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EMPLOYEE BENEFITS GUIDE 2027 PLAN YEAR:

JANUARY 1, 2027 - DECEMBER 31, 2027

CITY OF LINCOLNTON

WWW.PIERCEGROUPBENEFITS.COM

EMPLOYEE SERVICES: 888-662-7500

TABLE OF CONTENTS

EMPLOYEE BENEFITS GUIDE Welcome to City of Lincolnton’s 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: October 12, 2026 - October 30, 2026 PLAN YEAR & EFFECTIVE DATES: January 1, 2027 - December 31, 2027

Important Contact Information............................... 3 Eligibility Requirements......................................... 4 Overview Of Benefits............................................. 5 Important Notices................................................. 6 Qualifying Life Events............................................ 7 Enrollment Information.......................................... 9 Flexible Spending Account..................................... 10 The FSA Store....................................................... 13 Dependent Care Account....................................... 14 Dental Insurance................................................... 17 Vision Insurance.................................................... 21 Telemedicine Benefits........................................... 24 Group Term Life Insurance..................................... 31 Cancer Benefits..................................................... 34 Critical Illness Benefits.......................................... 41 Short-Term Disability Benefits................................ 54 Accident Benefits.................................................. 58 NC State Health Plan Comparison**....................... 70 Medical Bridge Benefits......................................... 72 Term Life Insurance............................................... 81 Whole Life Insurance............................................. 85 Colonial Life Policyholder Service Guide................. 89 Authorization For Colonial Life Insurance Form....... 90 COBRA Continuation Of Coverage.......................... 91 Privacy Notices..................................................... 93 Continuation Of Coverage...................................... 94

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

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

CITY OF LINCOLNTON 2027 Benefits Plan

January 1, 2027 - December 31, 2027

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 from those in this guide. Rev: 9/24/2026 **For informational purposes only

IMPORTANT CONTACT INFORMATION CARRIER

PHONE/FAX

WEBSITE

Flexible Spending Accounts

Ameriflex

P: 888-868-3539

service@myameriflex.com

www.myameriflex.com

Dental Insurance

Delta Dental of NC

P: 800-662-8856

customersupport@ deltadentalcoversme.com

www.deltadentalnc.com

Vision Insurance

Community Eye Care

P: 888-254-4290

www.communityeyecare.net

Short-Term Disability Benefits

USAble

P: 800-370-5856

www.usablelife.com

Group Term Life Insurance

MetLife

P: 800-638-5433

www.metlife.com

Telemedicine Benefits

Call A Doctor Plus

P: 800-835-2362

help@teladochealth.com

www.teladoc.com

North Carolina State Health Plan

SHPNC

P: 888-234-2416 F: 919-765-2322

www.shpnc.org

Custom Benefits Website

Pierce Group Benefits

P: 1-888-662-7500 F: 984-225-2605

service@ piercegroupbenefits.com

www.PierceGroupBenefits.com/ CityofLincolnton

www.coloniallife.com

Customer Service & Wellness Screenings

Supplemental Benefits

Colonial Life

1-800-325-4368 F:1-800-880-9325 TDD For Hearing Impaired Customers

1-800-798-4040

NC State Health Plan: Under certain qualifying events, employees and dependents have the opportunity to continue coverage for 18-36 months under the COBRA Act. Please contact the State Health Plan at 1-877-679-6272. If you are retiring, you must either log in to www.myncretirement.com or call 1-877-679-6272.

ELIGIBILITY REQUIREMENTS CURRENT EMPLOYEE? ANNUAL ENROLLMENT DATES:

October 12, 2026 - October 30, 2026

PLAN YEAR & EFFECTIVE DATES: January 1, 2027 - December 31, 2027

ELIGIBILITY • Employees working 30 hours or more per week are eligible for 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. Colonial Life Insurance Products and Telemedicine - You will be able to enroll during the next Annual Enrollment period. All Other Benefits - Please reach out to your Benefits Department within 30 days of your date of hire. 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/CityofLincolnton

OVERVIEW OF BENEFITS PRE – TAX BENEFITS

POST – TAX BENEFITS

Flexible Spending Accounts Ameriflex

Short-Term Disability Benefits USAble

- Medical Reimbursement: $3,400/year Max - Dependent Care Reimbursement: $7,500/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 December 31, 2026.

Critical Illness Benefits Colonial Life

Dental Insurance Delta Dental

Vision Insurance Community Eye Care

Group Term Life Insurance MetLife - Basic Group Term Life Insurance (Employer-Paid)

Cancer Benefits Colonial Life Life Insurance Colonial Life Accident Benefits Colonial Life

- Term Life Insurance - Whole Life Insurance

Medical Bridge Benefits Colonial Life

Telemedicine Benefits Call A Doctor Plus

Please note your insurance products will remain in effect unless you speak with a representative to change them. 5

IMPORTANT NOTICES When do my benefits start? The plan year for Colonial Life Insurance Products, Ameriflex Flexible Spending Accounts, Delta Dental, Community Eye Care Vision, MetLife Group Term Life, USAble Short-Term Disability and Call A Doctor Plus Telemedicine runs from January 1, 2027, through December 31, 2027. When do my deductions start? Deductions for Colonial Life Insurance Products, Ameriflex Flexible Spending Accounts, Delta Dental, Community Eye Care Vision, MetLife Group Term Life, USAble Short-Term Disability and Call A Doctor Plus Telemedicine start January 2027 for all enrolled employees. Why have my Cancer, Accident, or Medical Bridge benefits not started yet? The Colonial Cancer plan and the Health Screening Rider on the Colonial Accident and Colonial Medical Bridge plan have a 30-day waiting period for new enrollees. Coverage, therefore, will not begin until January 31, 2027. 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 3 months to submit claims for incurred qualified spending account expenses (or 3 months 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. My spouse is enrolled in a 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. Can I sign up for Health Insurance as well? No, Pierce Group Representatives are not authorized to assist employees with their SHP enrollment or make SHP enrollment elections on an employee’s behalf. 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 (QLE), as defined by the Internal Revenue Code. Examples of a QLE can be found in the chart on the next page. Once a QLE has occurred, an employee has 30 days to notify PGB’s Employee Services at 1-888-662-7500 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.

Employee Services: 888-662-7500

www.PierceGroupBenefits.com/ CityofLincolnton 6

Effective Dates: January 1, 2027 - December 31, 2027

QUALIFYING LIFE 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 Qualifying Life 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.

QUALIFYING LIFE 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 888-662-7500.

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

QUALIFYING LIFE EVENTS QUALIFYING LIFE 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 888-662-7500 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 888-662-7500 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 the enrollment period, you can meet one-onone with a PGB Benefits Representative via in-person appointment to review your benefits, get answers to your questions, and receive enrollment assistance.

ANNUAL ENROLLMENT PERIOD:

OCTOBER 12, 2026 - OCTOBER 30, 2026 BENEFITS AVAILABLE TO YOU YOU CAN MAKE THE FOLLOWING BENEFIT ELECTIONS DURING THE ENROLLMENT PERIOD: • • • • • • •

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 Group Term Life Insurance. Enroll in, change, or cancel Short-Term Disability Insurance. Enroll in, change, or cancel Telemedicine coverage. Enroll in, change, or cancel Colonial coverage.

+You will need to re-enroll in the Flexible Spending Accounts if you want them to continue each year.

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/CityofLincolnton 9

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

FLEXIBLE SPENDING ACCOUNT

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

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

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

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

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

Learn more at myameriﬂex.com | 844.423.4636 | info@myameriﬂex.com 11

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

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

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

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

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

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

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

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

Learn more at myameriﬂex.com | 844.423.4636 | info@myameriﬂex.com 12

THE FSA STORE Resources Available Through The FSA Store

• The largest selection of guaranteed FSAeligible 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

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

Easy tips and resources for living with an FSA.

Your funds go further with the FSA Store rewards program.

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.

Click or Scan to Shop Now 13

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

DEPENDENT CARE ACCOUNT

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

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

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

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

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

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

Private sitter

Daycare and elder care

Before- and after-school care

Summer day camp

Nanny service

Nursery school & Pre-school

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

Learn more at myameriﬂex.com | 844.423.4636 | info@myameriﬂex.com 15

www.myameriflex.com

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

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

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

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

DENTAL INSURANCE

Delta Dental PPO plus Premier™ Summary of Dental Plan Benefits For Group# 10924-0001, 0002, 0099 City of Lincolnton This Summary of Dental Plan Benefits should be read along with your Certificate. Your Certificate provides additional information about your Delta Dental plan, including information about plan exclusions and limitations. If a statement in this Summary conflicts with a statement in the Certificate, the statement in this Summary applies to you and you should ignore the conflicting statement in the Certificate. The percentages below are applied to Delta Dental's Maximum Approved Fee for each service and it may vary due to the Dentist's network participation.* Control Plan – Delta Dental of North Carolina Benefit Year – January 1 through December 31 Covered Services –

Nonparticipating Delta Dental PPO™ Delta Dental Dentist Premier® Dentist Dentist Plan Pays Plan Pays Plan Pays* Diagnostic & Preventive Diagnostic and Preventive Services – exams, cleanings, 100% 100% 100% fluoride, and space maintainers Emergency Palliative Treatment – to temporarily relieve pain 100% 100% 100% Sealants – to prevent decay of permanent teeth 100% 100% 100% Brush Biopsy – to detect oral cancer 100% 100% 100% Radiographs – X-rays 100% 100% 100% Basic Services Minor Restorative Services – fillings and crown repair 80% 80% 80% Oral Surgery Services – extractions and dental surgery 80% 80% 80% Other Basic Services – misc. services 80% 80% 80% Relines and Repairs – to bridges, implants, and dentures 80% 80% 80% Major Services Endodontic Services – root canals 50% 50% 50% Periodontic Services – to treat gum disease 50% 50% 50% Major Restorative Services – crowns 50% 50% 50% Prosthodontic Services – bridges, dentures, and crowns over 50% 50% 50% implants * When you receive services from a Nonparticipating Dentist, the percentages in this column indicate the portion of Delta Dental's Nonparticipating Dentist Fee that will be paid for those services. This Nonparticipating Dentist Fee may be less than what your dentist charges, which means that you will be responsible for the difference. The explanation and sample calculation of how these services will be paid can be found in Section VI – How Payment is Made in your Certificate.     

Oral exams (including evaluations by a specialist) are payable twice per calendar year. Prophylaxes (cleanings) are payable twice per calendar year. Full mouth debridement is payable once per lifetime. People with specific at-risk health conditions may be eligible for additional prophylaxes (cleanings) or fluoride treatment. The patient should talk with his or her Dentist about treatment. Fluoride treatments are payable once per calendar year for people age 14 and under. Bitewing X-rays are payable twice per calendar year and full mouth X-rays (which include bitewing X-rays) or a panorex are payable once in any three-year period.

NCPPOSUM2022-R

KR#62568135

      

Sealants are payable once per tooth per lifetime for first and second permanent molars for people age 13 and under. The surface must be free from decay and restorations. Composite resin (white) restorations are payable on all teeth, including posterior teeth. Porcelain and resin facings on crowns are payable on posterior teeth. Vestibuloplasty is a Covered Service. Full and partial dentures are payable once in any five-year period. Reline and rebase of dentures are payable once in any twoyear period. Implants and implant related services are not Covered Services. Crowns over implants are payable once per tooth in any five-year period. Services related to crowns over implants are Covered Services.

Passport Dental Having Delta Dental coverage makes it easy for you to get dental care almost everywhere in the world! You can now receive expert dental care when you are outside of the United States through our Passport Dental program. This program gives you access to a worldwide network of Dentists and dental clinics. English-speaking operators are available around the clock to answer questions and help you schedule care. For more information, check our website or contact your benefits representative to get a copy of our Passport Dental information sheet. Maximum Payment – $1,250 per Member total per Benefit Year on all services. Deductible – $50 Deductible per Member total per Benefit Year limited to a maximum Deductible of $100 per family per Benefit Year. The Deductible does not apply to diagnostic and preventive services, emergency palliative treatment, brush biopsy, X-rays, and sealants. Waiting Period – Enrollees who are eligible for Benefits are covered on the first day of the month following the date of hire. Eligible People – All full-time employees of the Contractor working at least 30 hours per week who choose the dental plan and all Enrollees who are eligible for and elect Continuation Coverage pursuant to the Consolidated Omnibus Budget Reconciliation Act of 1985 or similar non-preempted state law ("COBRA"). The Contractor pays the full cost of this plan for Subscribers. The Subscriber pays the additional cost of dependent coverage. Also eligible are your Spouse and your Children to the end of the month in which they turn 26, including your Children who are married, who no longer live with you, who are not your Dependents for Federal income tax purposes, and/or who are not permanently disabled. Enrollees and Dependents choosing this plan are required to remain enrolled for a minimum of 12 months. Should an Enrollee or Dependent choose to drop coverage after that time, he or she may not re-enroll prior to the date on which 12 months have elapsed. Dependents may only enroll if the Enrollee is enrolled (except under COBRA) and must be enrolled in the same plan as the Enrollee. An election may be revoked or changed at any time if the change is the result of a qualifying event as defined under Internal Revenue Code Section 125. Coordination of Benefits – If you and your Spouse are both eligible to enroll in This Plan as Enrollees, you may be enrolled together on one application or separately on individual applications, but not both. Your Dependent Children may only be enrolled on one application. Delta Dental will not coordinate Benefits between your coverage and your Spouse's coverage if you and your Spouse are both covered as Enrollees under This Plan. Benefits will cease on the last day of the month in which your employment is terminated.

NCPPOSUM2022-R

Customer Service Toll-Free Number: 800-662-8856 (TTY users call 711) https://www.DeltaDentalNC.com July 1, 2025 19

KR#62568135

DENTAL INSURANCE PREMIUMS 12 Month Rates Employee Only Employee & Spouse Employee & Child(ren) Employee & Family

Cost $32.66 $64.44 $92.82 $125.70

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

VISION INSURANCE

Vision Benefits Summary

City of Lincolnton

A Vision Plan for Everyone All members enrolled in the CEC vision plan can take advantage of our simple and flexible benefits. Each plan year, you’ll receive an eye exam, a flexible eyewear allowance, and a contact lens fitting.

Plan Features Flexible Eyewear Allowance Purchase exactly what you want—frames, lenses, contact lenses, sunglasses, special lens options, and any combination of these items. If the eyewear you want is sold in an optical shop, it’s covered!

Don’t Need Prescription Glasses? Non-prescription eyewear, including blue-light blocking glasses, sunglasses, safety glasses, and readers, is covered by your CEC vision plan. Don’t need prescription lenses? This is a great way to use your annual eyewear allowance!

Member Portal Our Member Portal gives you 24/7 access to find a provider, view your benefit information, check your current eligibility, print a temporary ID card, and more! Log in at: cecvision.com/members/login.

Expansive Provider Network CEC’s network includes optometrists, ophthalmologists, and national retail optical chains, ensuring you can easily find a provider that meets your needs. Visit cecvision.com/search to find an in-network provider near you.

Vision Care is Important Even if you have perfect vision, your annual eye exam is critical to your overall health and wellness. Common diseases, including glaucoma, diabetes, cardiovascular disease, and cancer, can be identified during an eye exam. Your exam is covered-in-full. You just cover the copay.

Prefer to Shop Online? Eyeconic offers CEC members special discounts when using the promo code CECMEMBERS at eyeconic.com.

Your CEC Vision Benefits Summary Company: City of Lincolnton CEC Coverage Effective Date: 1/1/2023 $225 PLAN Frequency: All benefits renew every 12 months BENEFIT

DESCRIPTION

COPAY

Exam

An annual routine eye exam.

Retinal Screening

An enhancement to the annual eye exam where high-resolution images are taken of the inside of the eye to detect and monitor conditions like diabetes.

Eyewear

An annual $225 flexible allowance for prescription and non-prescription eyewear. 20% discount on glasses/10% discount on contacts for any overages.

An annual fitting or evaluation.

$15

Contact Lens Fitting

OUT-OFNETWORK REIMBURSEMENT 100% minus the copay

$15

$39

None

MONTHLY RATES Employee Only

$10.00

Employee + Spouse

$19.40

Employee + Child(ren)

$20.00

Employee + Family

$33.60

SEMI-MONTHLY RATES Up to $225 minus the copay

100% minus the copay

Employee Only

$5.00

Employee + Spouse

$9.70

Employee + Child(ren)

$10.00

Employee + Family

$16.80

ADDITIONAL SAVINGS

Additional Pairs of Glasses or Contacts

Members receive a 20% savings on additional pairs of prescription and non-prescription glasses, and 10% savings on contact lenses, from any CEC in-network provider within 12 months of their last eye exam.

LASIK Discounts

Members can save up to 50% from participating QualSight LASIK providers, including TLC Laser Eye Center.

Special Offers

A variety of special offers are available to CEC members. Visit cecvision.com/members/specialoffers for additional information!

Benefits may vary by location.

Questions about your benefits? Visit us online at cecvison.com or call 888-254-4290. 23

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

TELEMEDICINE BENEFITS

24/7 access to quality care... on your schedule! City of Lincolnton Complete

Teladoc

✓

Connect in under 10 minutes to US-based, board certified physicians who can answer questions, diagnose and even prescribe when necessary.

Pharmacy Discount Card

✓

Save up to 75% on your prescription medication using our pharmacy discount card. It’s easy to use and accepted at over 50,000 pharmacies nationwide!

Life Assistance

✓

Access to professional Life Counselors and specialists who can help you achieve balance in your personal, family and work life is just a call away.

Bill Saver

✓

Our Bill Saver program can help reduce the amount you owe for medical and dental bills over $400, often resulting in savings between 25-50%.

Employee Only Employee & Family

24 deductions $6.00 $7.50

For more information, please contact Pierce Group Benefits We Win When You Win.

Talk to a doctor

anytime

Teladoc® gives you 24/7/365 access to U.S. board-certified doctors through the convenience of phone, video or mobile app visits. It's an affordable alternative to costly urgent care and ER visits when you need care now.

MEET OUR DOCTORS

GET THE CARE YOU NEED

WHEN CAN I USE TELADOC?

Teladoc is simply a new way to access

Teladoc doctors can treat many

Teladoc does not replace your primary

qualified doctors. All Teladoc doctors:

medical conditions, including:

physician it is a convenient and

•

Are practicing PCPs,

•

Cold & flu symptoms

pediatricians, and family

•

Allergies

•

When you need care now

medicine physicians

•

Sinus problems

•

If you're considering the

•

Average 20 years experience

•

Sore Throat

ER or urgent care for a

•

Are U.S. board-certified and

•

Respiratory infection

non-emergency issue

licensed in your state

•

Skin problems

Are credentialed every three

•

And more!

•

affordable option for quality care.

•

or away from home •

years, meeting NCQA standards

On vacation, on a business trip, For short term prescription refills

Talk to a doctor anytime for free! Teladoc.com 1-800-TELADOC (835-2362)

© 2019 Teladoc Health, Inc. All rights reserved. Teladoc and the Teladoc logo are registered trademarks of Teladoc Health, Inc. and may not be used without written permission. Teladoc does not replace the primary care physician. Teladoc does not guarantee that a prescription will be written. Teladoc operates subject to state regulation and may not be available in certain states. Teladoc does not prescribe DEA controlled substances, non therapeutic drugs and certain other drugs which may be harmful because of their potential for abuse. Teladoc physicians reserve the right to deny care for potential misuse of services.

04042016 10E-100B

So many reasons to use Teladoc ® Teladoc gives you access 24 hours, 7 days a week to a U.S. board-certified doctor through the convenience of phone, video or mobile app visits. It's an affordable option for quality medical care. 1

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

Prompt treatment, talk to a doctor in minutes

Receive quality care via phone, video or mobile app

• Cold & flu symptoms • Allergies • Pink Eye • Respiratory infection • Sinus problems • Skin problems • And more! With your consent, Teladoc is

A network of doctors that can treat every member of the family

Prescriptions sent to pharmacy of choice if medically necessary

Teladoc is less expensive than the ER or urgent care

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

Talk to a doctor anytime for free! Teladoc.com 1-800-TELADOC (835-2362) 27

03302016 10E-103B

Register Your Account Follow these simple steps to set up your Teladoc Health account and access your available services.

1. Get Started

Visit TeladocHealth.com or open the Teladoc Health app and select Register Now.

2. Create Your Login

Enter your email address, create a password, and follow the prompts to verify your email.

3. Verify Your Eligibility Enter your: • • •

First and last name Date of birth ZIP code

Make sure this information matches the information provided by your employer or organization. When prompted, do not check the box indicating that you do not have benefits through an employer or organization.

4. Confirm Your Benefits

Once your information is matched, you'll see your employer or organization and the Teladoc Health services available to you. Confirm your information and continue.

5. Complete Your Account

Follow the remaining prompts to finish setting up your account. That's it! You're ready to access care with Teladoc Health.

Can't Find Your Coverage?

If Teladoc can't find your information or asks you to enter your health insurance information, STOP and contact your HR team as soon as possible. This means Teladoc was unable to match you to your employer-sponsored benefits.

Access Teladoc 24/7 via the app, online at TeladocHealth.com or by calling (800) 835-2362. 28

EAP+Work/Life Program Compassionate and confidential support for employees and their families Problem-solving for personal, relationship and work issues • In-person, telephonic, text and video counseling • Help for stress, anxiety, depression, family issues, substance abuse and more • Referrals for long-term counseling or specialized care

Support for Supervisors and HR • Sensitive employee issues; conflict resolution • Critical events • Disability management

Help achieving work/life balance • Locate childcare, legal and financial experts

Emotional distress can reduce a worker’s capacity by

• Webinars, articles, budgeting calculators

Friendly awareness communications • Emails, posters, flyers, monitor screens and more • Monthly electronic member newsletter • News alerts

50% Source: Milenkovic, M (2019, September). 42 Worrying Workplace Stress Statistics. Retrieved from https://www.stress.org/42-worrying-workplace-stress-statistics

Combine with Health Advocacy for greater impact and support.

Tom called because he was stressed about his wife’s cancer diagnosis and related unpaid medical bills.

His Counselor addressed his emotional concerns and connected him to a Personal Health Advocate who:  Reviewed his wife’s diagnosis and treatment plan  Connected them to a Center of Excellence  Reviewed their benefifs coverage, and negotiated medical bills  Made the appointment and transferred medical records

866.799.2655 | info@HealthAdvocate.com | HealthAdvocate.com Health Advocate makes healthcare easier for over 12,500 organizations and their members by leveraging a combination of personal support, data and technology to engage people in their health and well-being. ©2020 Health Advocate HA-B-1906040-1.2FLY

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

GROUP TERM LIFE INSURANCE

Basic Term Life / AD&D

Plan Design for: City of Lincolnton For All Active Full Time Employees Basic Life

$25,000

Accidental Death & Dismemberment

An amount equal to Your Basic Life Insurance.

Plan Maximum

$25,000

Non-Medical Maximum

$25,000

Age Reduction Formula

Other

Employee Contribution  Basic Life  AD&D

0% 0%

Term Life Features (1)  Continuation of Life insurance while totally disabled as defined by the Group Policy (2)  Accelerated Benefits Option (3) Total Control Account (4)  AD&D Features (1)  Seat Belt Benefit (5) Common Carrier Benefit   Air Bag Benefit  Total Control Account

L0615428011[exp0816][All States][DC,GU,MP,PR,VI] Metropolitan Life Insurance Company, 200 Park Ave., New York, NY 10166

What Is Not Covered?

Like most insurance plans, this plan has exclusions. In addition, a reduction schedule may apply. Please see your benefits administrator or certificate for specific details. Accidental Death & Dismemberment insurance does not include payment for any loss which is caused by or contributed to by: physical or mental illness, diagnosis of or treatment of the illness; an infection, unless caused by an external wound accidentally sustained; suicide or attempted suicide; injuring oneself on purpose; the voluntary intake or use by any means of any drug, medication or sedative, unless taken as prescribed by a doctor or an over-the-counter drug taken as directed; voluntary intake of alcohol in combination with any drug, medication or sedative; war, whether declared or undeclared, or act of war, insurrection, rebellion or riot; committing or trying to commit a felony; any poison, fumes or gas, voluntarily taken, administered or absorbed; service in the armed forces of any country or international authority, except the United States National Guard; operating, learning to operate, or serving as a member of a crew of an aircraft; while in any aircraft for the purpose of descent from such aircraft while in flight (except for self preservation); or operating a vehicle or device while intoxicated as defined by the laws of the jurisdiction in which the accident occurs. Life and AD&D coverages are provided under a group insurance policy (Policy Form GPNP99 or G2130-S) issued to your employer by MetLife. Life and AD&D coverages under your employer’s plan terminates when your employment ceases when your Life and AD&D contributions cease, or upon termination of the group insurance policy. Should your life insurance coverage terminate for reasons other than non-payment of premium, you may convert it to a MetLife individual permanent policy without providing medical evidence of insurability. This summary provides an overview of your plan’s benefits. These benefits are subject to the terms and conditions of the contract between MetLife and your employer. Specific details regarding these provisions can be found in the certificate. If you have additional questions regarding the Life Insurance program underwritten by MetLife, please contact your benefits administrator or MetLife. Like most group life insurance policies, MetLife group policies contain exclusions, limitations, terms and conditions for keeping them in force. Please see your certificate for complete details. (1) Features may vary depending on jurisdiction. (2) Total disability or totally disabled means your inability to do your job and any other job for which you may be fit by education, training or experience, due to injury or sickness. Please note that this benefit is only available after you have participated in the Basic/Supplemental Term Life Plan for 1 year and it is only available to the employee. (3) When life expectancy is certified by a physician to be 12 months or less. The Accelerated Benefits Option (ABO) is subject to state availability and regulation. The ABO benefits are intended to qualify for favorable federal tax treatment in which case the benefits will not be subject to federal taxation. This information was written as a supplement to the marketing of life insurance products. Tax laws relating to accelerated benefits are complex and limitations may apply. You are advised to consult with and rely on an independent tax advisor about your own particular circumstances. Receipt of ABO benefits may affect your eligibility, or that of your spouse or your family, for public assistance programs such as medical assistance (Medicaid), Temporary Assistance to Needy Families (TANF), Supplementary Social Security Income (SSI) and drug assistance programs. You are advised to consult with social service agencies concerning the effect that receipt of ABO benefits will have on public assistance eligibility for you, your spouse or your family. (4) The Total Control Account (TCA) is provided for all Life and AD&D benefits of $5,000 or more. The TCA is not insured by the Federal Deposit Insurance Corporation or any government agency. The assets backing TCAs are maintained in MetLife’s general account and are subject to MetLife’s creditors. MetLife bears the investment risk of the assets backing the TCAs, and expects to receive a profit. Regardless of the investment experience of such assets, the interest credited to TCAs will never fall below the guaranteed minimum rate. Guarantees are subject to the financial strength and claims paying ability of MetLife. (5) The Seat Belt Benefit is payable if an insured person dies as a result of injuries sustained in an accident while driving or riding in a private passenger car and wearing a properly fastened seat belt _or a child restraint if the insured is a child_. In such case, his or her benefit can be increased by 10 percent of the Full Amount — but not less than $1,000 or more than $25,000.

L0615428011][All States][DC,GU,MP,PR,VI] Metropolitan Life Insurance Company, 200 Park Ave., New York, NY 10166

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

CANCER BENEFITS

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

Competitive advantages n Composite rates. n Four distinct plan levels, each featuring the same benefits with premiums and benefit

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

n Indemnity-based benefits pay exactly what’s listed for the selected plan level. n The plan’s Family Care Benefit provides a daily benefit when a covered dependent child

receives inpatient or outpatient cancer treatment.

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

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

Flexible family coverage options n Individual, Individual/Spouse, One-parent and Two-parent family policies. n Family coverage includes eligible dependent children (to age 26) for the same rate,

regardless of the number of children covered.

Attractive features n Available for businesses with 3+ eligible employees. n Broad range of policy issue ages, 17-75. n Each plan level features full schedule of 30+ benefits and three optional riders

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

n Benefits don’t coordinate with any other coverage from any other insurer. n HSA compliant. n Guaranteed renewable. n Portable. n Waiver of premium if named insured is disabled due to cancer for longer than 90

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

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

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

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

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

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

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

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

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

hospital for treatment of one of 34 specified diseases covered under the rider. 35

INDIVIDUAL CANCER INSURANCE

Cancer Assist Benefits Overview

Radiation/Chemotherapy

n Injected chemotherapy by medical personnel: $250-$1,000 once per calendar week n Radiation delivered by medical personnel: $250-$1,000 once per calendar week n Self-injected chemotherapy: $150-$400 once per calendar month n Topical chemotherapy: $150-$400 once per calendar month

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

n Chemotherapy by pump: $150-$400 once per calendar month n Oral hormonal chemotherapy (1-24 months): $150-$400 once per calendar month n Oral hormonal chemotherapy (25+ months): $75-$200 once per calendar month n Oral non-hormonal chemotherapy: $150-$400 once per calendar month

Anti-nausea Medication

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

Medical Imaging Studies

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

Outpatient Surgical Center

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

Skin Cancer Initial Diagnosis

$300-$600 payable once per lifetime

Surgical Procedures

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

Reconstructive Surgery

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

Anesthesia

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

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

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

Family Care

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

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

Home Health Care Services

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

Hospice Care

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

Transportation and Lodging

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

$0.50 per mile, up to $1,000-$1,500 per round trip

n Companion Transportation (for any companion, not just a family member) for commercial

travel when treatment is more than 50 miles from covered person’s home: $0.50 per mile, up to $1,000-$1,500 per round trip n Lodging for the covered person or any one adult companion or family member when treatment is more than 50 miles from the covered person’s home: $50-$80 per day, up to 70 days per calendar year

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

Benefits also included in each plan

Air Ambulance, Ambulance, Blood/Plasma/Platelets/Immunoglobulins, Bone Marrow or Peripheral Stem Cell Donation, Bone Marrow Donor Screening, Bone Marrow or Peripheral Stem Cell Transplant, Cancer Vaccine, Egg(s) Extraction or Harvesting/Sperm Collection and Storage (Cryopreservation), Experimental Treatment, Hair/External Breast/Voice Box Prosthesis, Private Full-time Nursing Services, Prosthetic Device/Artificial Limb, Skilled Nursing Facility, Supportive or Protective Care Drugs and Colony Stimulating Factors 36 INDIVIDUAL CANCER INSURANCE

Cancer Insurance Wellness Benefits

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

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

Cancer Wellness Tests

Health Screening Tests

■ Bone marrow testing

■ Blood test for triglycerides

■ Breast ultrasound

■ Carotid Doppler

■ CA 15-3 [blood test for breast cancer]

■ Echocardiogram [ECHO]

■ CA 125 [blood test for ovarian cancer]

■ Electrocardiogram [EKG, ECG]

■ CEA [blood test for colon cancer]

■ Fasting blood glucose test

■ Chest X-ray

■ Serum cholesterol test for HDL

and LDL levels

■ Colonoscopy ■ Flexible sigmoidoscopy

■ Stress test on a bicycle or treadmill

■ Hemoccult stool analysis ■ Mammography ■ Pap smear ■ PSA [blood test for prostate cancer] ■ Serum protein electrophoresis

[blood test for myeloma]

■ Skin biopsy ■ Thermography ■ ThinPrep pap test ■ Virtual colonoscopy

For more information, talk with your benefits counselor.

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

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

CANCER ASSIST WELLNESS – 101486

Level 1 Level 2 Level 3 Level 4 2 2 2 2 2 2 2 2 RI 6XUJLFDO 3URFHGXUHV %HQHILW $100 $160 $200 $240 $10,000 $10,000 $10,000 $10,000 2 2 2 2 $1,000 $1,000 $1,200 $1,500 $10,000 $12,500 $15,000 $15,000 $1,500 $2,000 $2,500 $3,000 30 days or twice the days confined $15,000 $15,000 $15,000 $15,000 70 70 70 70 $150 $250 $350 $450 $300 $600 $900 $1,200 $2,000 $3,000 $4,000 $6,000

Individual Cancer Insurance Description of Benefits 7KH SROLF\ DQG LWV ULGHUV PD\ KDYH DGGLWLRQDO H[FOXVLRQV DQG OLPLWDWLRQV )RU FRVW DQG FRPSOHWH GHWDLOV RI WKH FRYHUDJH VHH \RXU &RORQLDO /LIH EHQHILWV FRXQVHORU &RYHUDJH PD\ YDU\ E\ VWDWH DQG PD\ QRW EH DYDLODEOH LQ DOO VWDWHV &RYHUDJH LV GHSHQGHQW RQ DQVZHUV WR KHDOWK TXHVWLRQV $SSOLFDEOH WR SROLF\ IRUPV &DQ$VVLVW 1& DQG ULGHU IRUPV 5 &DQ$VVLVW,QG[ 1& 5 &DQ$VVLVW3URJ 1& DQG 5 &DQ$VVLVW6S'LV 1& Cancer Insurance Benefits Level 1 Level 2 Level 3 Level 4 5DGLDWLRQ &KHPRWKHUDS\ ,QMHFWHG FKHPRWKHUDS\ E\ PHGLFDO SHUVRQQHO SHU ZHHN 5DGLDWLRQ GHOLYHUHG E\ PHGLFDO SHUVRQQHO SHU ZHHN 6HOI ,QMHFWHG &KHPRWKHUDS\ SHU PRQWK 3XPS &KHPRWKHUDS\ SHU PRQWK 7RSLFDO &KHPRWKHUDS\ SHU PRQWK 2UDO +RUPRQDO &KHPRWKHUDS\ PRQWKV SHU PRQWK 2UDO +RUPRQDO &KHPRWKHUDS\ PRQWKV SHU PRQWK 2UDO 1RQ +RUPRQDO &KHPRWKHUDS\ SHU PRQWK 5HFRQVWUXFWLYH 6XUJHU\ SHU VXUJLFDO XQLW Maximum per procedure, including 25% for general $2,500 $2,500 $3,000 $3,000 6HFRQG 0HGLFDO 2SLQLRQ SHU OLIHWLPH 6NLOOHG 1XUVLQJ &DUH )DFLOLW\ SHU GD\ XS WR GD\V FRQILQHG 6NLQ &DQFHU ,QLWLDO 'LDJQRVLV SHU OLIHWLPH 6XSSRUWLYH 3URWHFWLYH &DUH 'UXJV &RORQ\ 6WLPXODWLQJ )DFWRUV SHU Maximum per year $400 $800 $1,200 $1,600 6XUJLFDO 3URFHGXUHV SHU VXUJLFDO XQLW Maximum per procedure $2,500 $3,000 $5,000 $6,000 7UDQVSRUWDWLRQ SHU PLOH Maximum per round trip $1,000 $1,000 $1,200 $1,500 :DLYHU RI 3UHPLXP <HV <HV <HV <HV Policy-Wellness Benefits %RQH 0DUURZ 'RQRU 6FUHHQLQJ SHU OLIHWLPH &DQFHU 9DFFLQH SHU OLIHWLPH 2QH DPRXQW SHU DFFRXQW RU 3DUW &DQFHU :HOOQHVV +HDOWK 6FUHHQLQJ SHU \HDU 3DUW &DQFHU :HOOQHVV +HDOWK 6FUHHQLQJ SHU \HDU 6DPH DV 3DUW Additional Riders may be available at an additional cost :$,7,1* 3(5,2' 7KH SROLF\ DQG LWV ULGHUV PD\ KDYH D ZDLWLQJ SHULRG :DLWLQJ SHULRG PHDQV WKH ILUVW GD\V IROORZLQJ WKH SROLF\¶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Ŷ ,I WKH GLDJQRVLV RU WUHDWPHQW RI FDQFHU LV UHFHLYHG RXWVLGH RI WKH WHUULWRULDO OLPLWV RI WKH 8QLWHG 6WDWHV DQG LWV SRVVHVVLRQV RU Ŷ )RU RWKHU FRQGLWLRQV RU GLVHDVHV H[FHSW ORVVHV GXH GLUHFWO\ IURP FDQFHU &RORQLDO /LIH $FFLGHQW ,QVXUDQFH &RPSDQ\ &ROXPELD 6& _ &RORQLDO /LIH LQVXUDQFH SURGXFWV DUH XQGHUZULWWHQ E\ &RORQLDO /LIH $FFLGHQW ,QVXUDQFH &RPSDQ\ IRU ZKLFK &RORQLDO /LIH LV WKH PDUNHWLQJ EUDQG 39

CANCER BENEFIT PREMIUMS LEVEL 1 - Composite Rates Employee

Employee/Spouse

One-Parent Family

Two-Parent Family

$9.13

$14.38

One-Parent Family

Two-Parent Family

$10.98

$17.08

One-Parent Family

Two-Parent Family

$13.55

$22.43

One-Parent Family

Two-Parent Family

$18.10

$30.00

One-Parent Family

Two-Parent Family

$0.88

$0.63

$0.88

$1.25

$0.80

$1.30

$3.90

$8.53

Level 1 with $100 Cancer Wellness/Health Screening 24-Pay Premium

$9.05

$14.30 LEVEL 2 - Composite Rates

Employee

Employee/Spouse

Level 2 with $100 Cancer Wellness/Health Screening 24-Pay Premium

$10.83

$16.93 LEVEL 3 - Composite Rates

Employee

Employee/Spouse

Level 3 with $100 Cancer Wellness/Health Screening 24-Pay Premium

$13.33

$22.20 LEVEL 4 - Composite Rates

Employee

Employee/Spouse

Level 4 with $100 Cancer Wellness/Health Screening 24-Pay Premium

$17.80

$29.70 OPTIONAL RIDERS

Employee

Employee/Spouse

Specified Disease Hospital Confinement Rider 24-Pay Premium

$0.63

Initial Diagnosis of Cancer Rider (per $1,000) 24-Pay Premium

$0.75

Initial Diagnosis of Cancer Progressive Payment Rider 24-Pay Premium

$3.90

$8.53

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

Critical Illness Insurance*

When life takes an unexpected turn due to a critical illness diagnosis, your focus should be on recovery — not finances. Our critical illness insurance helps provide financial support with a lump-sum benefit that you can use where you need it the most. Coverage amount: ____________________________

COVERED CRITICAL ILLNESS CONDITIONS

BENEFITS STORY

Sudden health crisis 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.

How Chris’ coverage helped

PERCENTAGE OF APPLICABLE COVERAGE AMOUNT

Coma

100%

End stage renal (kidney) failure

100%

Heart attack (myocardial infarction)

100%

Major organ failure requiring transplant

100%

Occupational human immunodeficiency virus (HIV) or hepatitis

100%

Permanent paralysis

100%

Stroke2

100%

Sudden cardiac arrest

100%

Coronary artery disease (major)

50%

Coronary artery disease (minor)

10%

Transient ischemic attack (TIA)

25%

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.

ICI6000 - CRITICAL ILLNESS

Reoccurrence of the same covered critical illness condition Key benefits

If you receive a benefit for the diagnosis of a critical illness and are later diagnosed with the same condition,3 25% of the coverage amount may be payable for that reoccurrence. Dates of diagnoses must be separated by more than 180 days.

• Available coverage for spouse and eligible dependents at 50% of your coverage amount 4

• Receive coverage regardless of medical history, within specified limits

Diagnosis of a different covered critical illness condition

• Works alongside your health savings account (HSA)

If you receive a benefit for the diagnosis of a critical illness and are later diagnosed with a different condition, 100% of the coverage amount may be payable for the subsequent condition. Dates of diagnoses must be separated by more than 180 days.

• Benefits payable regardless of other insurance

For more information about critical illness coverage, talk with your benefits counselor.

Covered conditions for dependent children 1

COVERED CONDITIONS

Behavioral health therapy benefit When recovering from a critical illness diagnosis, mental wellbeing can be as important as physical wellbeing. A benefit may be payable each day you receive behavioral health therapy for a covered loss.

PERCENTAGE OF APPLICABLE COVERAGE AMOUNT

Cerebral palsy

100%

Cleft lip or palate

100%

Congenital heart disease

100%

Cystic fibrosis

100%

Down syndrome

100%

Sickle cell anemia

100%

Spina bifida

100%

Type 1 diabetes

100%

• $50 payable up to a maximum of 15 days per insured per covered loss (up to two times per insured per calendar year). • Therapy must begin within 90 days after the covered loss, and all sessions must be received within 365 days of the covered loss.

An insured has a pre-existing condition if, within the 12 months just prior to the insured’s coverage effective date, they have an injury or sickness, whether diagnosed or not, for which:

* Critical Illness Insurance (ICI6000) is the marketing name of the insurance policy filed as “Individual Critical Illness Insurance Policy.” 1 Please refer to the policy for complete definitions of covered conditions.

• medical treatment, consultation, care or services, or diagnostic measures were received or recommended to be received during that period; or

2 In NH, the covered condition is called Severe Stroke. 3 Covered conditions that do not qualify include permanent paralysis, occupational human immunodeficiency virus (HIV) or hepatitis.

• drugs or medications were taken, or prescribed to be taken during that period; or

4 In LA and VA, includes domestic partner.

• symptoms existed. Pre-existing condition requirements are not applicable to children who are born or adopted while you are covered under this policy, and who are continuously covered from the date of birth or adoption.

THIS POLICY PROVIDES LIMITED BENEFITS. This coverage is a supplement to health insurance. It is not a substitute for essential health benefits or minimum essential coverage as defined in federal law. Insureds in some states must be covered by comprehensive health insurance before applying for this insurance.

The pre-existing condition provision applies to any insured’s initial coverage and any increases in coverage. Coverage effective date refers to the date initial coverage becomes effective.

EXCLUSIONS AND LIMITATIONS

We will not pay benefits for any covered loss that is caused by, contributed to by, or occurs as a result of felonies; intoxicants and narcotics; or war or combat. PRE-EXISTING CONDITION LIMITATION We will not pay benefits for a claim when the covered condition occurs in the first 12 months following an insured’s coverage effective date if the covered condition is caused by, contributed to by, or occurs as a result of any of the following: • a pre-existing condition; or • complications arising from treatment or surgery for, or medications taken for, a pre-existing condition.

Critical Illness and Cancer Insurance*

When life takes an unexpected turn due to a critical illness or cancer diagnosis, your focus should be on recovery — not finances. Our critical illness and cancer insurance helps provide financial support with a lump-sum benefit that you can use where you need it the most.

BENEFITS STORY

Support for care

Coma

100%

Rebecca was born with Down syndrome. Her parents’ critical illness and cancer coverage provided a benefit that can help cover expenses related to Rebecca’s care and her changing needs.

End stage renal (kidney) failure

100%

How their coverage helped

Heart attack (myocardial infarction)

100%

Major organ failure requiring transplant

100%

Occupational human immunodeficiency virus (HIV) or hepatitis

100%

Permanent paralysis

100%

Stroke

100%

Coverage amount: ____________________________ COVERED CRITICAL ILLNESS CONDITIONS

PERCENTAGE OF APPLICABLE COVERAGE AMOUNT

Sudden cardiac arrest

100%

Coronary artery disease (major)

50%

Coronary artery disease (minor)

10%

Transient ischemic attack (TIA)

25%

COVERED CANCER CONDITIONS

PERCENTAGE OF APPLICABLE COVERAGE AMOUNT

Invasive cancer (including all breast cancer)

100%

Non-invasive cancer

25%

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

For illustrative purposes only.

Skin cancer initial diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . $500 per lifetime

ICI6000 - CRITICAL ILLNESS AND CANCER

Reoccurrence of the same covered critical illness condition If you receive a benefit for the diagnosis of a critical illness and are later diagnosed with the same condition,3 25% of the coverage amount may be payable for that reoccurrence. Dates of diagnoses must be separated by more than 180 days.

Key benefits • Available coverage for spouse5 and eligible dependents at 50% of your coverage amount • Receive coverage regardless of medical history, within specified limits • Works alongside your health savings account (HSA) • Benefits payable regardless of other insurance

Diagnosis of a different covered condition If you receive a benefit for the diagnosis of a covered condition and are later diagnosed with a different condition, 100% of the coverage amount may be payable for the subsequent condition. Dates of diagnoses must be separated by more than 180 days.4

Reoccurrence of invasive cancer (including all breast cancer) If you receive a benefit for the diagnosis of an invasive cancer, an additional benefit of 25% may be payable upon reoccurrence if: • the new date of diagnosis is more than 180 days after the first diagnosis, and • there is no evidence of disease or treatment for at least 180 days immediately prior to the subsequent diagnosis.

Reoccurrence of non-invasive cancer If you receive a benefit for the diagnosis of a non-invasive cancer, an additional benefit of 25% may be payable upon reoccurrence if: • the new date of diagnosis is more than 180 days after the first diagnosis, and • there is no evidence of disease or treatment for at least 180 days immediately prior to the subsequent diagnosis.

Covered conditions for dependent children COVERED CONDITIONS 1

PERCENTAGE OF APPLICABLE COVERAGE AMOUNT

Cerebral palsy

100%

Cleft lip or palate

100%

Congenital heart disease

100%

Cystic fibrosis

100%

Down syndrome

100%

Sickle cell anemia

100%

Spina bifida

100%

Type 1 diabetes

100%

For more information, talk with your benefits counselor.

Behavioral health therapy benefit When recovering from a critical illness or cancer diagnosis, mental wellbeing can be as important as physical wellbeing. A benefit may be payable each day you receive behavioral health therapy for a covered loss. • $50 payable up to a maximum of 15 days per insured per covered loss (up to two times per insured per calendar year). • Therapy must begin within 90 days after the covered loss, and all sessions must be received within 365 days of the covered loss.

PRE-EXISTING CONDITION LIMITATION

*Critical Illness Insurance (ICI6000) is the marketing name of the insurance policy filed as “Individual Critical Illness Insurance Policy.”

We will not pay benefits for a claim when the covered condition occurs in the first 12 months following an insured’s coverage effective date if the covered condition is caused by, contributed to by, or occurs as a result of any of the following:

1 Please refer to the policy for complete definitions of covered conditions. 2 In NH, the covered condition is called Severe Stroke.

• a pre-existing condition; or

3 Covered conditions that do not qualify include permanent paralysis, occupational human immunodeficiency virus (HIV) or hepatitis. In addition, in GA, end stage renal (kidney) failure does not qualify.

• complications arising from treatment or surgery for, or medications taken for, a pre-existing condition. An insured has a pre-existing condition if, within the 12 months just prior to the insured’s coverage effective date, they have an injury or sickness, whether diagnosed or not, for which:

4 There is no required separation period between the date of diagnosis of invasive cancer (including all breast cancer), non-invasive cancer or skin cancer and any of the critical illnesses.

• medical treatment, consultation, care or services, or diagnostic measures were received or recommended to be received during that period; or

5 In LA and VA, includes domestic partner. THIS POLICY PROVIDES LIMITED BENEFITS.

• drugs or medications were taken, or prescribed to be taken during that period; or

This coverage is a supplement to health insurance. It is not a substitute for essential health benefits or minimum essential coverage as defined in federal law. Insureds in some states must be covered by comprehensive health insurance before applying for this insurance.

EXCLUSIONS AND LIMITATIONS We will not pay benefits for any covered loss that is caused by, contributed to by, or occurs as a result of felonies; intoxicants and narcotics; or war or combat.

The pre-existing condition provision applies to any insured’s initial coverage and any increases in coverage. Coverage effective date refers to the date initial coverage becomes effective.

GEOGRAPHICAL LIMITATION FOR CANCER

We will not pay the invasive cancer (including all breast cancer) benefit, non-invasive cancer benefit, or skin cancer benefit if the cancer is diagnosed or treated outside of the territorial limits of the United States, its possessions, or the countries of Canada and Mexico.

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 that can be used toward health care expenses or meeting day-to-day needs. Payable for each covered infectious disease, once per covered person per lifetime, if hospital confined for seven or more consecutive days for treatment of the infectious disease. These benefits are for you as well as your covered family members. PERCENTAGE OF APPLICABLE COVERAGE AMOUNT

COVERED INFECTIOUS DISEASES** 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%

Coronavirus disease 2019 (COVID-19)

50%

ICI6000 – INFECTIOUS DISEASES RIDER

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. Payable for each covered progressive disease if the covered person is unable to perform two or more activities of daily living1 or totally disabled2 for 90 or more continuous days. This benefit is for you as well as your covered family members. COVERED PROGRESSIVE DISEASES3

PERCENTAGE OF APPLICABLE COVERAGE AMOUNT

Amyotrophic lateral sclerosis (ALS)

50%

Addison’s disease

50%

Dementia (including Alzheimer’s disease)

50%

Functional loss4

50%

Huntington’s disease

50%

Lupus

50%

Multiple sclerosis (MS)

50%

Muscular dystrophy

50%

Myasthenia gravis (MG)

50%

Parkinson’s disease

50%

Systemic sclerosis (scleroderma)

50%

ICI6000 - PROGRESSIVE DISEASES RIDER

Critical Illness Insurance* Supplemental Conditions Rider

A critical illness can have life-altering effects that not only impact you physically, but financially as well. This rider provides a lump-sum benefit if you are diagnosed with a covered supplemental condition, so you can focus on your treatment, care and recovery. We will pay a benefit for each condition only once per covered person per lifetime. This benefit is for you as well as your covered family members. PERCENTAGE OF APPLICABLE COVERAGE AMOUNT

COVERED SUPPLEMENTAL CONDITIONS** Aggressive Crohn’s disease or severe ulcerative colitis

25%

Benign brain tumor

100%

Loss of hearing

100%

Loss of sight

100%

Loss of speech

100%

Pulmonary embolism

25%

Severe endometriosis

25%

ICI6000 - SUPPLEMENTAL CONDITIONS RIDER

Critical Illness Insurance* Wellbeing Assistance Benefit – Max

This benefit can help reduce the risk of serious illness through early detection of disease or other risk factors, giving you more protection from the unexpected. The wellbeing assistance benefit is available to you with critical illness coverage, as well as all your covered family members. Wellbeing assistance benefit . . . . . . . . . . . . . . . . . . . .$ ____________________ Payable once per covered person per calendar year • Annual physical (e.g., annual exams, sports physicals and well child visits) • Blood test for triglycerides • Bone marrow testing • BRCA1 or BRCA2 testing • Breast ultrasound • CA 15-3 (blood test for breast cancer) • CA 125 (blood test for ovarian cancer) • Carotid Doppler • CEA (blood test for colon cancer) • Chest X-ray • Colonoscopy • Echocardiogram (ECHO) • Electrocardiogram (EKG, ECG)

• Fasting blood glucose test • Flexible sigmoidoscopy • Hemoccult stool analysis • Immunizations • Mammography • Pap smear • PSA (blood test for prostate cancer)

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

• Serum cholesterol test for HDL and LDL levels • Serum protein electrophoresis (blood test for myeloma) • Skin cancer biopsy • Stress test on a bicycle or treadmill • Thermography • ThinPrep pap test • Virtual colonoscopy

ICI6000 – WELLBEING ASSISTANCE BENEFIT - MAX

CRITICAL ILLNESS BENEFIT PREMIUMS Plan 1- Critical Illness 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

24-Pay Premium

$0.11

$0.17

$0.11

$0.17

25-29

24-Pay Premium

$0.14

$0.22

$0.15

$0.23

30-34

24-Pay Premium

$0.19

$0.28

$0.20

$0.30

35-39

24-Pay Premium

$0.30

$0.45

$0.31

$0.47

40-44

24-Pay Premium

$0.40

$0.60

$0.42

$0.63

45-49

24-Pay Premium

$0.55

$0.83

$0.58

$0.88

50-54

24-Pay Premium

$0.71

$1.06

$0.75

$1.12

55-59

24-Pay Premium

$0.91

$1.40

$0.95

$1.47

60-64

24-Pay Premium

$1.16

$1.80

$1.22

$1.89

65-69

24-Pay Premium

$1.23

$2.02

$1.29

$2.12

70-74

24-Pay Premium

$1.33

$2.15

One-Parent Family $3.33

Two Parent Family $5.11

Welbeing Amount $100

$1.27 $2.05 Wellbeing Assistance Benefit Rates by wellbeing amount = 1 unit Named Employee & Insured Spouse $2.08 $3.20 24-Pay Premium

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

24-Pay Premium

$0.13

$0.20

$0.14

$0.22

25-29

24-Pay Premium

$0.19

$0.29

$0.20

$0.30

30-34

24-Pay Premium

$0.30

$0.47

$0.32

$0.49

35-39

24-Pay Premium

$0.51

$0.78

$0.54

$0.82

40-44

24-Pay Premium

$0.70

$1.07

$0.73

$1.12

45-49

24-Pay Premium

$0.88

$1.34

$0.92

$1.41

50-54

24-Pay Premium

$1.07

$1.62

$1.13

$1.70

55-59

24-Pay Premium

$1.30

$2.00

$1.37

$2.10

60-64

24-Pay Premium

$1.82

$2.81

$1.93

$2.95

65-69

24-Pay Premium

$1.94

$3.11

$2.05

$3.26

70-74

24-Pay Premium

$2.09

$3.30

One-Parent Family $3.33

Two Parent Family $5.11

Welbeing Amount $100

$1.98 $3.14 Wellbeing Assistance Benefit Rates by wellbeing amount = 1 unit Named Employee & Insured Spouse $2.08 $3.20 24-Pay Premium

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

EMPLOYEE BENEFITS SUMMARY | 50001843 CITY OF LINCOLNTON FOR ALL FULL TIME ACTIVE EMPLOYEES VOLUNTARY SHORT TERM DISABILITY

EMPLOYER CONTRIBUTION: 0%

AMOUNT OF COVERAGE: If you are age 69 or younger, you may purchase Voluntary Short Term Disability. You may purchase a benefit of up to 60% of your Basic Weekly Earnings in units of $10 to a maximum of $750 per week, less offsets for other income. Benefits begin on the 15th day of a covered disability resulting from an accident, and on the 15th day of a covered disability resulting from sickness, and are payable up to a maximum of 26 weeks for any one covered disability. Benefits reduce, based on your age, to 66 2/3% at age 65, and terminate when you are no longer eligible or when you reach age 70, whichever occurs first.

VOLUNTARY SHORT TERM DISABILITY (VSTD) is designed to provide partial income replacement should you become disabled as the result of sickness or injury. USAble Life will pay the weekly benefit if you become disabled while insured and are under the regular care of a physician due to sickness or injury; including pregnancy or complications of pregnancy.

VOLUNTARY SHORT TERM DISABILITY ALSO INCLUDES THE FOLLOWING:

• •

Recurrent Disability Waiver of Premium Benefit

Important Note If you are not actively at work on the date your insurance or any increase in insurance is scheduled to take effect, the coverage or increase in coverage will take effect on the day you return to active work. This benefit summary provides a very brief description of USAble Life’s insurance products. This is not an insurance policy and only the actual provisions of an issued policy control. USAble Life’s policies set forth the rights and obligations of covered persons and USAble Life. Please be aware that certain limitations and exclusions may apply, and certain coverage may reduce or terminate due to age or lack of eligibility. If you enroll and are approved for coverage, you will be furnished with a certificate of insurance. Please read your insurance documents carefully. This benefit summary was generated by USAble Life on 9/23/2020 at 9:49 AM and may not reflect changes recently submitted to USAble Life.

VSTD PREMIUMS | CITY OF LINCOLNTON PREMIUMS BASED ON 24 PAYROLL DEDUCTIONS PER YEAR Note: Employee may select any weekly benefit, in $10 increments, up to 60% of employee's weekly earnings. ANNUAL EARNINGS

BENEFIT UNITS

UNDER 50

50-59

60+

UP TO

$9,533.33

$100

$4.70

$6.90

$11.50

$9,533.34

$10,399.99

$110

$5.17

$7.59

$12.65

$10,400.00

$11,266.66

$120

$5.64

$8.28

$13.80

$11,266.67

$12,133.33

$130

$6.11

$8.97

$14.95

$12,133.34

$12,999.99

$140

$6.58

$9.66

$16.10

$13,000.00

$13,866.66

$150

$7.05

$10.35

$17.25

$13,866.67

$14,733.33

$160

$7.52

$11.04

$18.40

$14,733.34

$15,599.99

$170

$7.99

$11.73

$19.55

$15,600.00

$16,466.66

$180

$8.46

$12.42

$20.70

$16,466.67

$17,333.33

$190

$8.93

$13.11

$21.85

$17,333.34

$18,199.99

$200

$9.40

$13.80

$23.00

$18,200.00

$19,066.66

$210

$9.87

$14.49

$24.15

$19,066.67

$19,933.33

$220

$10.34

$15.18

$25.30

$19,933.34

$20,799.99

$230

$10.81

$15.87

$26.45

$20,800.00

$21,666.66

$240

$11.28

$16.56

$27.60

$21,666.67

$22,533.33

$250

$11.75

$17.25

$28.75

$22,533.34

$23,399.99

$260

$12.22

$17.94

$29.90

$23,400.00

$24,266.66

$270

$12.69

$18.63

$31.05

$24,266.67

$25,133.33

$280

$13.16

$19.32

$32.20

$25,133.34

$25,999.99

$290

$13.63

$20.01

$33.35

$26,000.00

$26,866.66

$300

$14.10

$20.70

$34.50

$26,866.67

$27,733.33

$310

$14.57

$21.39

$35.65

$27,733.34

$28,599.99

$320

$15.04

$22.08

$36.80

$28,600.00

$29,466.66

$330

$15.51

$22.77

$37.95

$29,466.67

$30,333.33

$340

$15.98

$23.46

$39.10

$30,333.34

$31,199.99

$350

$16.45

$24.15

$40.25

$31,200.00

$32,066.66

$360

$16.92

$24.84

$41.40

$32,066.67

$32,933.33

$370

$17.39

$25.53

$42.55

$32,933.34

$33,799.99

$380

$17.86

$26.22

$43.70

$33,800.00

$34,666.66

$390

$18.33

$26.91

$44.85

$34,666.67

$35,533.33

$400

$18.80

$27.60

$46.00

$35,533.34

$36,399.99

$410

$19.27

$28.29

$47.15

$36,400.00

$37,266.66

$420

$19.74

$28.98

$48.30

$37,266.67

$38,133.33

$430

$20.21

$29.67

$49.45

$38,133.34

$38,999.99

$440

$20.68

$30.36

$50.60

$39,000.00

$39,866.66

$450

$21.15

$31.05

$51.75

$39,866.67

$40,733.33

$460

$21.62

$31.74

$52.90

$40,733.34

$41,599.99

$470

$22.09

$32.43

$54.05

$41,600.00

$42,466.66

$480

$22.56

$33.12

$55.20

$42,466.67

$43,333.33

$490

$23.03

$33.81

$56.35

$43,333.34

$44,199.99

$500

$23.50

$34.50

$57.50

VSTD PREMIUMS | CITY OF LINCOLNTON

ANNUAL EARNINGS

BENEFIT UNITS

UNDER 50

50-59

60+

$44,200.00

$45,066.66

$510

$23.97

$35.19

$58.65

$45,066.67

$45,933.33

$520

$24.44

$35.88

$59.80

$45,933.34

$46,799.99

$530

$24.91

$36.57

$60.95

$46,800.00

$47,666.66

$540

$25.38

$37.26

$62.10

$47,666.67

$48,533.33

$550

$25.85

$37.95

$63.25

$48,533.34

$49,399.99

$560

$26.32

$38.64

$64.40

$49,400.00

$50,266.66

$570

$26.79

$39.33

$65.55

$50,266.67

$51,133.33

$580

$27.26

$40.02

$66.70

$51,133.34

$51,999.99

$590

$27.73

$40.71

$67.85

$52,000.00

$52,866.66

$600

$28.20

$41.40

$69.00

$52,866.67

$53,733.33

$610

$28.67

$42.09

$70.15

$53,733.34

$54,599.99

$620

$29.14

$42.78

$71.30

$54,600.00

$55,466.66

$630

$29.61

$43.47

$72.45

$55,466.67

$56,333.33

$640

$30.08

$44.16

$73.60

$56,333.34

$57,199.99

$650

$30.55

$44.85

$74.75

$57,200.00

$58,066.66

$660

$31.02

$45.54

$75.90

$58,066.67

$58,933.33

$670

$31.49

$46.23

$77.05

$58,933.34

$59,799.99

$680

$31.96

$46.92

$78.20

$59,800.00

$60,666.66

$690

$32.43

$47.61

$79.35

$60,666.67

$61,533.33

$700

$32.90

$48.30

$80.50

$61,533.34

$62,399.99

$710

$33.37

$48.99

$81.65

$62,400.00

$63,266.66

$720

$33.84

$49.68

$82.80

$63,266.67

$64,133.33

$730

$34.31

$50.37

$83.95

$64,133.34

$64,999.99

$740

$34.78

$51.06

$85.10

$65,000.00

OVER

$750

$35.25

$51.75

$86.25

Important Note: The above rates are subject to change. The rates shown here are meant as an illustration for you to determine the approximate deduction you may expect to see each paycheck. This is not part of an insurance policy and only the actual provisions of an issued policy control. USAble Life’s policies set forth the rights and obligations of covered persons and USAble Life. Please be aware that certain limitations and exclusions apply and that benefits may reduce or terminate. If you enroll for coverage, you will be provided with a certificate of insurance. Please read your certificate carefully.

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

ACCIDENT BENEFITS

Accident Insurance Preferred Plan

Our coverage includes:

If you are in an accident, your focus should be on recovery, not how you’re going to pay your bills. Colonial Life Accident Insurance can pay benefits directly to you to use however you like — from medical costs to everyday expenses — offering financial support when you need it.

• Benefits payable directly to you • No medical questions to qualify for coverage • Coverage for simple and complex injuries • Benefits payable regardless of other insurance • Worldwide coverage • Works alongside your Health Savings Account (HSA)

BENEFITS STORY

Jacob was running on the playground when he tripped and injured his hand. With Colonial Life accident benefits, Jacob’s parents were able to pay the annual deductible and co-payments.

JACOB’S ACCIDENT BENEFITS Jacob went to an urgent care facility and received immediate care.

Accident emergency treatment

$125

The doctor ordered an X-ray and discovered Jacob had fractured his hand.

• X-ray • Fracture (hand)

$30 $375

The doctor also found that Jacob had a cut on his hand.

Laceration (no stitches)

$30

Jacob was discharged with a splint.

Medical equipment (splint)

$30

Over the next several weeks, Jacob had three follow-up appointments with his doctor.

Accident follow-up treatment (3 visits)

$165

Total

$755

For illustrative purposes only for covered accidents. Beneﬁt amounts may vary and may not cover all expenses.

IAC4000 – PREFERRED PLAN

BENEFITS STORY

Olivia was driving to the store when she got into a car accident. Olivia’s accident benefits helped cover her annual deductible and co-payments. OLIVIA’S ACCIDENT BENEFITS Olivia arrived by ambulance at the nearest emergency room and received immediate care.

• Ambulance — ground or water • Accident emergency treatment • Injury due to auto accident

$200 $125 $250

The doctor ordered an X-ray and discovered Olivia had fractured her thigh (femur). He also ordered a CT scan of her head to check for a brain injury.

• X-ray • Medical imaging (CT) • Thigh fracture — femur (surgical)

$30 $200 $4,400

Olivia was admitted to the hospital for surgery on her leg. She was confined for three days.

• Hospital admission • Surgery (exploratory/arthroscopic) • Hospital confinement (3 days)

$1,000 $300 $750

Olivia had eight sessions of physical therapy to help regain the strength in her leg.

• Physical therapy (8 days) • Medical equipment (crutches)

$280 $100

Over the next several weeks, she had six follow-up appointments with her doctor.

Accident follow-up treatment (6 visits)

$330

Total

$7,965

For illustrative purposes only for covered accidents. Beneﬁt amounts may vary and may not cover all expenses.

Summary of Benefits Benefits are per covered person per covered accident unless stated otherwise.

Initial care

Dislocation — separated joint • Non-surgical — repair . . . . . . . . . . . . . . . . . . . . . . . $100–$2,250 Examples: elbow: $500 | ankle: $1,000 | hip: $2,250

Accident emergency treatment. . . . . . . . . . . . . . . . . . . . . . . . . $125 Hospital emergency room, urgent care facility or physician’s office

• Incomplete dislocation — or dislocation without anesthesia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25% (payable as a % of the applicable dislocation beneﬁt)

Accidental injury due to an automobile accident1 . . . . . . . . $250 Air ambulance2. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$2,000 Ambulance — ground or water2 . . . . . . . . . . . . . . . . . . . . . . . . $200

• Surgical — repair . . . . . . . . . . . . . . . . . . . . . . . . . . . .$200–$4,500 Examples: elbow: $1,000 | ankle: $2,000 | hip: $4,500

Observation room . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $150 per day (up to two days per calendar year)

Emergency dental work . . . . . . . . . . . . . . . . . . . . . . . . . . $100–$300 Dental extraction or dental crown, denture or implant

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

Common accidental injuries

Eye injury — with surgical repair or removal of a foreign object . . . . . . . . . . . . . . . . . . . . . . . . . . . . $200

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

Fracture — complete

Burn — skin graft . . . . . . . . . . . . . .50% of applicable burn benefit

• Non-surgical — repair . . . . . . . . . . . . . . . . . . . . . . . $250–$3,000 Examples: hand/foot: $375 | collarbone: $625 | leg: $1,000

Coma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $12,500 (lasting for seven or more consecutive days)

• Chip fracture . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25% (payable as a % of the applicable fracture beneﬁt )

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

• Surgical — repair . . . . . . . . . . . . . . . . . . . . . . . . . . . . $450–$5,000 Examples: hand/foot: $750 | collarbone: $1,250 | leg: $2,000

Follow-up care Accident follow-up treatment, including transportation/telemedicine . . . . . . . . . . . . . . . . . . . . . . . . . . . .$55 (up to six beneﬁts per covered person per covered accident and up to 12 beneﬁts per covered person per calendar year) Medical equipment • Tier 1. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $30 Arm sling, cane, medical ring cushion, neck brace or wrist/ankle splint • Tier 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$100 Bedside commode, cold therapy system (cryotherapy), crutches, leg brace, shower chair, walker or walking boot • Tier 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $200 Back brace, body jacket, continuous passive movement (CPM), halo, electric scooter, hospital bed (including rental), knee scooter, stair lift chair or wheelchair Medical imaging study — CT, CAT scan, EEG, EMG, MR or MRI. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $200 (one per calendar year) Pain management for epidural anesthesia — non-surgical . .$100 Post-traumatic stress disorder (PTSD) . . . . . . . . . . . . . . . . . $200 Prosthetic device/artificial limb Hearing-loss injuries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$120

• One . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $750

Knee cartilage — torn — with surgical repair . . . . . . . . . . . . . $650

• More than one . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $1,500

Laceration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $30–$600 (based on repair and length)

• Repair/replacement4 . . . . . . . . . . . . . . . . . . . . . . . . . . $375/$750

Rehabilitation unit confinement . . . . . . . . . . . . . . . . $150 per day (up to 15 days, not to exceed 30 days per calendar year)

Ruptured disc — with surgical repair . . . . . . . . . . . . . . . . . . . $750 Tendon/ligament/rotator cuff — with surgical repair

Therapy — occupational, physical or speech . . . . . . $35 per day (up to 10 days)

• One . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $650 • Two or more . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $1,300

Accidental dismemberment

Hospital care

Accidental dismemberment . . . . . . . . . . . . . . . . . . $4505–$20,000 • Loss, loss of use or paralysis – hand, arm, foot, leg, sight of eye • Loss, loss of use – ﬁnger, toe, partial dismemberment of ﬁnger or toe

Hospital admission . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $1,000 Hospital confinement . . . . . . . . . . . . . . . . . . . . . . . . . $250 per day (up to 365 days)

Accidental dismemberment due to a catastrophic accident

Hospital sub-acute intensive care unit confinement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $325 per day (up to 30 days)

• Named insured, spouse or child . . . . . . . . . . . . . . . . . .$25,0006 • Total and irrecoverable loss, loss of use or paralysis – 180-day elimination period • Loss of both hands, arms, feet, legs or the sight of both eyes; or any combination; or • Loss of hearing in both ears, or loss of ability to speak

Intensive care unit admission . . . . . . . . . . . . . . . . . . . . . . . .$2,000 Intensive care unit confinement . . . . . . . . . . . . . . . . $450 per day (up to 15 days)

Surgical care

Accidental death

Blood/plasma/platelets — transfusion . . . . . . . . . . . . . . . . . $300

Accidental death

Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $200–$1,500 (based on type of repair and surgery)

• Named insured, spouse . . . . . . . . . . . . . . . . . . . . . . . . . . $40,000 • Child . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$10,000

Transportation and lodging

Accidental death common carrier Examples of common carriers are mass transit trains, buses and planes

Transportation for hospital confinement . . $600 per round trip (up to three round trips, 50+ miles from home)

• Named insured, spouse . . . . . . . . . . . . . . . . . . . . . . . . . .$160,000

Lodging–companion . . . . . . . . . . . . . . . . . . . . . . . . . . $125 per day (up to 30 days)

• Child . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $30,000

For more information, contact your Colonial Life benefits counselor.

professional sports, sickness, suicide or injuries which any covered person intentionally does to himself, war or armed conflict. In addition, we will not pay Accidental Dismemberment Due to Catastrophic Accident benefits for injuries a child sustains during birth, or for injuries that are the result of intoxication or use of narcotics.

1 Requires transportation by a licensed professional air ambulance or ambulance (ground or water). 2 In Nevada, air ambulance or ambulance: We will pay this benefit directly to the provider unless the air ambulance or ambulance bill shows that all charges have been paid in full.

STATE VARIATIONS FOR EXCLUSIONS AND LIMITATIONS

3 One benefit for each injured ear per covered person per lifetime.

IL: Also includes “aviation.” Not applicable to “hazardous avocations, racing, semi-professional or professional sports.”

4 One repair or replacement per prosthetic device/artificial limb per covered person per lifetime.

MT: Not applicable to “suicide or injuries which you intentionally do to yourself” and “injuries a child sustains during birth.”

5 In Maine, the minimum benefit for full dismemberment of finger or toe is $1,000.

NV: Not applicable to “intoxicants and narcotics.”

6 Payable once per lifetime per covered person.

OK: Not applicable to “hazardous avocations, racing and semiprofessional or professional sports.” For Accidental Dismemberment Due to Catastrophic Accidents, replace “injuries a child sustains during birth, or for injuries that are the result of intoxication” with “alcoholism or drug addiction, or narcotics.”

UT: Also includes “aviation.” Not applicable to “hazardous avocations, racing, semi-professional or professional sports.”

EXCLUSIONS We will not pay benefits for losses that are caused by, contributed to by or occur as the result of a covered personʼs felonies or illegal occupations, hazardous avocations, racing, semi-professional or

Underwritten by Colonial Life & Accident Insurance Company, Columbia, SC. © 2024 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

8-24 | 101776-6

Accident Insurance Active Lifestyles Benefit

This benefit increases the amount you receive by 20% for your covered eligible benefits, giving you more financial protection for the unexpected. The active lifestyles benefit is available to you with accident coverage, as well as all your covered family members.

Example of a benefits calculation

Eligible benefits1

$2,500

Eligible beneﬁts

$2,500

Eligible beneﬁt amount

x 20%

Active lifestyles beneﬁt

$500

Active lifestyles beneﬁt calculation

$2,500

Eligible beneﬁt amount

+ $500

Active lifestyles beneﬁt

• Concussion • Dislocation • Emergency dental work • Eye injuries • Fractures • Knee cartilage (torn) • Laceration • Medical imaging study • Ruptured disc with surgical repair • Surgery ‐ cranial, open abdominal, thoracic/hernia

$3,000

‐ exploratory and arthroscopic

Total

• Tendon/ligament/rotator cuff with surgical repair • X-ray

For illustrative purposes only

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

IAC4000 – ACTIVE LIFESTYLES BENEFIT

1 Active lifestyles benefit applies to any combination of these injuries or services due to a covered accident. HEALTH SAVINGS ACCOUNT (HSA) COMPATIBLE This plan is compatible with HSA guidelines and any other HSA plan in which a covered family member may participate. It may also be offered to employees who do not have HSAs. THIS POLICY PROVIDES LIMITED BENEFITS. This coverage is a supplement to health insurance. It is not a substitute for essential health benefits or minimum essential coverage as defined in federal law. Insureds in some states must be covered by comprehensive health insurance before applying for this coverage. ADDITIONAL DISCLOSURES FOR KENTUCKY Eligibility for benefits: We will pay benefits for a covered accident if any covered person sustains an injury as a result of a covered accident if: • the covered accident occurs while the policy is in force; • the covered accident occurs on or after the policy coverage effective date; • the covered accident is an accident type listed on the policy schedule; and • the covered accident is not excluded by name or specific description in the policy. Noncancellable: This policy is noncancellable. We have no right to change the premiums we charge on this policy. Any riders attached to this policy may be subject to a change in premium. The premium can be changed following the approval of the Commissioner of Insurance only if we change it on all riders of the same kind in force in the state where the policy was issued. What is not covered by this policy: We will not pay benefits for losses that are caused by, contributed to by or occur as a result of the covered person’s felonies or illegal occupations, hazardous avocations, racing, semi-professional or professional sports, sickness or injuries which any covered person intentionally does to himself, war or armed conflict. In addition, we also will not pay the Accidental Dismemberment due to Catastrophic Accident benefit for injuries that are caused by or are the result of birth or intoxicants, narcotics and hallucinogencis. 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 form IAC4000 (including state abbreviations where used, for example: IAC4000-TX). For cost and complete details of coverage, call or write your Colonial Life benefits counselor or the company. An insurance producer may contact you. Underwritten by Colonial Life & Accident Insurance Company, Columbia, SC. © 2024 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

3-24 | 101778-3

Accident Insurance Sickness Hospital Confinement Rider

These beneﬁts can help with medical costs related to a hospital stay for a covered sickness, including costs that your health insurance may not cover, such as co-pays and deductibles. The sickness hospital conﬁnement rider is optional coverage available to you and all your covered family members. Daily sickness hospital confinement . . . . . . . . . . . . . . . . . . . . . . . $100 per day

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

Up to 30 days per covered person per confinement for a covered sickness Re-confinement for the same or related condition within 90 days of discharge is considered a continuation of a previous confinement.

IAC4000 – SICKNESS HOSPITAL CONFINEMENT RIDER

HEALTH SAVINGS ACCOUNT (HSA) COMPATIBLE This plan is compatible with HSA guidelines and any other HSA plan in which a covered family member may participate. It may also be offered to employees who do not have HSAs. THIS POLICY PROVIDES LIMITED BENEFITS. This coverage is a supplement to health insurance. It is not a substitute for essential health benefits or minimum essential coverage as defined in federal law. Insureds in some states must be covered by comprehensive health insurance before applying for this coverage. EXCLUSIONS AND LIMITATIONS We will not pay benefits for losses that are caused by, contributed to by or occur as the result of accidental injuries, alcoholism or drug addiction, dental procedures, elective procedures and cosmetic surgery, felonies or illegal occupations, psychiatric or psychological conditions, intoxicants and narcotics, psychiatric or psychological conditions, suicide or injuries which you intentionally do to yourself, war or armed conflict and well baby care. PRE-EXISTING CONDITION LIMITATION Pre-existing condition means a sickness or physical condition, whether diagnosed or not, for which a covered person was treated, had medical testing, received medical advice, or had taken medication within 12 months before the rider coverage effective date shown on the rider schedule. After this rider has been in force for 12 months from the rider coverage effective date shown on the rider schedule, we will pay benefits as stated in the rider for any loss as the result of a pre-existing condition not excluded by name or specific description if the covered loss began at least 12 months after the rider coverage effective date. STATE VARIATIONS FOR EXCLUSIONS AND LIMITATIONS AK: Replace “alcoholism or drug addiction” with “intoxicants or narcotics.” DE: Replace “alcoholism or drug addiction” with “substance abuse.” FL: Replace “psychiatric or psychological conditions” with “mental or nervous disorders.” IL: Pre-existing Condition Limitation definition also includes “produced symptoms.” LA: Replace “alcoholism or drug addiction” with “intoxicants and narcotics.” ME: Pre-existing Condition Limitation definition does not include “had taken medication.” MO: Replace “alcoholism or drug addiction” with “substance abuse.” MT: Pre-existing Condition Limitation definition does not include “whether diagnosed or not” or “had medical testing.” NC: Pre-existing Conditions Limitation definition also includes “If a covered person is 65 or older when this policy is issued, pre-existing conditions for that covered person will include only conditions specifically eliminated by rider.” OK: Replace “psychiatric or psychological conditions” with “mental or emotional conditions.” SC: Replace “psychiatric or psychological conditions” with “mental or emotional disorders.” SD: Not applicable to “alcoholism or drug addiction.” UT: Replace “psychiatric or psychological conditions” with “mental or nervous disorders.” VT: Not applicable to “alcoholism or drug abuse, psychiatric or psychological conditions, well baby care,” or the limitation for giving birth within the first nine months after the rider coverage effective date. ADDITIONAL DISCLOSURES FOR THE STATE OF KENTUCKY Eligibility for Benefits: We will pay the benefits for a covered accident if any covered person sustains an injury as a result of a covered accident if: • The covered accident occurs while the policy is in force; • The covered accident occurs on or after the policy coverage effective date; • The covered accident is on an accident type listed on the policy schedule; and • The covered accident is not excluded by name or specific description in the policy. What is not covered by this policy: We will not pay benefits for losses that are caused by, contributed to by or occurs as a result of the covered person’s felonies or illegal occupations, hazardous avocations, racing, semi-professional or professional sports, sickness or injuries which any covered person intentionally does to himself, war or armed conflict. In addition, we also will not pay the Accidental Dismemberment due to Catastrophic Accident benefit for injuries that are caused by or are the result of birth or intoxicants, narcotics, and hallucinogenics. Termination of this Rider: This rider will terminate on the earliest of: the date the policy to which this rider is attached terminates; the date premium for this rider is not paid by the end of the grace period; or the date we receive your written request to terminate this rider. Noncancellable: This policy is noncancellable. We have no right to change the premiums we charge on this policy. Any riders attached to this policy may be subject to a change in premium. The premium can be changed following the approval of the Commissioner of Insurance only if we change it on all riders of the same kind in force in the state where the policy was issued. 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 form IAC4000 and rider form R-SHC4000 (including state abbreviations where used, for example: IAC4000-AL). 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.

ColonialLife.com

© 2024 Colonial Life & Accident Insurance Company. All rights reserved. Colonial Life is a registered trademark and marketing brand of Colonial Life & Accident Insurance Company. FOR EMPLOYEES 3-24 | 101785-5

Accident Insurance Wellbeing Assistance Standard Benefit

This benefit can help reduce the risk of serious illness through early detection of disease or other risk factors, giving you more protection from the unexpected. Wellbeing assistance standard . . . . . . . . . . . . . . . . . . . . . .$____________________ Payable once per covered person per calendar year; subject to a 30-day waiting period1 • Blood test for triglycerides

• Hemoccult stool analysis

• Bone marrow testing

• Mammography

• Breast ultrasound

• Pap smear2

• CA 15-3 (blood test for breast cancer)

• PSA (blood test for prostate cancer)

• CA 125 (blood test for ovarian cancer)

• Serum cholesterol test for HDL and LDL levels

• Carotid Doppler • CEA (blood test for colon cancer)

• Serum protein electrophoresis (blood test for myeloma)

• Chest X-ray

• Skin cancer biopsy

• Colonoscopy

• Stress test on a bicycle or treadmill

• Echocardiogram (ECHO) • Electrocardiogram (EKG, ECG) • Fasting blood glucose test • Flexible sigmoidoscopy

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

• Thermography • ThinPrep pap test2 • Virtual colonoscopy

IAC4000 – WELLBEING ASSISTANCE STANDARD BENEFIT

1 No waiting period in ID, MD, MO, VA and VT. 2 In WV only, benefit is also payable for human papillomavirus screening test. THIS POLICY PROVIDES LIMITED BENEFITS . This coverage is a supplement to health insurance. It is not a substitute for essential health benefits or minimum essential coverage as defined in federal law. Insureds in some states must be covered by comprehensive health insurance before applying for this coverage. EXCLUSIONS FOR ARIZONA We will not pay benefits for losses that are caused by, contributed to by or occur as the result of a covered personʼs felonies or illegal occupations, hazardous avocations, racing, semi-professional or professional sports, sickness, suicide or injuries which any covered person intentionally does to himself, war or armed conflict. In addition, we will not pay Accidental Dismemberment Due to Catastrophic Accident benefit for injuries a child sustains during birth, or for injuries that are the result of intoxication or use of narcotics. ADDITIONAL DISCLOSURES FOR KENTUCKY Waiting Period: Waiting period means the first 30 days following each covered person’s coverage effective date during which no benefits are payable. Eligibility for Benefits: We will pay the benefits for a covered accident if any covered person sustains an injury as a result of a covered accident if: • The covered accident occurs while the policy is in force; • The covered accident occurs on or after the policy coverage effective date; • The covered accident is on an accident type listed on the policy schedule; and • The covered accident is not excluded by name or specific description in the policy. What is not covered by this policy: We will not pay benefits for losses that are caused by, contributed to by or occurs as a result of the covered person’s felonies or illegal occupations, hazardous avocations, racing, semi-professional or professional sports, sickness or injuries which any covered person intentionally does to himself, war or armed conflict. In addition, we also will not pay the Accidental Dismemberment due to Catastrophic Accident benefit for injuries that are caused by or are the result of birth or intoxicants, narcotics, and hallucinogencis. Noncancellable: This policy is noncancellable. We have no right to change the premiums we charge on this policy. Any riders attached to this policy may be subject to a change in premium. The premium can be changed following the approval of the Commissioner of Insurance only if we change it on all riders of the same kind in force in the state where the policy was issued. 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 form IAC4000 (including state abbreviations where used, for example: IAC4000-TX). For cost and complete details of coverage, call or write your Colonial Life benefits counselor or the company. An insurance producer may contact you. Underwritten by Colonial Life & Accident Insurance Company, Columbia, SC. © 2024 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

6-24 | 101781-5

ACCIDENT BENEFIT PREMIUMS Preferred with Active Lifestyles - On/Off-Job Accident Coverage and Standard $100 Wellbeing Assistance

24-Pay Premium Named Insured

$13.56

Employee & Spouse

$20.76

Spouse Only

$13.56

Dependent Only

$13.56

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

2027 STATE HEALTH PLAN COMPARISON ACTIVE and NON-MEDICARE Subscribers STANDARD PPO Plan Non Preferred

Out of Network

Preferred

Access

$5,000 Ind $15,000 Ind $15,000 Fam $45,000 Fam

$1,000 Ind $3,000 Fam

$1,500 Ind $4,500 Fam

$12,000 Ind $4,000 Ind $6,500 Ind ACA LIMIT $36,000 Ind $12,000 Fam $16,300 Fam $24,000 Fam $72,000 Fam

$3,000 Ind $9,000 Fam

$5,000 Ind $10,000 Ind $30,000 Ind $15,000 Fam $20,000 Fam $60,000 Fam

Preferred

Access

Annual Deductible

$1,500 Ind $4,500 Fam

$3,000 Ind $9,000 Fam

Out-of-Pocket Maximum

(combined medical & pharmacy)

PLUS PPO Plan Non Preferred

Out of Network

$4,000 Ind $12,000 Ind $12,000 Fam $36,000 Fam

ACA LIMIT

In-Network (deducitble & OOP max cross-accumulates)

MEDICAL BENEFITS $0 Preventive Services

Preventive

$0 Preventive Services

Primary Care Provider (PCP)

$15 Preferred PCP listed on ID card $40 other PCP listed on ID card $50 other PCP

50% after deductible

$10 PCP Preferred PCP listed on ID card $30 other PCP listed on ID card $40 other PCP

40% after deductible

Walk-In Clinic

$40 other PCP on ID card $50 other PCP

50% after deductible

$30 other PCP on ID card $40 other PCP

40% after deductible

Specialist

$40

30% after deductible

$65

50% after deductible

$25

20% after deductible

$50

40% after deductible

Behavioral Health

$15

50% after deductible

$10

40% after deductible

Speech, Occupational, Chiropractic, Physical Therapy

$62

50% after deductible

$42

40% after deductible

High-Cost Imaging

$400

30% after deductible

$1,000, then 30% after ded

50% after deductible

$250

20% after deductible

$500, then 20% after ded

Urgent Care

$100

$70

Emergency Room

$600, then 30% after deductible (copay waived with admission)

$500, then 20% after deductible (copay waived with admission)

40% after deductible

Inpatient Hospital

$750

$600, then $1,500, then 30% after ded 30% after ded

50% after deductible

$500

$500, then $1,000, then 20% after ded 20% after ded

40% after deductible

Outpatient Surgery

$600

$350, then $1,000, then 30% after ded 30% after ded

50% after deductible

$300

$300, then $500, then 20% after ded 20% after ded

40% after deductible

Ambulatory Surgical Center

$400

50% after deductible

$250

Lantern

30% after deductible

$1,000, then 30% after ded

Lantern Surgical Benefit $0 Member Cost 70

20% after deductible

$500, then 20% after ded

40% after deductible

Lantern Surgical Benefit $0 Member Cost

2027 STATE HEALTH PLAN COMPARISON ACTIVE and NON-MEDICARE Subscribers STANDARD PPO Plan

PLUS PPO Plan

PHARMACY BENEFITS Rx Tier 1

$25

$15

Rx Tier 2

$75

$55

Rx Tier 3

Deductible / Coinsurance

Rx Tier 4

$200

$100

Rx Tier 5

$600

$500

Rx Tier 6

Deductible / Coinsurance

Preferred Blood Glucose Meters and Supplies*

$10*

$5*

Preferred & Non-Preferred Insulin

Preventive Medications

Rx copays for 30-day supply.

*This does not include Continuous Glucose Monitoring Systems or associated supplies. These are considered a Tier 2 member copay.

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

MEDICAL BRIDGE BENEFITS

Hospital Confinement Indemnity Insurance Plan 2

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

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

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

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

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

For more information, talk with your benefits counselor.

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

Tier 1 outpatient surgical procedures Breast

Gynecological

– Axillary node dissection – Breast capsulotomy – Lumpectomy

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

Cardiac

Liver

– Pacemaker insertion

– Paracentesis

Digestive

Musculoskeletal system

– Colonoscopy – Fistulotomy – Hemorrhoidectomy – Lysis of adhesions

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

Skin – Laparoscopic hernia repair – Skin grafting

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

IMB7000 – PLAN 2

Tier 2 outpatient surgical procedures Breast

Gynecological

– Breast reconstruction – Breast reduction

– Hysterectomy – Myomectomy

Cardiac

Musculoskeletal system

– Angioplasty – Cardiac catheterization

Digestive – Exploratory laparoscopy – Laparoscopic appendectomy – Laparoscopic cholecystectomy

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

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

Thyroid – Excision of a mass

Urologic

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

– Lithotripsy

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

5-18 | 101578-1-NC

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

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

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

Waiver of premium

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

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

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

For more information, talk with your benefits counselor.

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

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

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

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

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

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

Tier 1 outpatient surgical procedures Breast

Gynecological

Cardiac

Liver

Digestive

Musculoskeletal system

– Axillary node dissection – Breast capsulotomy – Lumpectomy

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

– Pacemaker insertion

– Paracentesis

– Colonoscopy – Fistulotomy – Hemorrhoidectomy – Lysis of adhesions

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

Skin

– Laparoscopic hernia repair – Skin grafting

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

Tier 2 outpatient surgical procedures Breast

Gynecological

Cardiac

Musculoskeletal system

– Breast reconstruction – Breast reduction

– Hysterectomy – Myomectomy

– Angioplasty – Cardiac catheterization

Digestive

– Exploratory laparoscopy – Laparoscopic appendectomy – Laparoscopic cholecystectomy

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

Thyroid

– Excision of a mass

Eye

ColonialLife.com

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

Urologic

– Lithotripsy

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

7-15 | 101581-NC

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

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

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

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

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

For more information, talk with your benefits counselor.

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

ColonialLife.com

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

IMB7000 – HEALTH SCREENING BENEFIT | 2-15 | 101579

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

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

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

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

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

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

For more information, talk with your benefits counselor.

Maximum of two visits per covered person per calendar year

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

THIS POLICY PROVIDES LIMITED BENEFITS. EXCLUSIONS

ColonialLife.com

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

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

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

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

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

For more information, talk with your benefits counselor.

EXCLUSIONS

ColonialLife.com

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

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

MEDICAL BRIDGE BENEFIT PREMIUMS INDIVIDUAL MEDICAL BRIDGE Plan 2 Named Insured

Hospital Confinement Medical Treatment Pkg $100 Health Screening Outpatient Surgical Procedure

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

24-Pay Premium 24-Pay Premium 24-Pay Premium 24-Pay Premium

Level 3

Level 4

$1,500.00

$2,000.00

Option 2 Tier 1 $750 Tier 2 $1,500 CY Max $2,500 $19.18 $25.13 $31.95 $45.20

Option 2 Tier 1 $750 Tier 2 $1,500 CY Max $2,500 $23.23 $30.65 $39.45 $56.23

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

24-Pay Premium 24-Pay Premium 24-Pay Premium 24-Pay Premium 24-Pay Premium 24-Pay Premium 24-Pay Premium 24-Pay Premium

$3.32 $3.53 $3.79 $3.99 $4.59 $5.86 $8.09 $11.68

$5.30 $5.83 $6.47 $6.98 $8.46 $11.65 $17.22 $26.20

$5.11 $5.11 $5.63 $7.02 $9.31 $12.79 $18.19 $26.98

$8.21 $8.21 $9.25 $12.04 $16.63 $23.58 $34.38 $51.96

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

24-Pay Premium 24-Pay Premium 24-Pay Premium 24-Pay Premium 24-Pay Premium 24-Pay Premium 24-Pay Premium 24-Pay Premium

$3.36 $3.56 $3.85 $4.12 $4.84 $6.34 $9.03 $13.42

$5.39 $5.91 $6.62 $7.29 $9.11 $12.85 $19.57 $30.55

$5.27 $5.27 $5.79 $7.71 $10.90 $15.79 $23.17 $36.00

$8.54 $8.54 $9.59 $13.42 $19.79 $29.58 $44.33 $70.00

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. 86

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 24-Pay Premium 24-Pay Premium 24-Pay Premium 24-Pay Premium 24-Pay Premium 24-Pay Premium

$10,000.00 $4.67 $5.50 $6.76 $8.48 $11.21 $15.59

$25,000.00 $11.68 $13.76 $16.90 $21.19 $28.01 $38.98

$50,000.00 $23.36 $27.52 $33.79 $42.38 $56.02 $77.96

$100,000.00 $46.71 $55.04 $67.59 $84.75 $112.04 $155.92

$150,000.00 $70.07 $82.57 $101.38 $127.13 $168.07 $233.88

$100,000.00 $43.00 $49.50 $58.59 $70.75 $89.13 $114.75 $153.67 $205.92

$150,000.00 $64.50 $74.25 $87.88 $106.13 $133.69 $172.13 $230.50 $308.88

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

Pay Premium 24-Pay Premium 24-Pay Premium 24-Pay Premium 24-Pay Premium 24-Pay Premium 24-Pay Premium 24-Pay Premium 24-Pay Premium

$10,000.00 $4.30 $4.95 $5.86 $7.08 $8.92 $11.48 $15.37 $20.59

$25,000.00 $10.75 $12.38 $14.65 $17.69 $22.28 $28.69 $38.42 $51.48

$50,000.00 $21.50 $24.75 $29.29 $35.38 $44.57 $57.38 $76.84 $102.96

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

Colonial Life for Policyholders Portal A faster, simpler way to manage your beneﬁts

THE PORTAL OFFERS YOU: Faster service than calling/emailing Conﬁrmation when a claim has been submitted

Colonial Life for Policyholders is an online portal created with you in mind. It’s the most convenient and efficient way to ﬁle a claim and manage your beneﬁts.

Here’s what you can do on Colonial Life for Policyholders:

Simpliﬁed bill payment and management Answers to frequently asked questions and live chat assistance if you don’t see what you are looking for.

LEARN MORE Find out how simple your claims and beneﬁts experience can be by learning more about the Colonial Life for Policyholders portal. Just visit ColonialLife.com to see what this online account administration platform can do for you.

File claims with a simple, guided form

Set up direct deposit for approved payments

View claim status or policy details anytime

Opt for instant alerts by email or text

Update your personal info & preferences

BECOME A MEMBER TODAY: 1

Go to ColonialLife .com/access to register.

Click “create an account”, ﬁll out the required information and click Submit.

Enjoy faster service and improved beneﬁts awareness.

NEED TO FILE A CLAIM? Filing online means never waiting for mail or dealing with fax machines and complex paper forms . Our guided question wizard walks you through the process and checks for missing information that could cause delays. Opting for direct deposit can also get approved payments to you up to a week faster than paper check.

AFTER YOU FILE: Check your claim status by logging into your account at ColonialLife .com/access. You can also sign up for text or email alerts so you know instantly if status changes or more information is needed. For your convenience, you can login anytime with a mobile device to photograph and upload documents with your camera.

Colonial Life products are underwritten by Colonial Life & Accident Insurance Company, Columbia, SC. ©2022 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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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 re- disclose the information unless permitted or required by those laws. Re-disclosed information may no longer be protected by federal privacy 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 (Social Security (Signature) (Date Signed) subject to this disclosure) Number) If applicable, I signed on behalf of the proposed insured as ____________________(indicate relationship). If legal Guardian, Power of Attorney Designee, or Conservator. ______________________________ (Printed name of legal representative)

____________________________ (Signature of legal representative)

UW Authorization

____________ (Date Signed) 62891-1

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 City of Lincolnton 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.

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:

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

When is COBRA continuation coverage available?

• 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: Patti Lofland at City of Lincolnton. 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, or a second qualifying event during the initial period of coverage,

COBRA CONTINUATION OF COVERAGE may permit a beneficiary to receive a maximum of 36 months of coverage.

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.

For more information visit https://www.medicare.gov/medicare-and-you.

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

If you have questions: Questions concerning your Plan or your COBRA continuation coverage rights should be addressed to the contact or contacts identified below. For more information about your rights under the Employee Retirement Income Security Act (ERISA), including COBRA, the Patient Protection and Affordable Care Act, and other laws affecting group health plans, contact the nearest Regional or District Office of the U.S. Department of Labor’s Employee Benefits Security Administration (EBSA) in your area or visit www.dol.gov/ebsa. (Addresses and phone numbers of Regional and District EBSA Offices are available through EBSA’s website.) For more information about the Marketplace, visit www.HealthCare. gov. Keep your Plan informed of address changes: To protect your family’s rights, let the Plan Administrator know about any changes in the addresses of family members. You should also keep a copy, for your records, of any notices you send to the Plan Administrator. Plan Contact Information City of Lincolnton ATTN: Leigh Bogdany P.O. Box 617 Lincolnton, NC 28093 Phone: (704) 736-8980

FSA COBRA Administrator: Ameriflex 2508 Highlander Way, Suite 200 Carrollton, TX 75006 Fax: 609-257-0136

• The month after your employment ends; or • The month after group health plan coverage based on current employment ends. If you don’t enroll in Medicare and elect COBRA continuation coverage instead, you may have to pay a Part B late enrollment penalty and you may have a gap in coverage if you decide you want Part B later. If you elect COBRA continuation coverage and later enroll in Medicare Part A or B before the COBRA continuation coverage ends, the Plan may terminate your continuation coverage. However, if Medicare Part A or B is effective on or before the date of the COBRA election, COBRA coverage may not be discontinued on

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. If you believe NPI we have about you is incorrect, please write us. Your letter should include your full name, address, telephone number and policy number if we have issued a policy. Your letter should also explain why you believe the NPI is inaccurate. If we agree with you, we will correct the NPI and notify you of the correction. We will also notify any person who may have received the incorrect NPI from us in the past two years if you ask us to contact that person. 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 93

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 Credit Reporting Act. The address of the Bureau’s information office is: 50 Braintree Hill Park, Suite 400, Braintree, MA 02184-8734, telephone (617) 4263660. Colonial or its reinsure may also release information in its file to other life insurance companies to whom you may apply for life or health insurance or to whom a claim for benefits may be submitted.

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 888-662-7500 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 888-662-7500 for assistance.

Please visit www.piercegroupbeneﬁts.com/individualcoverage or call 888-662-7500 for more information on these policies, as well as to enroll/continue your benefits.

NORTH CAROLINA STATE HEALTH PLAN INSURANCE Under certain qualifying events, employees and dependents have the opportunity to continue coverage for 18-36 months under the COBRA Act. Please contact the North Carolina State Health Plan at 1-877-679-6272.

If you are retiring, you must either log into www.myncretirement.com or call 1-877-679-6272.

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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