporting and auditing purposes. We may share NPI with parties to a proposed or final sale of insurance business or for study purposes. We may also share NPI when otherwise required or permitted by law, such as sharing with governmental or other legal authorities. When legal necessary, we ask your permission before sharing NPI about you our practices apply to our former, current and future customers. Please be assured we do not share your health NPI to market any product or service. We also do not share any NPI to market non financial products and services. For example, we do not sell your name to catalog companies. The law allows us to share NPI as described above (except health information) will affiliates to market financial products and services. The law does not allow you to restrict these disclosures. We may also share with companies that help us market our insurance products and services, such as vendors that provide mailing services to us. We may share with other financial institution to jointly market financial products and services. When required by law, we ask your permission before we share NPI for marketing purposes. When other companies help us conduct business, we expect them to follow applicable privacy laws. We do not authorize them to use or share NPI except when necessary to conduct the work they are performing for us or to meet regulatory or other governmental requirements.

Our affiliated companies, including insurers and insurance service providers, may share NPI about you with each other. The NPI might not be directly related to our transaction or experience with you. It may include financial or other personal information such as employment history. Consistent with the Fair Credit Reporting Act, we ask your permission before sharing NPI that is not directly related to our transaction or experience with you. We have physical, electronic and procedural safeguards that protect the confidentiality and security of NPI. We give access only to employees who need to know the NPI to provide insurance products or services to you. You may request access to certain NPI we collect to provide you with insurance products and services, You must make your request in writing and send it to the address, telephone number and policy number if we have issued a policy. If you request, we will send copies of the NPI to you. If the NPI includes health information, we may provide the health information to you through a health care provider you designate. We will also send you information related to disclosures. We may charge a reasonable fee to cover our copying costs. This section applies to NPI we collect tor provide you with coverage. It does not apply to NPI we collect in anticipation of a claim or civil or criminal proceeding.

in our files. We will file your statement with the disputed NPI. We will include your statement any time we disclose the disputed NPI. We will also give the statement to any person designated by your if we may have disclosed the disputed NPI to that person int he past two years.

Disclosure Notice Concerning The Medical Information Bureau Information regarding your insurability will be treated as confidential. Colonial or its reinsure(s) may, however, make a brief report thereon to the Medical Information Bureau, a nonprofit membership organization of life insurance companies which operates an information exchange on behalf of its members. If you apply to another Bureau member company for life or health insurance coverage, or a claim for benefits is submitted to such company, the Bureau, upon request, will supply such company with the information in its file.

Upon receipt of a request from you, the Bureau will arrange disclosure of any information it may have in your file. If you question the accuracy of information in the Bureau’s file, you may contact the Bureau and seek a correction in accordance with the procedure set forth in the federal Fair If you believe NPI we have about you Credit Reporting Act. The address of is incorrect, please write us. Your letter the Bureau’s information office is: 50 should include your full name, address, Braintree Hill Park, Suite 400, Braintree, telephone number and policy number if we have issued a policy. Your letter should MA 02184-8734, telephone (617) 4263660. also explain why you believe the NPI is inaccurate. If we agree with you, we will Colonial or its reinsure may also correct the NPI and notify you of the release information in its file to other correction. We will also notify any person who may have received the incorrect NPI life insurance companies to whom you from us in the past two years if you ask us may apply for life or health insurance or to whom a claim for benefits may be to contact that person. submitted. If we disagree with you, we will tell you we are not going to make the correction, We will give the reason(s) for our refusal. We will also tell you that you may submit a statement to us. Your statement should include the NPI you believe is correct. It should also include the reasons(s) why you disagree with our decision not to correct the NPI 105

CONTINUATION OF COVERAGE We are committed to being there for you and your family at every stage of life. Pierce Group Benefits makes it easy to stay protected! The following benefits can be self-enrolled online or by contacting PGB Employee Services, with Individual and Family coverage options available for most plans. You are eligible to sign-up the first day after the end date of your employer-sponsored plan.

DENTAL BENEFITS

VISION BENEFITS

TELEMEDICINE BENEFITS

SUPPLEMENTAL/VOLUNTARY POLICIES Your individual supplemental/voluntary policies through Colonial Life are portable! To transfer your benefits from payroll deduction to direct billing or automatic bank draft, please call Employee Services at 800-387-5955 within 30 days of becoming unemployed, switching careers, or retiring.

TRANSFERRING EMPLOYERS? If you are transferring from a current PGB client to another, some benefits may be eligible for transfer. Please call Employee Services at 800-387-5955 for assistance.

Please visit www.piercegroupbeneﬁts.com/individualcoverage or call 800-387-5955 for more information on these policies, as well as to enroll/continue your benefits.

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ABOUT PIERCE GROUP BENEFITS Pierce Group Benefits is a leading full-service employee benefits administration and consulting agency serving employer groups across the Southeast. By leveraging market strength, exclusive partnerships, and industry expertise, we deliver trusted advice, products, and solutions that benefit employers and employees alike; delivered by one team and driven by one purpose — together we can do more.

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