Issuu

EMPLOYEE BENEFITS GUIDE 2026 PLAN YEAR:

OCTOBER 1, 2026 - SEPTEMBER 30, 2027

FRANKLIN CITY PUBLIC SCHOOLS

WWW.PIERCEGROUPBENEFITS.COM

EMPLOYEE SERVICES: 800-387-5955

TABLE OF CONTENTS

EMPLOYEE BENEFITS GUIDE Welcome to Franklin City Public Schools’ comprehensive benefits program. This guide highlights the benefits offered to all eligible employees for the plan year listed below. Benefits described in this guide are voluntary, employeepaid benefits unless otherwise noted.

ENROLLMENT DATES: August 14, 2026 - August 21, 2026 PLAN YEAR & EFFECTIVE DATES: October 1, 2026 - September 30, 2027

Important Contact Information............................... 3 Eligibility Requirements......................................... 4 Overview Of Benefits............................................. 5 Important Notices................................................. 6 Mid-Year Events..................................................... 7 Enrollment Information.......................................... 9 EE Navigator Enrollment Instructions..................... 10 Health Insurance................................................... 12 Dental Insurance................................................... 20 Vision Insurance.................................................... 27 Flexible Spending Account..................................... 31 The FSA Store....................................................... 34 Dependent Care Account....................................... 35 Employee Assistance Program............................... 38 Cancer Benefits..................................................... 41 Critical Illness Benefits.......................................... 51 Short-Term Disability Benefits................................ 64 Long-Term Disability Benefits................................. 76 Accident Benefits.................................................. 79 Medical Bridge Benefits......................................... 89 Term Life Insurance............................................... 98 Whole Life Insurance............................................. 102 Legal Benefits....................................................... 106 Colonial Life Policyholder Service Guide................. 108 Authorization For Colonial Life Insurance Form....... 109 Required Health Care Notices................................ 110 COBRA Continuation Of Coverage.......................... 115 Privacy Notices..................................................... 117 Continuation Of Coverage...................................... 118

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.

FRANKLIN CITY PUBLIC SCHOOLS 2026-2027 Benefits Plan

October 1, 2026 - September 30, 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: 7/29/2026

IMPORTANT CONTACT INFORMATION CARRIER

PHONE/FAX

WEBSITE

Health Insurance

Sentara Health Plans

P: 800-950-7040

www.sentarahealthplans.com

Flexible Spending Accounts

Ameriflex

P: 888-868-3539

service@myameriflex.com

www.myameriflex.com

Dental Insurance

Anthem

P: 800-331-1476 F: 844-452-8074

www.anthem.com

Vision Insurance

Superior Vision

P: 800-507-3800 F: 410-752-8969

www.superiorvision.com

Long-Term Disability Benefits

Reliance Standard

P: 800-351-7500

www.reliancestandard.com

Employee Assistance Program

Sentara Health Plans

P: 800-950-7040

www.sentarahealthplans.com

Legal Benefits

Legal Resources

P: 800-728-5768 F: 757-498-4114

info@legalresources.com

www.legalresources.com

Employee Navigator Enrollment

EENavigator

www.employeenavigator.com/ benefits/account/login

Custom Benefits Website

Pierce Group Benefits

P: 1-800-387-5955 F: 984-225-2605

service@ piercegroupbenefits.com

www.PierceGroupBenefits.com/ FranklinCityPublicSchools

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

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

ELIGIBILITY REQUIREMENTS CURRENT EMPLOYEE? ANNUAL ENROLLMENT DATES:

August 14, 2026 - August 21, 2026

PLAN YEAR & EFFECTIVE DATES: October 1, 2026 - September 30, 2027

ELIGIBILITY • Employees must work 30 hours or more per week to be eligible for LTD benefits. • Employees working 20 hours or more per week are eligible for all other 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, Flexible Spending Accounts and Long-Term Disability - 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. New hire benefits will be effective the first of the month following hire date. If hired on the first day of a month, benefits will be effective that day. New employees hired before September 30, 2026 can enroll in all benefits. 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/FranklinCityPublicSchools 4

OVERVIEW OF BENEFITS PRE – TAX BENEFITS Health Insurance Sentara Health Plans

Flexible Spending Accounts Ameriflex - Medical Reimbursement: $3,400/year Max - Dependent Care Reimbursement: $7,500/year Max

POST – TAX BENEFITS Short-Term Disability Benefits Colonial Life

Long-Term Disability Benefits Reliance Standard

*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 September 30, 2026.

Dental Insurance Anthem

Critical Illness Benefits Colonial Life

Vision Insurance Superior Vision

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

Cancer Benefits Colonial Life Legal Benefits Legal Resources Accident Benefits Colonial Life

Medical Bridge Benefits Colonial Life

ADDITIONAL BENEFITS Employee Assistance Program Sentara Health Plans

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, Sentara Health, Ameriflex Flexible Spending Accounts, Anthem Dental, Superior Vision, Reliance Standard Long-Term Disability and Legal Resources Legal Select Plan runs from October 1, 2026, through September 30, 2027. When do my deductions start? Deductions for Sentara Health, Anthem Dental and Superior Vision start September 2026 for all enrolled employees. Deductions for Colonial Life Insurance Products, Ameriflex Flexible Spending Accounts, Reliance Standard Long-Term Disability and Legal Resources Legal Select Plan start October 2026 for all enrolled employees. Please note: Ameriflex Flexible Spending Accounts only have 22 deductions, skipping the month of September 2026. Why have my Medical Bridge benefits not started yet? The Health Screening Rider on the Colonial Medical Bridge plan has a 30day waiting period for new enrollees. Coverage, therefore, will not begin until October 31, 2026. What is an EAP? Your employer offers an Employee Assistance Program (EAP) for you and your eligible family members. An EAP is an employer-sponsored benefit that offers confidential support and resources for personal or work-related challenges and concerns. Please see the EAP pages of this benefit guide for more details and contact information. How do Flexible Spending Account (FSA) funds work, and do my FSA funds have to be used by a specific deadline? Flexible Spending Account expenses must be incurred during the plan year to be eligible for reimbursement. After the plan year ends, an employee has 90 days to submit claims for incurred qualified spending account expenses (or 90 days after employment termination date). If employment is terminated before the plan year ends, the spending account also ends. Failure to use all allotted funds in the FSA account will result in a “Use It or Lose It” scenario. Your plan includes a grace period which is an additional 2.5 months (running October 1, 2027, through December 15, 2027), during which you can incur eligible expenses that can be reimbursed. Therefore, you have from October 1, 2026, through December 15, 2027, to incur qualified expenses eligible for reimbursement. If you do not incur qualified expenses by December 15, 2027, and/or file by December 31, 2027, any contributions are forfeited under the “Use It or Lose It” rule. 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. Your plan includes a grace period which is an additional 2.5 months (running October 1, 2027, through December 15, 2027), during which you can incur eligible expenses that can be reimbursed. Therefore, you have from October 1, 2026, through December 15, 2027, to incur qualified expenses eligible for reimbursement. If you do not incur qualified expenses by December 15, 2027, and/or file by December 31, 2027, any contributions are forfeited under the “Use It or Lose It” rule. When will I get my card? If you will be receiving a new debit card, whether you are a new participant or to replace your expired card, please be aware that it may take up to 30 days following your plan effective date for your card to arrive. Your card will be delivered by mail in a plain white envelope. During this time you may use manual claim forms for eligible expenses. Please note that your debit card is good through the expiration date printed on the card. I want to sign my family up for benefits as well, what information will I need? If signing up for any coverage on your spouse and/or children, please have their dates of birth and social security numbers available when speaking with the Beneﬁts Representative. What does Pre-Tax vs. Post-Tax Change? Pre-Tax benefits take funds directly from your paycheck to cover benefits before going through State and Federal taxing process. Post-Tax collects funds for benefits after taxes have been taken out. Please be aware there are certain coverages that may be subject to federal and state tax when premium is paid by pretax deduction or employee contribution. Can I change my benefit elections outside of the enrollment period? Elections made during this enrollment period CANNOT BE CHANGED AFTER THE ENROLLMENT PERIOD unless there is a family status change, otherwise known as a qualifying life event (Mid-Year Events), as defined by the Internal Revenue Code. Examples of Mid-Year Events can be found in the chart on the next page. Once a Mid-Year Event has occurred, an employee has 30 days to notify PGB’s Employee Services at 1-800-387-5955 to request a change in elections. I have a pre-existing condition. Will I still be covered? Some policies may include a pre-existing condition clause. Please read your policy carefully for full details. 6

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

MID-YEAR EVENT

ACTION REQUIRED

RESULT IF ACTION IS NOT TAKEN

New Hire

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

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

Marriage

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

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

Divorce

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

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

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

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

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

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

Death of a Spouse or Dependent

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

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

Change in Spouse’s Employment or Coverage

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

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

Birth or Adoption of a Child

Dependent Aging Out

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

MID-YEAR EVENTS MID-YEAR EVENT

ACTION REQUIRED

RESULT IF ACTION IS NOT TAKEN

Part-Time to Full-Time or Vice Versa

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

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

Transferring Employers

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

You may lose the opportunity to transfer benefits.

Loss of Government or Education Sponsored Health Coverage

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

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

Entitlement to Medicare or Medicaid

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

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

Non-FMLA Leave

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

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

Retiring

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

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

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

ENROLLMENT INFORMATION IN-PERSON, VIRTUAL & SELF-ENROLL During your annual enrollment period, a PGB Benefits Representative will be available by in-person or virtual appointment to meet with you one-on-one to help you evaluate your benefits based on your individual and family needs, answer any questions you may have, and assist you in the enrollment process. If you prefer, you may also self-enroll online following the instructions on the next page of this guide.

ANNUAL ENROLLMENT PERIOD:

AUGUST 14, 2026 - AUGUST 21, 2026 BENEFIT ELECTION OPTIONS YOU CAN MAKE THE FOLLOWING BENEFIT ELECTIONS DURING THE ANNUAL ENROLLMENT PERIOD: • • • • • • •

Enroll in, change, or cancel Health Insurance. 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 Long-Term Disability Insurance. Enroll in, change, or cancel Legal Benefits. 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/FranklinCityPublicSchools 9

EE NAVIGATOR ENROLLMENT INSTRUCTIONS Below is a series of instructions outlining the enrollment process. Please have the following information available before you begin: •

Username and password. If you have forgotten your password, please visit the enrollment website and select “Reset a forgotten password”. • Social security numbers of the spouse or any dependents you wish to enroll • Dates of birth for the spouse and any dependents you wish to enroll • Beneficiary names and social security numbers

HELPFUL TIPS : • If you are a new employee, please refer to the New Hire information on the Eligibility Requirements page of this guide or contact PGB Employee Services at 800-387-5955 between 8:30am and 5:00pm for assistance. • If you are an existing employee and unable to log into the online system, please contact the PGB Employee Services at 800-387-5955, or speak with the Benefits Representative assigned to your location.

1. LOGGING IN First time users: To get started, click the registration link in the email from your administrator or click on the link below and select Register as a New User. Follow the prompts to create your account and set up your own username and password. You will need your Company ID when registering as a new user! Company ID: FRACS Returning users: Click on the link below and select Login. Log in with the username and password you previously set.

To login, visit: www.employeenavigator.com/benefits/account/login

2. 2. WELCOME After you login click Let’s Begin to complete your required tasks.

1. 4. START ENROLLMENT

3. ONBOARDING Complete any assigned onboarding tasks before enrolling in your benefits.

Once you’ve completed your tasks click Start Enrollment to begin your enrollments.

TIP: If you hit “Dismiss, complete later” you’ll be taken to your Home Page. You’ll still be able to start enrollments again by clicking “Start Enrollments”

Enrollment instructions continued on next page

EE NAVIGATOR ENROLLMENT INSTRUCTIONS

5. PERSONAL INFORMATION After clicking Start Enrollment, you’ll need to complete some personal & dependent information before moving to your benefit elections.

6. DEPENDENT SELECTIONS

7. BENEFIT ELECTIONS

To enroll dependents in a benefit, click the checkbox next to the dependent’s name under: Who am I enrolling?

Below your dependents you can view your available plans and the cost per pay. To elect a benefit, click Select Plan underneath the plan cost.

SAVE & CONTINUE

8. SAVE & CONTINUE Click Save & Continue at the bottom of each screen to save your elections. If you do not want a benefit, click Don’t want this benefit? at the bottom of the screen and select a reason from the drop-down menu.

11.

PRINT & REVIEW You can either print a summary of your elections for your records or login at any point during the year to view your summary online.

9. FORMS

10.

If you have elected benefits that require a beneficiary designation, Primary Care Physician, or completion of an Evidence of Insurability form, you will be prompted to add in those details.

12. HR TASKS (IF APPLICABLE) To complete any required HR tasks, click Start Tasks. If your HR department has not assigned any tasks, you’re finished! 11

SIGN & AGREE Review the benefits you selected on the enrollment summary page to make sure they are correct then click Sign & Agree to complete your enrollment.

TIP: If you miss a step, you’ll see Enrollment Not Complete in the progress bar with the incomplete steps highlighted. Click on any incomplete steps to complete them.

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

HEALTH INSURANCE

Franklin City Public Schools POS 1000/25/30% Health Benefits

In-Network

Benefit Year Deductible (Individual/Family)

Member Pays

$1000/$2000

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

In and Out-of-Network Out-of-Pocket Maximums are separate

50%

$4500/$9000

$9000/$18000 Unlimited

Recommended Exams, screening, tests, immunizations, and other services (Preventive) Primary Care Visit Virtual Consult Specialist Visit

Inpatient Services - Pre-Authorization required for nonemergency Diagnostic Procedures MH Outpatient Office Visits (PCP and Specialist) MH Outpatient Office Visits (Virtual Consult) Outpatient Surgery - Pre-Authorization may be required Advanced Imaging – CT, PET, MRI, MRA, CTA, MRS, SPECT – Pre-Authorization Required Urgent Care Services Emergency Services Emergency Ambulance Vision Exams – Limited to one routine eye exam every 12 months from participating VSP provider Hospice Care – Pre-Authorization is required

No Charge

50% after deductible

$25 copay

50% coinsurance after deductible

No charge

Not covered

$50 copay

50% coinsurance after deductible

$350 global copayment for delivering Obstetrician prenatal, delivery and postpartum services

50% coinsurance after deductible

30% coinsurance after deductible

50% coinsurance after deductible

30% coinsurance after deductible $35 copay $35 copay 30% coinsurance after deductible

50% coinsurance after deductible 50% coinsurance after deductible Not covered 50% coinsurance after deductible

30% coinsurance after deductible

50% coinsurance after deductible

$50 copay 30% coinsurance after deductible 30% coinsurance after deductible

50% coinsurance after deductible 30% coinsurance after deductible 30% coinsurance after deductible Members will be reimbursed up to $30 for one routine eye exam only

No Charge No Charge after deductible

50% coinsurance after the deductible

$25 copay

50% coinsurance after the deductible

30% coinsurance after deductible

50% coinsurance after deductible

Home Health Care (Limited to 100 visits per Plan Year). Includes Skilled home health care. Separate copayment and coinsurance for therapies and infused medications at home. Prior authorization required Physical Therapy and Occupational Therapy (limited to 30 combined visits)

$2000/$4000

30%

Maximum Lifetime Benefit Per Member

Maternity Care - Pre-Authorization is required for prenatal services

Out-of-Network

Speech Therapy (limited to 30 visits)

Diabetes Treatment 13

Page 1 of 2

Health Benefits

In-Network

Member Pays

Out- of -Network

Includes supplies, equipment, and education. An annual diabetic eye exam is covered from an In-Network Plan Provider or a participating EyeMed Vision Services provider at the office visit Copayment or Coinsurance amount.

Insulin Pumps* – Pre-Authorization may be required

No Charge

50% coinsurance after deductible

Pump Infusion Sets and Supplies – prior authorization may be required

30% coinsurance after deductible

50% coinsurance after deductible

Covered under the Plan’s Prescription Drug Benefit

Testing Supplies Includes test strips, lancets, lancet devices, blood glucose monitors and control solution. *PreAuthorization is required for talking blood glucose monitors Insulin, Needles, Syringes Employee Assistance Visits Services include short-term problem assessment by licensed behavioral health providers, and referral services for employees, and other Covered family members and household members. To use services call 757-363-6777 or 1-800-899-8174.

No Charge for up to 5 visits from Plan Employee Assistance providers per presenting issue as determined by treatment protocols

Retail Pharmacy Cost Sharing When You pick up Your drug at a retail pharmacy You will pay the Copayment (one Copayment for each 30-day supply) or the Coinsurance amount listed under the applicable Tier for Your Drug: • You pay one Copayment or the Coinsurance for up to a 30-day supply; • You pay two Copayments or the Coinsurance for a 31 to 60-day supply; • You pay three Copayments or the Coinsurance for a 61 to 90-day supply. Tier 4 Specialty Drugs are only available from a Plan Specialty Pharmacy including Proprium Pharmacy and are limited to a 30-day supply Preferred Generic Drugs: Tier 1 - $15 Copay Preferred Brand & Other Generic Drugs: Tier 2 - $50 Copay Non-Preferred Brand Drugs: Tier 3 - $85 copay Specialty Drugs: Tier 4 – 20% coinsurance up to maximum of $250

Formulary

This Plan has a closed formulary and Covers a specific list of drugs and medications. If Your drug is not on Our formulary, We have a process in place to request Coverage. Please use the following link to see a list of drugs on the Plan’s formulary: sentarahealthplans.com/members/manage-plans/employer-groupprescription-drug-lists. If a brand-name medication is dispensed instead of a generic equivalent, You must pay the cost difference between the dispensed brand-name drug and the Generic Drug in addition to the Copayment or Coinsurance charge, unless authorized by the Plan.

This overview does not replace your Certificate of Coverage. Many words are defined in the Certificate, and other limitations or exclusions may be listed in other sections of your Certificate. Reading this overview by itself could give you an inaccurate impression of the terms of your coverage. This overview must be read with the rest of your Certificate of Coverage. Prior authorization is required for specific 14 services.

Page 2 of 2

Franklin City Public Schools POS 500/20/20% Health Benefits

In-Network

Benefit Year Deductible (Individual/Family)

Member Pays

$500/$1000

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

In and Out-of-Network Out-of-Pocket Maximums are separate

40%

$3000/$6000

$8000/$16000 Unlimited

Recommended Exams, screening, tests, immunizations, and other services (Preventive) Primary Care Visit Virtual Consult Specialist Visit

No Charge

40% after deductible

$20 copay

40% coinsurance after deductible

No charge

Not covered

$40 copay

40% coinsurance after deductible

$350 global copayment for delivering Obstetrician prenatal, delivery and postpartum services

40% coinsurance after deductible

20% coinsurance after deductible

40% coinsurance after deductible

20% coinsurance after deductible $30 copay $30 copay 20% coinsurance after deductible

40% coinsurance after deductible 40% coinsurance after deductible Not covered 40% coinsurance after deductible

20% coinsurance after deductible

40% coinsurance after deductible

$40 copay 20% coinsurance after deductible 20% coinsurance after deductible

40% coinsurance after deductible 20% coinsurance after deductible 20% coinsurance after deductible Members will be reimbursed up to $30 for one routine eye exam only

No Charge No Charge after deductible

40% coinsurance after the deductible

$20 copay

40% coinsurance after the deductible

20% coinsurance after deductible

40% coinsurance after deductible

$1000/$2000

20%

Maximum Lifetime Benefit Per Member

Maternity Care - Pre-Authorization is required for prenatal services

Out-of-Network

Speech Therapy (limited to 30 visits)

Diabetes Treatment 15

Page 1 of 2

Health Benefits

In-Network

Member Pays

Out- of -Network

Insulin Pumps* – Pre-Authorization may be required

No Charge

40% coinsurance after deductible

Pump Infusion Sets and Supplies – prior authorization may be required

20% coinsurance after deductible

40% coinsurance after deductible

Covered under the Plan’s Prescription Drug Benefit

Testing Supplies Includes test strips, lancets, lancet devices, blood glucose monitors and control solution. *PreAuthorization is required for talking blood glucose monitors

Covered under the Plan’s Prescription Covered under the Plan’s Prescription Drug Benefit Drug Benefit Employee Assistance Visits Services include short-term problem assessment by licensed behavioral health providers, and referral services for employees, and other Covered family members and household members. To use services call 757-363-6777 or 1-800-899-8174. No Charge for up to 5 visits from Plan Employee Assistance providers per presenting issue as determined by treatment protocols Insulin, Needles, Syringes

Formulary

Page 2 of 2

Sentara Well-being Rewards Employees are encouraged to complete activities from the list below in an effort to learn more about their overall health while setting attainable and timebound goals to improve it. Activities can be logged and monitored using the WebMD ONE Portal, accessible through the Sentara Health Plans website or mobile app. Rewards for completed activities will be dispersed on a monthly basis with up to $250* in rewards for the year.

Healthy employees are vital to a successful business. Powered by our partnership with WebMD® Health Services, the Sentara Well-being Rewards program offers a flexible and inclusive solution for employers to engage their workforce in activities that lead to better health outcomes.

Program Activities Include: Complete a Personal Health Assessment

$50

Complete a Daily Habit (max of 4 for up to $200)

Get Preventive Screenings

Asthma

$50

Back Health

$50

Balanced Living

$50

Annual Physical

$50

Colorectal Cancer Screening

$25

Balance Your Diet

$50

Mammogram

$25

CAD

$50

Prostate Cancer Screening

$25

COPD

$50

Skin Cancer Screening

$25

Cope with the Blues

$50

Diabetes

$50

Enjoy Exercise

$50

Connect with Condition Management Diabetes

$50

Heart Failure

$50

Cardiovascular

$50

High Blood Pressure

$50

Respiratory

$50

Keep Stress in Check

$50

Lose Weight

$50

Partners in Pregnancy

$50

Maternal Health (1, 2, or 3)

$50

Pregnant Partner Support

$50

Quit Tobacco

$50

Sleep Well

$50

Stay Connected

$50

Work Life Balance

$50

Explore WebMD ONE (complete all 3) Sign Up for a Newsletter View Health Topic

$25

Find a Recipe

For more information, visit sentarahealthplans.com * Rewards may be considered income and are subject to applicable taxes.

Sentara Health Plans is a trade name of Sentara Health Plans, Sentara Health Insurance Company, Sentara Health Administration, Inc., and Sentara Behavioral Health Services, Inc.

Omada and Sentara Health Plans

A Whole New Way to Get Healthy Imagine all you could do if you were healthier and more energized. Omada® is a digital, lifestyle-change program focused on reducing the risk of obesity-related chronic disease. The program combines the latest technology with ongoing support so you can make the changes that matter most—whether around eating, activity, sleep, or stress.

You’ll get your own: •

interactive program that adapts to you

•

professional health coach to keep you on track

•

small online peer group for real-time support

•

weekly online lessons to empower you

•

wireless smart scale to monitor your progress

If you are covered by a Sentara Health Plans product and at risk for type 2 diabetes or heart disease, there is no cost for you to join. Participants will be accepted on a first-come, first-served basis. Claim your spot today at omadahealth.com/sentara

All this at no additional cost to you! Find out if you’re eligible: omadahealth.com/sentara

Sentara Health Plans is a trade name of Sentara Health Plans, Sentara Health Insurance Company, Sentara Health Administration, Inc., 18 and Sentara Behavioral Health Services, Inc.

v0124

Exceptional Care, Anywhere

24/7/365 on-demand access to quality healthcare. Anytime, Anywhere. With MDLIVE, you can visit with a doctor 24/7 from your home, or on the go. MDLIVE’s network of Board Certiﬁed doctors is available by phone or secure video to assist with non-emergency medical conditions.

Who are our doctors? MDLIVE has the nation’s largest network of telehealth doctors and behavioral health providers. On average, MDLIVE’s doctors have 15 years of experience practicing medicine and are licensed in the state where patients are located. Their specialties include primary care, pediatrics, emergency medicine, and family medicine. MDLIVE’s doctors are committed to providing convenient, quality care and are always ready to take your call.

Common Conditions We Treat

When should I use MDLIVE?

•

allergies

•

infections

•

asthma

•

insect bites

•

behaviorial health

•

joint aches

for non-emergency issues that do not require a trip to the ER or an urgent care center

•

bronchitis

•

rashes

•

cold and flu

•

respiratory infections

during or after normal business hours, nights, weekends, and even holidays

•

diarrhea

•

sinus infection

•

if your primary care doctor is not available

•

ear aches

•

urinary tract infections

•

if you need to request prescription reﬁlls (when appropriate)

•

fever

•

sore throat

•

headache

•

and more!

if you are traveling and in need of medical care

Pediatric Care •

cold and flu

•

nausea

•

constipation

•

pink eye

•

ear aches

•

and more!

Exceptional Care, Anywhere

MDLIVE has pediatricians on call 24/7/365.

Disclaimers: MDLIVE does not replace the primary care physician. MDLIVE is not an insurance product nor a prescription fulfillment warehouse. MDLIVE operates subject to state regulation and may not be available in certain states. MDLIVE does not guarantee that a prescription will be written. MDLIVE does not prescribe DEA controlled substances, non-therapeutic drugs and certain other drugs which may be harmful because of their potential for abuse. MDLIVE physicians reserve the right to deny care for potential misuse of services. MDLIVE phone consultations are available 24/7/365, while video consultations are available during the hours of 7 am to 9 pm ET 7 days a week 19 or by scheduled availability. MDLIVE and the MDLIVE logo are registered trademarks of MDLIVE, Inc. and may not be used without written permission. For complete terms of use visit www.mdlive.com/pages/terms.html 010113. v0124

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

DENTAL INSURANCE

Summary of Benefits

Anthem Dental Essential Choice Franklin City Public Schools Anthem Dental Complete Network High Plan

WELCOME TO YOUR DENTAL PLAN!

Regular dental checkups can help find early warning signs of certain health problems, which means you can get the care you need to get healthy. So, don't skimp on your dental care, good oral care can mean better overall health! Powerful and easily accessible member tools. Ask a Hygienist: Dental members can simply email their dental questions to a team of licensed dental professionals who in turn will respond in about 24 hours.

Dentists in your plan network. You'll save money when you visit a dentist in your plan network because Anthem and the dentist have agreed on pricing for covered services. Dentists who are not in your

Dental Health Risk Assessment: We want our dental members to better understand their oral health and their risk factors for tooth decay, gum disease and oral cancer. This easy to use online tool can help them do this.

plan network have not agreed to pricing, and may bill you for the difference between what Anthem pays them and what the dentist usually charges.

Dental Care Cost Estimator: In order to help our dental member better understand the cost of their dental care, we offer access to a user-friendly, web-based tool that provides estimates on common dental procedures and treatments when using a network dentist. More Capabilities: With our latest mobile application, Anthem Anywhere, members can find a network dentist as well as view their claims. It's available both for Android and Apple phones.

• To find a dentist by name or location, go to anthem.com or call dental customer service at the number listed on the back of your ID card. Ready to use your dental benefits? Choose a dentist from the network

Need to contact us? See the back of your ID card for who to call, write or email.

Your dental benefits at a glance

The following benefit summary outlines how your dental plan works and provides you with a quick reference of your dental plan benefits. For complete coverage details, please refer to your policy.

In-Network Annual Benefit Maximum · Per insured person

Out-of-Network

Calendar Year $1,500

$1,500

D&P applies to Annual Maximum

Yes

Annual Maximum Carryover / Carry in

No/No

Orthodontic Lifetime Benefit Maximum · Per eligible insured person

$1,500

Annual Deductible (Does not apply to Orthodontic Services) · Per insured person/Family maximum Calendar Year Deductible Waived for Diagnostic/Preventive Services

$25/3X Individual Yes

Out-of-Network Reimbursement:

Prime (MAC)

Anthem BCBS is the trade name for Anthem Health Plans, Inc., an independent licensee of the Blue Cross and Blue Shield Association.

QuoteID: 16235114

VA_PCLG_FI-Custom

In-Network Anthem Pays:

Dental Services

Out-of-Network Anthem Pays:

Waiting Period

Diagnostic and Preventive Services 100% Coinsurance 100% Coinsurance No Waiting Period · Periodic oral exam 2 per 12 months · Teeth cleaning (prophylaxis) 2 per 12 months; w/periodontal maintenance · Bitewing X-rays: 1 set per 12 months · Full-mouth or Panoramic X-rays: · Fluoride application: · Sealants Basic Services · Consultation (second opinion)

1 per 36 months 1 per 12 months through age 18 1 per 60 months; through age 15 80% Coinsurance

80% Coinsurance

No Waiting Period

80% Coinsurance

No Waiting Period

80% Coinsurance

No Waiting Period

80% Coinsurance

No Waiting Period

Periodontics (Surgical) 1 per quadrant per 36 months 80% Coinsurance · Periodontal Surgery (osseous, gingivectomy, graft procedures)

80% Coinsurance

No Waiting Period

Oral Surgery (Simple) · Simple Extractions

80% Coinsurance

No Waiting Period

1 per tooth per lifetime

Oral Surgery (Complex) · Surgical Extractions

80% Coinsurance

No Waiting Period

1 per tooth per lifetime 50% Coinsurance

50% Coinsurance

No Waiting Period

50% Coinsurance

No Waiting Period

80% Coinsurance

No Waiting Period

50% Coinsurance

No Waiting Periods

1 per 12 months

· Space Maintainer · Amalgam (silver-colored) Filling · Composite (tooth-colored) Filling

1 per lifetime through age 14; posterior teeth 1 per tooth per 24 months 1 per tooth per 24 months posterior (back) fillings alternated to amalgam benefit (silver-colored filling) · Brush Biopsy (cancer test) Covered, 1 per 12 months; all ages Endodontics (Non-Surgical) · Root Canal and retreatments

1 per tooth per lifetime

Endodontics (Surgical) · Apicoectomy and apexification

1 per tooth per lifetime

Periodontics (Non-Surgical) · Periodontal Maintenance · Scaling and root planing

Major (Restorative) Services · Crowns, onlays, veneers · Cosmetic teeth whitening Prosthodontics · Dentures and bridges · Dental Implants Prosthodontic Repairs/Adjustments · Crown, denture, bridge repairs · Denture and bridge adjustments:

2 per 12 months; w/teeth cleaning 1 per quadrant per 24 months

1 per tooth per 60 months Not Covered 1 per tooth per 60 months Covered, 1 per tooth per 60 months 1 per 12 months; 6 months after placement 2 per 12 months; 6 months after placement

Orthodontic Services ·Adults & Dependent Children

*Child orthodontic runs through age 18. This means that the child must have been banded prior to their 19th birthday in order to receive coverage.

Anthem BCBS is the trade name for Anthem Health Plans, Inc., an independent licensee of the Blue Cross and Blue Shield Association.

QuoteID: 16235114

VA_PCLG_FI-Custom

Additional Services and Programs Anthem Whole Health Connection -Dental Eligible services are paid at 100% and won't reduce your coverage year annual maximum (if applicable)

Accidental Dental Injury Benefit (if applicable). No deductibles, member coinsurance, or waiting periods apply

Extension of Benefits termination of coverage under the plan and eligible services will be covered

International Emergency Dental Program Eligible covered services will be paid 100% with no deductibles, member coinsurance, or waiting periods and won't reduce the member coverage year annual maximum (if applicable)

Additional Limitations & Exclusions

Below is a partial listing of non-covered services under your dental plan. Please see your policy for a full list. Services provided before or after the term of this coverage - Services received before your effective date or after your coverage ends, unless otherwise specified in the dental plan certificate Orthodontics (unless included as part of your dental plan benefits) including orthodontic braces, appliances and all related services Cosmetic dentistry (unless included as part of your dental plan benefits) provided by dentists solely for the purpose of improving the appearance of the tooth when tooth structure and function are satisfactory and no pathologic conditions (cavities) exist

Drugs and medications including intravenous conscious sedation, IV sedation and general anesthesia when performed with nonsurgical dental care

Analgesia, analgesic agents, and anxiolysis nitrous oxide, therapeutic drug injections, medicines or drugs for nonsurgical or surgical dental care except that intravenous conscious sedation is eligible as a separate benefit when performed in conjunction with complex surgical services. Waiting periods for endodontic, periodontic and oral surgery services may differ from other Basic Services or Major Services under the same dental plan. There is a waiting period of up to 24 months for replacement of congenitally missing teeth or teeth extracted prior to coverage under this plan.

This is not a contract; it is a partial listing of benefits and services. All covered services are subject to the conditions, limitations, exclusions, terms and provisions of your certificate of coverage. In the event of a discrepancy between the information in this summary and the certificate of coverage, the certificate will prevail.

Anthem BCBS is the trade name for Anthem Health Plans, Inc., an independent licensee of the Blue Cross and Blue Shield Association.

QuoteID: 16235114

VA_PCLG_FI-Custom

Summary of Benefits

Anthem Dental Essential Choice Franklin City Public Schools Anthem Dental Complete Network Low Plan

WELCOME TO YOUR DENTAL PLAN!

Dentists in your plan network. You'll save money when you visit a dentist in your plan network because Anthem and the dentist have agreed on pricing for covered services. Dentists who are not in your

plan network have not agreed to pricing, and may bill you for the difference between what Anthem pays them and what the dentist usually charges.

Need to contact us? See the back of your ID card for who to call, write or email.

Your dental benefits at a glance

The following benefit summary outlines how your dental plan works and provides you with a quick reference of your dental plan benefits. For complete coverage details, please refer to your policy.

In-Network Annual Benefit Maximum · Per insured person

Out-of-Network

Calendar Year $1,000

$1,000

D&P applies to Annual Maximum

Yes

Annual Maximum Carryover / Carry in

No/No

Orthodontic Lifetime Benefit Maximum · Per eligible insured person

N/A

Annual Deductible · Per insured person/Family maximum Calendar Year Deductible Waived for Diagnostic/Preventive Services

$25/3X Individual Yes

Out-of-Network Reimbursement:

Prime (MAC)

Anthem BCBS is the trade name for Anthem Health Plans, Inc., an independent licensee of the Blue Cross and Blue Shield Association.

QuoteID: 16162146

VA_PCLG_FI-Custom

In-Network Anthem Pays:

Dental Services

Out-of-Network Anthem Pays:

Waiting Period

1 per 36 months 1 per 12 months through age 18 1 per 60 months; through age 15 80% Coinsurance

80% Coinsurance

No Waiting Period

80% Coinsurance

No Waiting Period

80% Coinsurance

No Waiting Period

80% Coinsurance

No Waiting Period

Periodontics (Surgical) 1 per quadrant per 36 months 80% Coinsurance · Periodontal Surgery (osseous, gingivectomy, graft procedures)

80% Coinsurance

No Waiting Period

Oral Surgery (Simple) · Simple Extractions

80% Coinsurance

No Waiting Period

1 per tooth per lifetime

Oral Surgery (Complex) · Surgical Extractions

80% Coinsurance

No Waiting Period

1 per tooth per lifetime Not Covered

Not Covered

No Waiting Period

Not Covered

No Waiting Period

80% Coinsurance

No Waiting Period

Not Covered

N/A

1 per 12 months

· Space Maintainer · Amalgam (silver-colored) Filling · Composite (tooth-colored) Filling

1 per tooth per lifetime

Endodontics (Surgical) · Apicoectomy and apexification

1 per tooth per lifetime

Periodontics (Non-Surgical) · Periodontal Maintenance · Scaling and root planing

2 per 12 months; w/teeth cleaning 1 per quadrant per 24 months

1 per tooth per 60 months Not Covered 1 per tooth per 60 months Not Covered 1 per 12 months; 6 months after placement 2 per 12 months; 6 months after placement

Orthodontic Services ·None

Anthem BCBS is the trade name for Anthem Health Plans, Inc., an independent licensee of the Blue Cross and Blue Shield Association.

QuoteID: 16162146

VA_PCLG_FI-Custom

Additional Services and Programs Anthem Whole Health Connection -Dental Eligible services are paid at 100% and won't reduce your coverage year annual maximum (if applicable)

Accidental Dental Injury Benefit (if applicable). No deductibles, member coinsurance, or waiting periods apply

Extension of Benefits termination of coverage under the plan and eligible services will be covered

Additional Limitations & Exclusions

Drugs and medications including intravenous conscious sedation, IV sedation and general anesthesia when performed with nonsurgical dental care

Anthem BCBS is the trade name for Anthem Health Plans, Inc., an independent licensee of the Blue Cross and Blue Shield Association.

QuoteID: 16162146

VA_PCLG_FI-Custom

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

VISION INSURANCE

superiorvision.com | 1 (800) 507-3800

Vision Care Plan for Franklin City Public Schools Benefits through Superior National network

Frequency

Exam Frame Contact lens fitting Eyeglass lenses Contact Lenses

12 months 12 months 12 months 12 months 12 months

(based on date of service)

Need help? Contact 1 (800) 507-3800 or visit superiorvision.com for assistance. Exams Eye exam copay:

$25

Contact lens fitting2 (standard and specialty):

Materials1 Materials copay:

$20

$25

Specialty In-network allowance:

$50

Frames In-network allowance:

$100

Contacts4 in lieu of glasses

In-network allowance:

$100

Lenses (per pair)

In-Network Coverage

Out-of-Network Reimbursement

Single vision

Covered-in-full

Up to $29

Bifocal

Covered-in-full

Up to $42

Trifocal

Covered-in-full

Up to $53

Progressives

See description3

Up to $53

Shop with convenience while using your benefits through these in-network online retailers.

Lens Add-On Discounts5

Your Cost

Anti-scratch coating

$15

Ultraviolet coating

$12

Tints - solid / gradient

$15 / $18

Polycarbonate lenses

$40

Blue light filtering

$15

Digital single vision

$30

Progressive lenses (standard / premium / ultra / ultimate)

$55 / $110 / $150 / $225

Anti-reflective coating (standard / premium / ultra / ultimate)

$50 / $70 / $85 / $120

Polarized lenses

$75

Plastic photochromic lenses

$80

Hi-index (1.67 / 1.75)

$80 / $120

Overage Discounts5

Amount

Frames

20% off amount over allowance

Conventional contacts

20% off amount over allowance

Disposable contacts

10% off amount over allowance

Non-Covered Services Discounts5

Amount

Exams, frames, prescription lenses

30% off retail

Contacts, miscellaneous options

20% off retail

Disposable contact lenses

10% off retail

Retinal imaging

$39 cost

LASIK Discounts5

Multiple discounts on laser vision correction procedures may be

available to you. To learn more, visit superiorvision.com or

contact your benefits coordinator.

Hearing Aid Discounts5

Through Your Hearing Network,

you have access to discounts on hearing services, devices, and

accessories. To learn more, visit superiorvision.com or contact your benefits coordinator.

Free Mobile App

With the free Superior Vision app

Additional Out-of-Network Reimbursements

Amount

Eye exam (MD)

Up to $34

Eye exam (OD)

Up to $26

Frame

Up to $47

Contact lens fitting (standard / specialty)2

Not covered

Contact lenses

Up to $80

(available for Android and Apple devices), you can create an

account, check your eligibility and benefits, find providers, and view your member ID card.

MetLife Vision benefits are underwritten by Metropolitan Life Insurance Company, New York, NY. Certain claims and network administration services are provided through Superior Vision Services, Inc. (“Superior Vision”), a Delaware corporation. Superior Vision is part of the MetLife family of companies. Like most group benefit programs, benefit programs offered by MetLife and its affiliates contain certain exclusions, exceptions, reductions, limitations, waiting periods and terms for keeping them in force. Please contact MetLife or your plan administrator for costs and complete details. Co-pays apply to in-network benefits; co-pays for out-of-network visits are deducted from reimbursements 1. Materials co-pay applies to lenses and frames only, not contact lenses. 2. Standard contact lens fitting applies to a current contact lens user who wears disposable, daily wear, or extended wear lenses only. Specialty contact lens fitting applies to new contact wearers and/or a member who wear toric, gas permeable, or multi-focal lenses. 3. Covered to provider’s in-office standard retail lined trifocal amount; member pays difference between progressive and standard retail lined trifocal, plus applicable co-pay 4. Contact lenses are in lieu of eyeglass lenses and frames benefit. 5. Not all providers support these discounts, including the member out-of-pocket features. Call your provider prior to scheduling an appointment to confirm if they offer the discount and member out-of-pocket features. The discount and member out-of-pocket features are not insurance. Discounts and member out-of-pocket are subject to change without notice and do not apply if prohibited by the manufacturer. Lens options may not be available from all providers / all locations.

Franklin City Public Schools October 1, 2026 - September 30, 2027 Sentara Health POS 1000/25/30%

Monthly Premium Monthly ER Monthly EE

Full Time - 30+ Hours Employee Only Employee + Spouse Employee + Child(ren) Employee + Family $ 825.76 $ 1,734.08 $ 1,419.06 $ 2,837.39 $ 685.54 $ 1,243.30 $ 1,017.44 $ 2,034.35 $ 140.22 $ 490.78 $ 401.62 $ 803.04

Employee Premium per 24 deduction

Monthly Premium Monthly ER Monthly EE

$ $ $

70.11 $ 245.39 Part Time - 20+ Hours 825.76 $ 1,734.08 342.77 $ 621.65 482.99 $ 1,112.43

Employee Premium per 24 deduction

241.50 $

200.81 $

401.52

$ $ $

1,419.06 $ 508.72 $ 910.34 $

2,837.09 1,017.18 1,819.92

556.22 $

455.17 $

909.96

Sentara Health POS 500/20/20%

Monthly Premium Monthly ER Monthly EE Employee Premium per 24 deduction Monthly Premium Monthly ER Monthly EE Employee Premium per 24 deduction

Full Time - 30+ Hours Employee Only Employee + Spouse Employee + Child(ren) Employee + Family $ 911.10 $ 1,913.27 $ 1,573.16 $ 3,127.22 $ 756.39 $ 1,371.78 $ 1,127.93 $ 2,242.16 $ 154.71 $ 541.49 $ 445.23 $ 885.06 $ $ $ $

77.36 $ 270.75 Part Time - 20+ Hours 911.10 $ 1,913.27 378.20 $ 685.89 532.91 $ 1,227.38

222.62 $

442.53

$ $ $

1,573.16 $ 563.97 $ 1,009.20 $

3,127.22 1,121.08 2,006.14

266.45 $

613.69 $

504.60 $

1,003.07

Anthem Dental

Monthly Premium Employee Premium per 24 deduction

High Plan Employee Only Employee + Spouse Employee + Child(ren) Employee + Family $ 37.24 $ 79.77 $ 82.30 $ 142.18 $

18.62 $

39.89 $ 41.15 $ 71.09 Low Plan Employee Only Employee + Spouse Employee + Child(ren) Employee + Family $ 19.37 $ 41.58 $ 42.84 $ 71.99 $

9.69 $

20.79 $

21.42 $

36.00

Superior Vision

Monthly Premium Employee Premium per 24 deduction

Employee Only Employee + Spouse Employee + Child(ren) Employee + Family $ 5.09 $ 10.19 $ 11.32 $ 17.57 $

Legal Resources

Monthly Premium Employee Premium per 24 deduction

2.55 $

5.10 $

$22.00 $11.00

5.66 $

8.79

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 32

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 33

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 34

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 36

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 Employee Assistance Programs!

EMPLOYEE ASSISTANCE PROGRAM

Our work/life resources support you through life’s ups and downs. Navigating life’s challenges while handling the demands of your job can be stressful. We can help you find the right work/life balance. Connect with a Work/Life Consultant Our experts provide confidential guidance to help you find the right childcare, eldercare, pet care, and education and solve other everyday living needs. Get Legal Advice Qualified attorneys provide assistance with civil, consumer, criminal, estate, financial, immigration, IRS, personal/family, real estate, and other matters. Talk to a Financial Expert Certified financial planners, certified public accountants, and credit counselors provide support for budget, debt, real estate, bankruptcy, credit, identity theft, retirement planning, and more.

•

Visit sentaraEAP.com and enter your organization’s username.

•

Click on “Work/Life” and “Access Enhanced Online Resources.” Enter the company code shown below.

•

Create a unique username and password to access the resources.

Company code:

SentaraCore

Access 24/7 Online Resources Search our expansive library of articles, webinars, calculators, videos, assessments, and other interactive tools to find information on health, wellness, family, aging, education, legal, and financial topics.

Call Sentara EAP at 1-800-899-8174

Sentara EAP is administered by Sentara Behavioral Health Services, Inc.

v.1123

5 Things to Know in 5 Minutes About the Sentara Employee Assistance Program

Helpful resource Sentara EAP (Employee Assistance Program) is a resource to help you overcome life’s challenges, solve personal concerns, and address work-related issues. Our services are confidential, short-term, and solution-focused.

2 Extends to you and

household members

Confidential Confidentiality is an important component of our program. Discussions with our counselors are protected by strict Protected Health Information (PHI) privacy laws. Sentara EAP will not share any PHI, either in written or verbal form, unless you give prior consent.

Easy to contact us Our phones are personally staffed and answered 24 hours a day, 365 days a year. You do not need to go through your manager or the Human Resources Department to access EAP services. Additional online resources are available by signing in to sentaraEAP.com.

Sentara EAP services are available to all members of your household at no cost. The benefit provides up to Five (____) 5 ________ counseling sessions per presenting issue.

3 Free and convenient

Sentara EAP services are paid for by your employer and available at no cost to you or your household members. Call 1-800-899-8174 and our representatives will work to schedule an appointment with a counselor near you.

SentaraEAP Username: _________________

Call us at 1-800-899-8174 or visit sentaraEAP.com for more resources.

Sentara EAP is administered by Sentara Behavioral Health Services, Inc. 40

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

CANCER BENEFITS

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

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

CANCER ASSIST

One family’s journey

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

SECOND OPINION

SURGERY

Travel expenses

Out-of-pocket costs

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

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

For illustrative purposes only

With cancer insurance: ■ Coverage options are available for you

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

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

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

change jobs or retire.

ONLY of ALL

CANCERS are

hereditary.

American Cancer Society, Cancer Facts & Figures, 2013

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

TREATMENT

RECOVERY

Experimental care

Follow-up evaluations

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

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

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

(inpatient or outpatient)

Surgery benefits ■ Surgical procedures

■ Radiation/chemotherapy

■ Anesthesia

■ Anti-nausea medication

■ Reconstructive surgery

■ Medical imaging studies

■ Outpatient surgical center

■ Supportive or protective care drugs

■ Prosthetic device/artificial limb

and colony stimulating factors ■ Second medical opinion

Travel benefits

■ Blood/plasma/platelets/

■ Transportation

immunoglobulins ■ Bone marrow or peripheral stem

■ Companion transportation ■ Lodging

LIFETIME RISK OF DEVELOPING CANCER

MEN 1 in 2

cell donation ■ Bone marrow or peripheral stem

cell transplant ■ Egg(s) extraction or harvesting/

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

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

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

Additional benefits WOMEN

■ Family care

1 in 3

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

American Cancer Society, Cancer Facts & Figures, 2013

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

ColonialLife.com

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

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

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

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

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

1-16 | 101481-VA

Cancer Insurance Level 4 Benefits BENEFIT DESCRIPTION

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

BENEFIT AMOUNT

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

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

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

Anesthesia

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

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

per prescription filled

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

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

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

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

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

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

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

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

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

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

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

For more information, talk with your benefits counselor.

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

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

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

Hospice (initial or daily care)

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

CANCER ASSIST – LEVEL 4

BENEFIT DESCRIPTION

BENEFIT AMOUNT

Hospital confinement

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

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

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

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

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

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

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

Radiation/chemotherapy

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

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

ColonialLife.com

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

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

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

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

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

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

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

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

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

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

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

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

1-16 | 101485-NJ-VA

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

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

Underwritten by Colonial Life & Accident Insurance Company, Columbia, SC ©2018 Colonial Life & Accident Insurance Company. All rights reserved. Colonial Life is a registered trademark and marketing brand of Colonial Life & Accident Insurance Company. ADR1962-2018

CANCER BENEFIT PREMIUMS LEVEL 1 - Composite Rates

24-Pay Premium

Employee

Employee/Spouse

One-Parent Family

Two-Parent Family

$5.73

$9.13

$5.80

$9.20

LEVEL 2 - Composite Rates

24-Pay Premium

Employee

Employee/Spouse

One-Parent Family

Two-Parent Family

$7.50

$11.75

$7.65

$11.90

LEVEL 3 - Composite Rates

24-Pay Premium

Employee

Employee/Spouse

One-Parent Family

Two-Parent Family

$10.00

$17.03

$10.23

$17.25

LEVEL 4 - Composite Rates

24-Pay Premium

Employee

Employee/Spouse

One-Parent Family

Two-Parent Family

$14.48

$24.53

$14.78

$24.83

One-Parent Family

Two-Parent Family

$0.88

$0.63

$0.88

$1.25

$0.80

$1.30

$3.90

$8.53

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%

For more information, talk with your Colonial Life benefits counselor.

ICI6000 - SUPPLEMENTAL CONDITIONS RIDER

Critical Illness Insurance* Wellbeing Assistance 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. 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 • Blood test for triglycerides

• Flexible sigmoidoscopy

• Bone marrow testing

• Hemoccult stool analysis

• BRCA1 or BRCA2 testing

• Mammography

• Breast ultrasound

• Pap smear

• 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

• Serum protein electrophoresis (blood test for myeloma)

• CEA (blood test for colon cancer)

• Skin cancer biopsy

• Chest X-ray

• Stress test on a bicycle or treadmill

• Colonoscopy

• Thermography

• Echocardiogram (ECHO)

• ThinPrep pap test

• Electrocardiogram (EKG, ECG)

• Virtual colonoscopy

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

• Fasting blood glucose test

ICI6000 – WELLBEING ASSISTANCE BENEFIT

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 $3.79

Two Parent Family $5.81

Welbeing Amount $100

$1.27 $2.05 Wellbeing Assistance Benefit Rates by wellbeing amount = 1 unit Named Employee & Insured Spouse $2.37 $3.63 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 $3.79

Two Parent Family $5.81

Welbeing Amount $100

$1.98 $3.14 Wellbeing Assistance Benefit Rates by wellbeing amount = 1 unit Named Employee & Insured Spouse $2.37 $3.63 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

Educator Disability Income Insurance

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

$_________________

$_________________ Total $_________________

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

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

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

On-Job

Off-Job

First 3 months

$_____________/month

Next 9 months

$_____________/month

First 6 months

$_____________/month

Next 6 months

$_____________/month

= Total Disability

Educator Disability 1.0-VA

Option A Option B = Partial Disability Up to 3 months

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

After a Sickness: ___________ days

How much will it cost? Your cost will vary based on the level of coverage you select. 65

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

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

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

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

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

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

Complete Fractures Complete Fractures requiring closed reduction Hip, Thigh ....................................................................................................................................................................................$1,500 Vertebrae ....................................................................................................................................................................................... 1,350 Pelvis ............................................................................................................................................................................................... 1,200 Skull (depressed) ......................................................................................................................................................................... 1,125 Leg .......................................................................................................................................................................................................900 Foot, Ankle, Kneecap .....................................................................................................................................................................750 Forearm, Hand, Wrist .....................................................................................................................................................................750 Lower Jaw ..........................................................................................................................................................................................600 Shoulder Blade, Collarbone ........................................................................................................................................................600 Skull (simple) ....................................................................................................................................................................................525 Upper Arm, Upper Jaw .................................................................................................................................................................525 Facial Bones ......................................................................................................................................................................................450 Vertebral Processes ........................................................................................................................................................................300 Coccyx, Rib, Finger, Toe ................................................................................................................................................................120 66

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

Additional Features l

Waiver of Premium

Worldwide Coverage

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

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

Hospital Confinement Benefit for Accident or Sickness l

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

Accidental Death and Dismemberment Benefits l

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

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

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

Here are some

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

What if I change employers?

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

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

When am I considered totally disabled?

Can my premium change?

Totally disabled means you are: l

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

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

When do disability benefits end? The Total Disability Benefit will end on the policy anniversary date on or after your 70th birthday. The Hospital Confinement benefit increases when the Total Disability Benefit ends. A pre-existing condition is when you have a sickness or physical condition for which you were treated, had medical testing, received medical advice, or had taken medication within 12 months testing, or before the effective date of your policy.

What is a covered accident or a covered sickness? A covered accident is an accident. A covered sickness means an illness, infection, disease or any other abnormal physical condition, not caused by an injury. A covered accident or covered sickness: l Occurs after the effective date of the policy; l Occurs while the policy is in force; l Is of a type listed on the Policy Schedule; and l Is not excluded by name or specific description in the policy. EXCLUSIONS We will not pay benefits for injuries received in accidents or sicknesses which are caused by or are the result of: alcoholism or drug addiction; flying; giving birth within the first nine months after the effective date of the policy; felonies or illegal occupations; having a pre-existing condition as described and limited by the policy; psychiatric or psychological condition; committing or trying to commit suicide or injuring yourself intentionally; being exposed to war or any act of war or serving in the armed forces of any country or authority. For cost and complete details, see your Colonial Life benefits counselor. Applicable to policy form ED DIS 1.0-VA. Coverage may vary by state and may not be available in all states. This is not an insurance contract and only the actual policy provisions will control.

If you become disabled because of a pre-existing condition, Colonial Life will not pay for any disability period if it begins during the first 12 months the policy is in force. Colonial Life 1200 Colonial Life Boulevard Columbia, South Carolina 29210 coloniallife.com 6/11

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

Colonial Life and Making benefits count are registered service marks of Colonial Life &71381-1 Accident Insurance Company. 100252 68

Educator Disability 1.0-VA

What is a pre-existing condition?

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

Ã$! ÿ Äÿ #& ÿ ÿ Å&" &+&% ÿ& ")$ !ÿ& ÿÆ&$& &

ÿ ÿ !"ÿ!#!$ % & ÿ'ÿ!#! ÿ ()$ÿ*& & +ÿ"&%) %&( ,ÿ

-6 9 66 ÿ67 297 5ÿ 97ÿ 5.ÿ 1 ÿ.9 ÿ812ÿ5/52 09 ÿ6/671ÿ52.57 5 ÿ970ÿ55.ÿ 1 ÿ 81 50ÿ17ÿ9671ÿ 925ÿ18ÿ 5ÿ75 ÿ9006617ÿ1ÿ 1 2ÿ8946

345ÿ789:;8<8=>ÿ8?9@A:?BCÿB:?ÿDC<E

012ÿ4125ÿ6781249617ÿ 9 ÿ 6 ÿ 1 2ÿ 57586 ÿ 1 7 512

Fÿ ÿGÿ 5ÿ 9ÿ25 1/52 ÿ.52610ÿ6 ÿ 62ÿ 55 ÿH717I 5 92597ÿ056/52 Jÿ12ÿ561 ÿ 55 ÿH 5 92597ÿ 056/52 J ÿ-6 9 66 ÿ 57586 ÿ18ÿ .ÿ1ÿKLÿ 55 ÿ49 ÿ 5ÿ9/969 5ÿ68ÿ 1 ÿ 1767 5ÿ1ÿ 5ÿ 06 9 50ÿ8214ÿ 60 62 Fÿ ÿM57586 ÿ925ÿ.960ÿ0625 ÿ1ÿ 1 ÿ1ÿ 5ÿ9 ÿ 1 ÿ 55ÿ86 Fÿ ÿN1 2ÿ06 9 66 ÿ 57586 ÿ925ÿ71ÿ9O5 50ÿ ÿ 1 2ÿ54.1 52P ÿ59/5ÿ18ÿ9 57 5ÿ.211294ÿ 5ÿ 0946 ÿQ506 9ÿ 59/5ÿR ÿH0Q RJÿ 1 2ÿ 6 ÿ59/5ÿ12ÿ.960ÿ645ÿ1OS/9 9617ÿ645 Fÿ ÿT8ÿ 1 ÿ 525ÿ71ÿ.251797ÿ 58125ÿ 1 2ÿ 1/52915ÿ5O5 6/5ÿ095ÿ.251797 ÿ 14.6 9617 ÿ ÿ 9 ÿ.25I524ÿ9 12ÿ15 96179ÿ069 55 ÿ970ÿ.25I5 94. 69ÿ925ÿ25950ÿU ÿ65ÿ97 ÿ1 52ÿ 1/5250ÿ 6 75 N1 2ÿ06 9 66 ÿ.16 ÿ 9 ÿ9ÿ16/671ÿ 62 ÿ6469617ÿ 6 ÿ4597 ÿ 11769ÿ 685ÿ 6ÿ71ÿ.9 ÿ06 9 66 ÿ 57586 ÿ68ÿ 1 ÿ16/5ÿ 62 ÿ 6 67ÿ 5ÿ862 ÿ7675ÿ417 ÿ9V52ÿ 1 2ÿ 1/52915ÿ5O5 6/5ÿ095 ÿT8ÿ 5ÿ .251797 ÿ6 ÿ 17 605250ÿ9ÿ.25I526 671ÿ 1706617ÿ97 ÿ095 ÿ46 50ÿ8214ÿ 12ÿ0 5ÿ1ÿ.251797 ÿ 056/52 ÿ12ÿ9 1 6950ÿ 14.6 9617 ÿ49 ÿ71ÿ 5ÿ 1/5250

W?7CA9=:?78?Xÿ>4@AÿB<:8YÿE:>YC?=

T8ÿ 1 2ÿ 964ÿ812ÿ 60 62 ÿ6 ÿ9..21/50ÿ 1 2ÿ 57586 ÿ 6ÿ 92ÿ8214ÿ 1 2ÿ862 ÿ09 ÿ18ÿ06 9 66 ÿ0 5ÿ1ÿ 60 62 ÿG 6 ÿ6 ÿ9..6 9 5ÿ812ÿZ6216769ÿ06 9 66 ÿ.16 65 ÿ 9ÿ 9/5ÿ9ÿ 1/52915ÿ5O5 6/5ÿ095ÿ18ÿ [ ÿKÿL\LKÿ12ÿ952 ·®®¸ ·®®¸ÿ·®®¸ ·®®¸ ·®®¸ ·®®¸ ·®®¸ ·®®¸ ·®®¸ ·®®¸ ·®®¸ ·®®¸ ²®®¯ª«ª¬ ³°µ́±®®±°¶ªÿ ¹ º » ¼ ½ ¾ ¿ À Á ¹Â ¹¹ ¹º

11769 685 14

²®®¯³°µ́±®®±°¶ª

·®®¸ ·®®¸ÿ·®®¸ ·®®¸ ·®®¸ ·®®¸ ·®®¸ ·®®¸ ·®®¸ ·®®¸ ·®®¸ ·®®¸ ¹ º » ¼ ½ ¾ ¿ À Á ¹Â ¹¹ ¹º

Fÿxb_h_gnÿkibic_h`ÿmgugkniÿ Fÿ dbh_boijÿj_`gk_n_hu ÿ ÿ ÿ ÿ ÿ ÿ ÿ ÿ ÿ ÿ ÿ¡ ¢ ÿ ÿ ÿ ÿ £ ÿ ¤ÿ ÿ¥ ÿ ÿ ÿ ÿ ¦ÿ ÿ§¨ÿ¡ ¢ ÿ ÿ ÿ ¤ÿ¡ ÿ ÿ ÿ ÿ ÿ ÿ ÿ¡ ¢ ÿ £ ©

Ç8<8?Xÿ>4@Aÿ789:;8<8=>ÿB<:8Y

T8ÿ 525ÿ925ÿ71ÿ 14.6 9617 ÿ 1 ÿ 1 0ÿ865ÿ 1 2ÿ 964ÿ9V52ÿ056/52 ÿ012ÿ 14.6 9617 ÿ 58125ÿ056/52 ÿ 1 ÿ 1 0ÿ865ÿ 1 2ÿ 964ÿ9 ÿ 117ÿ9 ÿ 5ÿ01 12ÿ6706 95 ÿ 1 ÿ925ÿ 79 5ÿ 1ÿ 1767 5ÿ 12671

]^_`ÿ_bcdefgh_dbÿ_`ÿbdhÿ_bhibjijÿhdÿkiÿgÿldfmnihiÿji`le_mh_dbÿdcÿhîÿ_bòegbliÿldpiegqiÿgpg_ngknirÿ]îÿ_bòegbliÿ ^g`ÿislno`_db`ÿgbjÿn_f_hgh_db`ÿt^_l^ÿfguÿgvilhÿgbuÿkibic_h`ÿmgugknirÿwmmn_lgkniÿhdÿmdn_luÿcdefÿxy]z{|||}~wÿgbjÿe_jieÿ cdefÿxy]z{|||}wzx }~w ÿmdn_luÿcdefÿzxy |||}~w ÿmdn_luÿcdefÿzxy |||}{ }~w ÿmdn_luÿcdefÿ zzxy r|}~w ÿmdn_luÿcdefÿ zxy}}~wÿgbjÿlieh_c_lghiÿcdefÿ zxy} }~wrÿ deÿld`hÿgbjÿldfmnihiÿjihg_ǹÿdcÿldpiegqi ÿlgnnÿdeÿte_hiÿudoeÿ dndb_gnÿ _ciÿ kibic_h`ÿldobìndeÿdeÿhîÿldfmgburÿ Èbjiete_hhibÿkuÿ dndb_gnÿ _ciÿÉÿwll_jibhÿxbòegbliÿ dfmgbu ÿ dnofk_g ÿy Ê | ÿ dndb_gnÿ _ciÿÉÿwll_jibhÿxbòegbliÿ dfmgburÿwnnÿe_q^h`ÿeiìepijrÿ dndb_gnÿ _ciÿ_`ÿgÿ eiq_`hieijÿhegjifgeËÿgbjÿfgeËih_bqÿkegbjÿdcÿ dndb_gnÿ _ciÿÉÿwll_jibhÿxbòegbliÿ dfmgbur

} ÿ ÿ || |{}~w

69 µ8 AX8?8:ÿ́¯Ì²»ÂÂÂÍÿ²89:;8<8=>ÿ¹ÂÂÂÍÿ®7@B:=4Aÿ²89:;8<8=>ÿ58=Dÿ:ÿ®²ÿ4Îÿ¿Ï¹Ïº¹ÿ4Aÿ<:=CAÿ«±ÿ

ÐA4@Eÿ²89:;8<8=>ÿY:9=CAÿE4<8B>ÿ58=Dÿ®²ÿ¿Ï¹Ïº¹ÿ4Aÿ<:=CAÑ

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

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

Benefit Amount

Elimination Period

First 3 months

Next 9 Months

Units

0/7

0/14

14/14

0/30

30/30

400

200

$18.40

$16.00

$15.00

$14.80

$12.80

600

300

$24.30

$20.70

$19.20

$18.90

$15.90

800

400

$30.20

$25.40

$23.40

$23.00

$19.00

1000

500

$36.10

$30.10

$27.60

$27.10

$22.10

1200

600

$42.00

$34.80

$31.80

$31.20

$25.20

1400

700

$47.90

$39.50

$36.00

$35.30

$28.30

1600

800

$53.80

$44.20

$40.20

$39.40

$31.40

1800

900

$59.70

$48.90

$44.40

$43.50

$34.50

2000

1000

$65.60

$53.60

$48.60

$47.60

$37.60

2200

1100

$71.50

$58.30

$52.80

$51.70

$40.70

2400

1200

$77.40

$63.00

$57.00

$55.80

$43.80

2600

1300

$83.30

$67.70

$61.20

$59.90

$46.90

2800

1400

$89.20

$72.40

$65.40

$64.00

$50.00

3000

1500

$95.10

$77.10

$69.60

$68.10

$53.10

3200

1600

$101.00

$81.80

$73.80

$72.20

$56.20

3400

1700

$106.90

$86.50

$78.00

$76.30

$59.30

3600

1800

$112.80

$91.20

$82.20

$80.40

$62.40

3800

1900

$118.70

$95.90

$86.40

$84.50

$65.50

4000

2000

$124.60

$100.60

$90.60

$88.60

$68.60

4200

2100

$130.50

$105.30

$94.80

$92.70

$71.70

4400

2200

$136.40

$110.00

$99.00

$96.80

$74.80

4600

2300

$142.30

$114.70

$103.20

$100.90

$77.90

4800

2400

$148.20

$119.40

$107.40

$105.00

$81.00

5000

2500

$154.10

$124.10

$111.60

$109.10

$84.10

Spouse and Dependent Premiums Rider

Monthly Premium

Spouse Accident & Sickness Benefit Coverage

$5.50

Child(ren) Accident & Sickness Benefit Coverage

$7.50

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

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

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

Benefit Amount

Elimination Period

First 3 months

Next 9 Months

Units

0/7

0/14

14/14

0/30

30/30

400

200

$23.60

$21.40

$19.40

$18.80

$16.00

600

300

$32.10

$28.80

$25.80

$24.90

$20.70

800

400

$40.60

$36.20

$32.20

$31.00

$25.40

1000

500

$49.10

$43.60

$38.60

$37.10

$30.10

1200

600

$57.60

$51.00

$45.00

$43.20

$34.80

1400

700

$66.10

$58.40

$51.40

$49.30

$39.50

1600

800

$74.60

$65.80

$57.80

$55.40

$44.20

1800

900

$83.10

$73.20

$64.20

$61.50

$48.90

2000

1000

$91.60

$80.60

$70.60

$67.60

$53.60

2200

1100

$100.10

$88.00

$77.00

$73.70

$58.30

2400

1200

$108.60

$95.40

$83.40

$79.80

$63.00

2600

1300

$117.10

$102.80

$89.80

$85.90

$67.70

2800

1400

$125.60

$110.20

$96.20

$92.00

$72.40

3000

1500

$134.10

$117.60

$102.60

$98.10

$77.10

3200

1600

$142.60

$125.00

$109.00

$104.20

$81.80

3400

1700

$151.10

$132.40

$115.40

$110.30

$86.50

3600

1800

$159.60

$139.80

$121.80

$116.40

$91.20

3800

1900

$168.10

$147.20

$128.20

$122.50

$95.90

4000

2000

$176.60

$154.60

$134.60

$128.60

$100.60

4200

2100

$185.10

$162.00

$141.00

$134.70

$105.30

4400

2200

$193.60

$169.40

$147.40

$140.80

$110.00

4600

2300

$202.10

$176.80

$153.80

$146.90

$114.70

4800

2400

$210.60

$184.20

$160.20

$153.00

$119.40

5000

2500

$219.10

$191.60

$166.60

$159.10

$124.10

Spouse and Dependent Premiums Rider

Monthly Premium

Spouse Accident & Sickness Benefit Coverage

$5.50

Child(ren) Accident & Sickness Benefit Coverage

$7.50

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

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

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

Benefit Amount

Elimination Period

First 3 months

Next 9 Months

Units

0/7

0/14

14/14

0/30

30/30

400

200

$27.00

$23.60

$21.80

$21.60

$17.80

600

300

$37.20

$32.10

$29.40

$29.10

$23.40

800

400

$47.40

$40.60

$37.00

$36.60

$29.00

1000

500

$57.60

$49.10

$44.60

$44.10

$34.60

1200

600

$67.80

$57.60

$52.20

$51.60

$40.20

1400

700

$78.00

$66.10

$59.80

$59.10

$45.80

1600

800

$88.20

$74.60

$67.40

$66.60

$51.40

1800

900

$98.40

$83.10

$75.00

$74.10

$57.00

2000

1000

$108.60

$91.60

$82.60

$81.60

$62.60

2200

1100

$118.80

$100.10

$90.20

$89.10

$68.20

2400

1200

$129.00

$108.60

$97.80

$96.60

$73.80

2600

1300

$139.20

$117.10

$105.40

$104.10

$79.40

2800

1400

$149.40

$125.60

$113.00

$111.60

$85.00

3000

1500

$159.60

$134.10

$120.60

$119.10

$90.60

3200

1600

$169.80

$142.60

$128.20

$126.60

$96.20

3400

1700

$180.00

$151.10

$135.80

$134.10

$101.80

3600

1800

$190.20

$159.60

$143.40

$141.60

$107.40

3800

1900

$200.40

$168.10

$151.00

$149.10

$113.00

4000

2000

$210.60

$176.60

$158.60

$156.60

$118.60

4200

2100

$220.80

$185.10

$166.20

$164.10

$124.20

4400

2200

$231.00

$193.60

$173.80

$171.60

$129.80

4600

2300

$241.20

$202.10

$181.40

$179.10

$135.40

4800

2400

$251.40

$210.60

$189.00

$186.60

$141.00

5000

2500

$261.60

$219.10

$196.60

$194.10

$146.60

Spouse and Dependent Premiums Rider

Monthly Premium

Spouse Accident & Sickness Benefit Coverage

$5.50

Child(ren) Accident & Sickness Benefit Coverage

$7.50

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

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

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

Elimination Period

First 3 months

Next 9 Months

Units

0/7

0/14

14/14

0/30

30/30

400

200

$14.45

$12.05

$10.85

$10.05

$9.25

600

300

$19.35

$15.75

$13.95

$12.75

$11.55

800

400

$24.25

$19.45

$17.05

$15.45

$13.85

1000

500

$29.15

$23.15

$20.15

$18.15

$16.15

1200

600

$34.05

$26.85

$23.25

$20.85

$18.45

1400

700

$38.95

$30.55

$26.35

$23.55

$20.75

1600

800

$43.85

$34.25

$29.45

$26.25

$23.05

1800

900

$48.75

$37.95

$32.55

$28.95

$25.35

2000

1000

$53.65

$41.65

$35.65

$31.65

$27.65

2200

1100

$58.55

$45.35

$38.75

$34.35

$29.95

2400

1200

$63.45

$49.05

$41.85

$37.05

$32.25

2600

1300

$68.35

$52.75

$44.95

$39.75

$34.55

2800

1400

$73.25

$56.45

$48.05

$42.45

$36.85

3000

1500

$78.15

$60.15

$51.15

$45.15

$39.15

3200

1600

$83.05

$63.85

$54.25

$47.85

$41.45

3400

1700

$87.95

$67.55

$57.35

$50.55

$43.75

3600

1800

$92.85

$71.25

$60.45

$53.25

$46.05

3800

1900

$97.75

$74.95

$63.55

$55.95

$48.35

4000

2000

$102.65

$78.65

$66.65

$58.65

$50.65

4200

2100

$107.55

$82.35

$69.75

$61.35

$52.95

4400

2200

$112.45

$86.05

$72.85

$64.05

$55.25

4600

2300

$117.35

$89.75

$75.95

$66.75

$57.55

4800

2400

$122.25

$93.45

$79.05

$69.45

$59.85

5000

2500

$127.15

$97.15

$82.15

$72.15

$62.15

Spouse and Dependent Premiums Rider

Monthly Premium

Spouse Accident & Sickness Benefit Coverage

$5.50

Child(ren) Accident & Sickness Benefit Coverage

$7.50

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

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

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

Elimination Period

First 3 months

Next 9 Months

Units

0/7

0/14

14/14

0/30

30/30

400

200

$19.65

$16.05

$14.45

$12.85

$11.65

600

300

$27.15

$21.75

$19.35

$16.95

$15.15

800

400

$34.65

$27.45

$24.25

$21.05

$18.65

1000

500

$42.15

$33.15

$29.15

$25.15

$22.15

1200

600

$49.65

$38.85

$34.05

$29.25

$25.65

1400

700

$57.15

$44.55

$38.95

$33.35

$29.15

1600

800

$64.65

$50.25

$43.85

$37.45

$32.65

1800

900

$72.15

$55.95

$48.75

$41.55

$36.15

2000

1000

$79.65

$61.65

$53.65

$45.65

$39.65

2200

1100

$87.15

$67.35

$58.55

$49.75

$43.15

2400

1200

$94.65

$73.05

$63.45

$53.85

$46.65

2600

1300

$102.15

$78.75

$68.35

$57.95

$50.15

2800

1400

$109.65

$84.45

$73.25

$62.05

$53.65

3000

1500

$117.15

$90.15

$78.15

$66.15

$57.15

3200

1600

$124.65

$95.85

$83.05

$70.25

$60.65

3400

1700

$132.15

$101.55

$87.95

$74.35

$64.15

3600

1800

$139.65

$107.25

$92.85

$78.45

$67.65

3800

1900

$147.15

$112.95

$97.75

$82.55

$71.15

4000

2000

$154.65

$118.65

$102.65

$86.65

$74.65

4200

2100

$162.15

$124.35

$107.55

$90.75

$78.15

4400

2200

$169.65

$130.05

$112.45

$94.85

$81.65

4600

2300

$177.15

$135.75

$117.35

$98.95

$85.15

4800

2400

$184.65

$141.45

$122.25

$103.05

$88.65

5000

2500

$192.15

$147.15

$127.15

$107.15

$92.15

Spouse and Dependent Premiums Rider

Monthly Premium

Spouse Accident & Sickness Benefit Coverage

$5.50

Child(ren) Accident & Sickness Benefit Coverage

$7.50

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

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

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

Elimination Period

First 3 months

Next 9 Months

Units

0/7

0/14

14/14

0/30

30/30

400

200

$22.25

$17.45

$16.05

$14.25

$12.65

600

300

$31.05

$23.85

$21.75

$19.05

$16.65

800

400

$39.85

$30.25

$27.45

$23.85

$20.65

1000

500

$48.65

$36.65

$33.15

$28.65

$24.65

1200

600

$57.45

$43.05

$38.85

$33.45

$28.65

1400

700

$66.25

$49.45

$44.55

$38.25

$32.65

1600

800

$75.05

$55.85

$50.25

$43.05

$36.65

1800

900

$83.85

$62.25

$55.95

$47.85

$40.65

2000

1000

$92.65

$68.65

$61.65

$52.65

$44.65

2200

1100

$101.45

$75.05

$67.35

$57.45

$48.65

2400

1200

$110.25

$81.45

$73.05

$62.25

$52.65

2600

1300

$119.05

$87.85

$78.75

$67.05

$56.65

2800

1400

$127.85

$94.25

$84.45

$71.85

$60.65

3000

1500

$136.65

$100.65

$90.15

$76.65

$64.65

3200

1600

$145.45

$107.05

$95.85

$81.45

$68.65

3400

1700

$154.25

$113.45

$101.55

$86.25

$72.65

3600

1800

$163.05

$119.85

$107.25

$91.05

$76.65

3800

1900

$171.85

$126.25

$112.95

$95.85

$80.65

4000

2000

$180.65

$132.65

$118.65

$100.65

$84.65

4200

2100

$189.45

$139.05

$124.35

$105.45

$88.65

4400

2200

$198.25

$145.45

$130.05

$110.25

$92.65

4600

2300

$207.05

$151.85

$135.75

$115.05

$96.65

4800

2400

$215.85

$158.25

$141.45

$119.85

$100.65

5000

2500

$224.65

$164.65

$147.15

$124.65

$104.65

Spouse and Dependent Premiums Rider

Monthly Premium

Spouse Accident & Sickness Benefit Coverage

$5.50

Child(ren) Accident & Sickness Benefit Coverage

$7.50

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

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

LONG-TERM DISABILITY BENEFITS

Plan Highlights

Voluntary Group Long Term Disability Insurance

Franklin City Public Schools COVERAGE

RATES

Disability income protection insurance provides a benefit for “long term” disability resulting from a covered injury or sickness. Benefits begin at the end of the elimination period and continue while you are disabled up to the maximum benefit duration.

See attached Rate Sheet.

FEATURES FMLA Continuation Minimum Benefit Payable – $50 Own Occupation Coverage – 24 months Residual and Partial Disability Specific Indemnity Benefit Survivor Benefit – 3 months Work Incentive & Child Care provisions

ELIGIBILITY Each Active, Full‐time employee working 30 or more hours per week, and earning an annual salary of at least $15,000, except any person working on a temporary or seasonal basis.

BENEFIT AMOUNT You may elect a monthly benefit in increments of $500, from a minimum of $500 up to a maximum benefit of $6,000 per month, not to exceed 60% of your covered earnings (rounded to the next lower increment).

VALUE ADDED SERVICES Travel Assistance Service

LIMITATIONS

ELIMINATION PERIOD 90 consecutive days of total disability

Please note‐ pre‐ex limitations also apply to benefit increases

MAXIMUM BENEFIT DURATION

EXCLUSIONS

Benefits will not extend beyond the longer of: Social Security Normal Retirement Age or Duration of Benefits below:

Benefits will not be payable for any disability caused by: an intentionally self‐inflicted injury; an act of war (declared or undeclared); commission of a felony;injury or sickness occurring while confined in any penal or correctional institution.

Age at Disablement Duration of Benefits 61 or less

to age 65

3 ½ years

3 years

2 ½ years

2 years

1 ¾ years

1 ½ years

1 ¼ years

69 or more

1 year

CONTRIBUTION REQUIREMENTS

For a comprehensive list of exclusions, limitations, and any applicable benefit offsets, please refer to the Certificate of Insurance. The Certificate also provides all requirements necessary to be eligible for coverage and benefits. This Plan Highlights is a brief description of the key features of the RSL insurance plan. The availability of the benefits and features described may vary by state. It is not a certificate of insurance or evidence of coverage. Insurance is provided under group policy form LRS‐6564, et al.

Coverage is 100% employee paid.

www.RelianceStandard.com

Reliance Standard Voluntary Plans Voluntary Group Long Term Disability Insurance Premium Table Plan Holder: Franklin City Public Schools - VPL # 302578 Scheduled Benefit: Each eligible employee may elect an amount of insurance, in increments of $500 from a minimum of $500 to a maximum of $6,000 per month up to 60% of covered earnings. You may select any benefit amount from $500 up to your maximum monthly benefit. Locate your annual earnings to determine your maximum monthly benefit amount. If your covered earnings fall between ranges, the lesser benefit amount will apply.

Employee Monthly Premiums Monthly Benefit Amount

Age -19

Age 20-24

Age 25-29

Age 30-34

Age 35-39

Age 40-44

$15,000

$500

$0.60

$0.95

$1.75

$2.80

$4.85

$20,000

$1,000

$1.20

$1.90

$3.50

$5.60

$9.70

$30,000

$1,500

$1.80

$2.85

$5.25

$8.40

$14.55

$40,000

$2,000

$2.40

$3.80

$7.00

$11.20

$19.40

$50,000

$2,500

$3.00

$4.75

$8.75

$14.00

$60,000

$3,000

$3.60

$5.70

$10.50

$70,000

$3,500

$4.20

$6.65

$80,000

$4,000

$4.80

$7.60

$90,000

$4,500

$5.40

$100,000

$5,000

$6.00

$110,000

$5,500

$6.60

$120,000

$6,000

$7.20

Annual Earnings

Age 65-69

Age 70+

$8.95

$6.05

$4.40

$17.90

$12.10

$8.80

$26.85

$18.15

$13.20

$35.80

$24.20

$17.60

$58.00

$44.75

$30.25

$22.00

$54.00

$69.60

$53.70

$36.30

$26.40

$44.45

$63.00

$81.20

$62.65

$42.35

$30.80

$50.80

$72.00

$92.80

$71.60

$48.40

$35.20

$43.65

$57.15

$81.00

$104.40

$80.55

$54.45

$39.60

$48.50

$63.50

$90.00

$116.00

$89.50

$60.50

$44.00

$30.80

$53.35

$69.85

$99.00

$127.60

$98.45

$66.55

$48.40

$33.60

$58.20

$76.20

$108.00

$139.20

$107.40

$72.60

$52.80

Age 50-54

Age 55-59

$6.35

$9.00

$11.60

$12.70

$18.00

$23.20

$19.05

$27.00

$34.80

$25.40

$36.00

$46.40

$24.25

$31.75

$45.00

$16.80

$29.10

$38.10

$12.25

$19.60

$33.95

$14.00

$22.40

$38.80

$8.55

$15.75

$25.20

$9.50

$17.50

$28.00

$6.60

$10.45

$19.25

$7.20

$11.40

$21.00

Age 45-49

Age 60-64

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)

$40 $475

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)

$40

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

Accident follow-up treatment (3 visits)

$165

Total

$875

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 • Accident emergency treatment • Injury due to auto accident

$250 $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)

$40 $250 $5,600

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)

$1,250 $350 $900

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

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

$360 $125

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

Accident follow-up treatment (6 visits)

$330

Total

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

$9,830

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

Initial care

Dislocation — separated joint • Non-surgical — repair . . . . . . . . . . . . . . . . . . . . . . . $125–$2,750 Examples: elbow: $600 | ankle: $1,250 | hip: $2,750

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 ambulance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $2,400 Ambulance — ground or water . . . . . . . . . . . . . . . . . . . . . . . . . $250

• Surgical — repair . . . . . . . . . . . . . . . . . . . . . . . . . . . . $250–$5,500 Examples: elbow: $1,200 | ankle: $2,500 | hip: $5,500

Observation room . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$175 per day (up to two days per calendar year)

Emergency dental work . . . . . . . . . . . . . . . . . . . . . . . . . . $125–$350 Dental extraction or dental crown, denture or implant

X-ray. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $40

Common accidental injuries

Eye injury — with surgical repair or removal of a foreign object . . . . . . . . . . . . . . . . . . . . . . . . . . . . $350

Burn . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $1,000–$15,000 (based on size and degree)

Fracture — complete

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

• Non-surgical — repair . . . . . . . . . . . . . . . . . . . . . . . $300–$3,750 Examples: hand/foot: $475 | collarbone: $775 | leg: $1,250

Coma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $15,000 (lasting for seven or more consecutive days)

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

Concussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $200

• Surgical — repair . . . . . . . . . . . . . . . . . . . . . . . . . . . . $600–$7,500 Examples: hand/foot: $950 | collarbone: $1,550 | leg: $2,500

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. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $40 Arm sling, cane, medical ring cushion, neck brace or wrist/ankle splint • Tier 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $125 Bedside commode, cold therapy system (cryotherapy), crutches, leg brace, shower chair, walker or walking boot • Tier 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $250 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. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $250 (one per calendar year) Pain management for epidural anesthesia — non-surgical . . $125 Post-traumatic stress disorder (PTSD) . . . . . . . . . . . . . . . . . $250 Prosthetic device/artificial limb Hearing-loss injuries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$140

• One . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $950

Knee cartilage — torn — with surgical repair . . . . . . . . . . . . . $800

• More than one . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $1,900

Laceration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $30–$750 (based on repair and length)

• Repair/replacement3 . . . . . . . . . . . . . . . . . . . . . . . . . . $475/$950

Rehabilitation unit confinement . . . . . . . . . . . . . . . . .$175 per day (up to 15 days, not to exceed 30 days per calendar year)

Ruptured disc — with surgical repair . . . . . . . . . . . . . . . . . . . $950 Tendon/ligament/rotator cuff — with surgical repair

Therapy — occupational, physical or speech . . . . . . $45 per day (up to 10 days)

• One . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $800 • Two or more . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $1,600

Accidental dismemberment

Hospital care

Accidental dismemberment . . . . . . . . . . . . . . . . . $1,050–$40,000 • 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 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $1,250 Hospital confinement . . . . . . . . . . . . . . . . . . . . . . . . . $300 per day (up to 365 days) Hospital sub-acute intensive care unit confinement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $400 per day (up to 30 days)

Accidental death

Intensive care unit admission . . . . . . . . . . . . . . . . . . . . . . . .$2,500

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

Accidental death • Child . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$10,000

Intensive care unit confinement . . . . . . . . . . . . . . . . $550 per day (up to 15 days)

Surgical care

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

Blood/plasma/platelets — transfusion . . . . . . . . . . . . . . . . . $400

• Named insured, spouse . . . . . . . . . . . . . . . . . . . . . . . . . .$160,000 • Child . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $30,000

Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $250–$1,900 (based on type of repair and surgery)

Transportation and lodging Transportation for hospital confinement . . $700 per round trip (up to three round trips, 50+ miles from home) Lodging–companion . . . . . . . . . . . . . . . . . . . . . . . . . . $150 per day (up to 30 days)

For more information, contact your Colonial Life benefits counselor.

1 Requires transportation by a licensed professional air ambulance or ambulance (ground or water). 2 One benefit for each injured ear per covered person per lifetime. 3 One repair or replacement per prosthetic device/artificial limb per covered person per lifetime. 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 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, sickness, suicide or injuries which any covered person intentionally does to himself, war or armed conflict. 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-VA. 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. © 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

7-24 | 101954-1-VA

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 BENEFIT PREMIUMS Preferred with Active Lifestyles On/Off-Job Accident Coverage

24-Pay Premium Named Insured

$9.14

Employee & Spouse

$15.41

One Parent Family Employee

$20.12

Two Parent Family

$26.38

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

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

MEDICAL BRIDGE BENEFITS

Hospital Confinement Indemnity Insurance Plan 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

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

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

– 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

IMB7000 – PLAN 2

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

– 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, war, or giving birth within the first nine months after the effective date of the policy. We will not pay benefits for hospital confinement of a newborn who is neither injured nor sick. We will not pay benefits for loss during the first 12 months after the effective date due to a pre-existing condition. A pre-existing condition is a sickness or physical condition for which a covered person was treated, had medical testing, received medical advice or had taken medication within the 12 months before the effective date of the policy. For cost and complete details, see your Colonial Life benefits counselor. Applicable to policy number IMB7000 (including state abbreviations where used, for example: IMB7000-TX). Coverage may vary by state and may not be available in all states. This is not an insurance contract and only the actual policy provisions will control. 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.

8-18 | 101578-1

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

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

Waiver of premium

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

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

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

For more information, talk with your benefits counselor.

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

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

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

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

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

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

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

1-16 | 101581-1

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

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

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

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

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

For more information, talk with your benefits counselor.

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

ColonialLife.com

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

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

Hospital Confinement Indemnity Insurance Medical Treatment Package

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

Air ambulance ............................................................................................. $1,000 Maximum of one benefit per covered person per calendar year

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

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

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

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

For more information, talk with your benefits counselor.

Maximum of two visits per covered person per calendar year

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

THIS POLICY PROVIDES LIMITED BENEFITS.

ColonialLife.com

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

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

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

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

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

For more information, talk with your benefits counselor.

EXCLUSIONS

ColonialLife.com

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

MEDICAL BRIDGE BENEFIT PREMIUMS INDIVIDUAL MEDICAL BRIDGE Plan 2 Named Insured Level 3

Level 4

Hospital Confinement Medical Treatment Pkg $100 Health Screening

$1,500.00

$2,000.00

Outpatient Surgical Procedure

Option 2 Tier 1 $750 Tier 2 $1,500 CY Max $2,500

$18.38 $24.18 $30.65 $39.43

$22.30 $29.45 $37.93 $49.03

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

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

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

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

TERM LIFE INSURANCE

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

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

Talk with your Colonial Life benefits counselor to learn more.

ColonialLife.com

Spouse coverage options

Dependent coverage options

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

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

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

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

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

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

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

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

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

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

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

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

Critical illness accelerated death benefit rider

£ Critical illness accelerated death benefit rider

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

£ Waiver of premium benefit rider

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

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

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

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

ColonialLife.com

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

100

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.

101

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. 103

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

104

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.

105

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

LEGAL BENEFITS

LEGAL SELECT BENEFIT PLAN

LEGAL RESOURCES COVERS 100% OF THE ATTORNEY FEES FOR FULLY COVERED LEGAL SERVICES

General Advice and Consultation

• Unlimited in-person or telephone advice and consultation for fully covered services

Family Law

• Uncontested domestic adoption • Uncontested divorce • Uncontested name change

Elder Law

• Estate advice • Powers of attorney for members’ parents

Criminal Matters2

• Defense of misdemeanor • Misdemeanor defense of juveniles Fully covered for first offense involving alcohol or illegal drugs

ID THEFT COVERAGE

INCLUDED WITH

LEGAL SELECT

Wills and Estate Planning

• Will preparation and periodic updates • Advance medical directive • Financial powers of attorney • Contingent trust for minor children

Traffic Violations

• Traffic infractions and misdemeanors • Speeding • Reckless driving • Driving under the influence 1st Offense

Civil Actions

• Representation as defendant • Representation as plaintiff • Insurance matters • Initial administrative hearing • Small Claims Court advice

Preparation and Review of Routine Legal Documents • Unlimited pages and occurrences

Real Estate

• Purchase, sale, or refinance of primary residence • Deed preparation • Tenant-Landlord matters • Landlord-Tenant consultation

Consumer Relations and Credit Protection • Warranty disputes • Billing disputes • Collection agency harassment

24/7 full-service restoration with a Certified Restoration Specialist Lost wallet & emergency cash assistance $1,000,000 of Identity Theft insurance to cover out of pocket expenses incurred to repair the victims identity

Don’t see your legal need listed? The Legal Resources Plan offers a 25% discount4 on all other legal needs, including pre-existing legal matters.

HOW THE PLAN WORKS

Choose a law firm that best suits your needs from our highly rated law firm network. Use our Law Firm Finder at LegalResources.com to find a firm near you.4 If you need to transfer to another Plan Law Firm, call Member Services.

Certified paralegals in our Member Services Department provide backup and support to assist you with any coverage or attorney-related questions.

This SUMMARY OF COVERAGE is intended to provide a broad general overview of plan coverage and is not a contract. Coverage may vary by organization. For specific coverage questions, please call Member Services at 800.728.5768.

107 99

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.

108

43233-41

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

109

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

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

110

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

REQUIRED HEALTH CARE NOTICES GEORGIA - MEDICAID

ALABAMA - MEDICAID Website: myalhipp.com Phone: 1-855-692-5447

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

ALASKA - MEDICAID

INDIANA - MEDICAID

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

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

ARKANSAS - MEDICAID

IOWA - MEDICAID AND CHIP (HAWKI)

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

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

CALIFORNIA - MEDICAID

KANSAS - MEDICAID

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

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

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

KENTUCKY - MEDICAID

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

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

FLORIDA - MEDICAID

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

LOUISIANA - MEDICAID

Website: www.flmedicaidtplrecovery.com/flmedicaidtplrecovery.com/hipp/index.html Phone: 1-877-357-3268 111

REQUIRED HEALTH CARE NOTICES MAINE - MEDICAID

NEVADA - MEDICAID

Website: www.maine.gov/dhhs/ofi/public assistance/index.html Phone: 1-800-442-6003 TTY: Maine Relay 711

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

NEW HAMPSHIRE - MEDICAID

MASSACHUSETTS - MEDICAID AND CHIP

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

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

NEW JERSEY - MEDICAID AND CHIP

MINNESOTA - MEDICAID

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

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

NEW YORK - MEDICAID

KANSAS - MEDICAID

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

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

NORTH CAROLINA - MEDICAID

MISSOURI - MEDICAID

Website: medicaid.ncdhhs.gov Phone: 919-855-4100

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

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

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

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

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

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

112

REQUIRED HEALTH CARE NOTICES PENNSYLVANIA - MEDICAID

VERMONT - MEDICAID

Website: www.dhs.pa.gov/providers/Providers/ Pages/Medical/HIPP-Program.aspx Phone: 1-800-692-7462

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

VIRGINIA - MEDICAID AND CHIP

RHODE ISLAND - MEDICAID AND CHIP

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

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

WASHINGTON - MEDICAID

SOUTH CAROLINA - MEDICAID

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

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

WEST VIRGINIA - MEDICAID

SOUTH DAKOTA - MEDICAID

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

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

TEXAS - MEDICAID

WISCONSIN - MEDICAID AND CHIP

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

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

UTAH - MEDICAID

WYOMING - MEDICAID

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

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

113

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

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

Paperwork Reduction Act Statement According to the Paperwork Reduction Act of 1995 (Pub. L. 104-13) (PRA), no persons are required to respond to a collection of information unless such collection displays a valid Office of Management and Budget (OMB) control number. The Department notes that a Federal agency cannot conduct or sponsor a collection of information unless it is approved by OMB under the PRA, and displays a currently valid OMB control number, and the public is not required to respond to a collection of information unless it displays a currently valid OMB control number. See 44 U.S.C. 3507. Also, notwithstanding any other provisions of law, no person shall be subject to penalty for failing to comply with a collection of information if the collection of information does not display a currently valid OMB control number. See 44 U.S.C. 3512. The public reporting burden for this collection of information is estimated to average approximately seven minutes per respondent. Interested parties are encouraged to send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the U.S. Department of Labor, Employee Benefits Security Administration, Office of Policy and Research, Attention: PRA Clearance Officer, 200 Constitution Avenue, N.W., Room N-5718, Washington, DC 20210 or email ebsa.opr@dol.gov and reference the OMB Control Number 1210-0137.

114

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 Franklin City Public Schools and that bankruptcy results in the loss of coverage of any retired employee covered under the Plan, the retired employee will become a qualified beneficiary. The retired employee’s spouse, surviving spouse, and dependent children will also become qualified beneficiaries if bankruptcy results in the loss of their coverage under the Plan.

What Is Cobra Continuation Coverage?: COBRA continuation coverage is a continuation of Plan coverage when it would otherwise end because of a life event. This is also called a “qualifying event.” Specific qualifying events are listed later in this notice. After a qualifying event, COBRA continuation coverage must be offered to each person who is a “qualified beneficiary.” You, your spouse, and your dependent children could become qualified beneficiaries if coverage under the Plan is lost because of the qualifying event. Under the Plan, qualified beneficiaries who elect COBRA continuation coverage [choose and enter appropriate information: must pay or aren’t required to pay] for COBRA continuation coverage.

When is COBRA continuation coverage available?

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

The Plan will offer COBRA continuation coverage to qualified beneficiaries only after the Plan Administrator has been notified that a qualifying event has occurred. The employer must notify the Plan Administrator of the following qualifying events: • The end of employment or reduction of hours of employment; • Death of the employee; • The employee’s becoming entitled to Medicare benefits (under Part A, Part B, or both). For all other qualifying events (divorce or legal separation of the employee and spouse or a dependent child’s losing eligibility for coverage as a dependent child), you must notify the Plan Administrator within 60 days after the qualifying event occurs. You must provide this notice to: Angela Edwards at Franklin City Public Schools. Applicable documentation will be required i.e. court order, certificate of coverage etc. How is COBRA continuation coverage provided? Once the Plan Administrator receives notice that a qualifying event has occurred, COBRA continuation coverage will be offered to each of the qualified beneficiaries. Each qualified beneficiary will have an independent right to elect COBRA continuation coverage. Covered employees may elect COBRA continuation coverage on behalf of their spouses, and parents may elect COBRA continuation coverage on behalf of their children. COBRA continuation coverage is a temporary continuation of coverage that generally lasts for 18 months due to employment termination or reduction of hours of work. Certain qualifying events,

115

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

the COBRA election, COBRA coverage may not be discontinued on account of Medicare entitlement, even if you enroll in the other part of Medicare after the date of the election of COBRA coverage.

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

If you are enrolled in both COBRA continuation coverage and Medicare, Medicare will generally pay first (primary payer) and COBRA continuation coverage will pay second. Certain plans may pay as if secondary to Medicare, even if you are not enrolled in Medicare.

Disability extension of 18-month period of COBRA continuation coverage: If you or anyone in your family covered under the Plan is determined by Social Security to be disabled and you notify the Plan Administrator in a timely fashion, you and your entire family may be entitled to get up to an additional 11 months of COBRA continuation coverage, for a maximum of 29 months. The disability would have to have started at some time before the 60th day of COBRA continuation coverage and must last at least until the end of the 18-month period of COBRA continuation coverage. Second qualifying event extension of 18-month period of continuation coverage: If your family experiences another qualifying event during the 18 months of COBRA continuation coverage, the spouse and dependent children in your family can get up to 18 additional months of COBRA continuation coverage, for a maximum of 36 months, if the Plan is properly notified about the second qualifying event. This extension may be available to the spouse and any dependent children getting COBRA continuation coverage if the employee or former employee dies; becomes entitled to Medicare benefits (under Part A, Part B, or both); gets divorced or legally separated; or if the dependent child stops being eligible under the Plan as a dependent child. This extension is only available if the second qualifying event would have caused the spouse or dependent child to lose coverage under the Plan had the first qualifying event not occurred. Are there other coverage options besides COBRA Continuation Coverage?: Yes. Instead of enrolling in COBRA continuation coverage, there may be other coverage options for you and your family through the Health Insurance Marketplace, Medicare, Medicaid, Children’s Health Insurance Program (CHIP), or other group health plan coverage options (such as a spouse’s plan) through what is called a “special enrollment period.” Some of these options may cost less than COBRA continuation coverage. You can learn more about many of these options at www.healthcare.gov. Can I enroll in Medicare instead of COBRA continuation coverage after my group health plan coverage ends?: In general, if you don’t enroll in Medicare Part A or B when you are first eligible because you are still employed, after the Medicare initial enrollment period, you have an 8-month special enrollment period to sign up for Medicare Part A or B, beginning on the earlier of

For more information visit https://www.medicare.gov/medicare-and-you. If you have questions: Questions concerning your Plan or your COBRA continuation coverage rights should be addressed to the contact or contacts identified below. For more information about your rights under the Employee Retirement Income Security Act (ERISA), including COBRA, the Patient Protection and Affordable Care Act, and other laws affecting group health plans, contact the nearest Regional or District Office of the U.S. Department of Labor’s Employee Benefits Security Administration (EBSA) in your area or visit www.dol.gov/ebsa. (Addresses and phone numbers of Regional and District EBSA Offices are available through EBSA’s website.) For more information about the Marketplace, visit www.HealthCare. gov. Keep your Plan informed of address changes: To protect your family’s rights, let the Plan Administrator knowabout any changes in the addresses of family members. You should also keep a copy, for your records, of any notices you send to the Plan Administrator. Plan Contact Information Franklin City Public Schools ATTN: Angela Edwards 207 West Second Avenue Franklin, VA 23851 FSA COBRA Administrator: Ameriflex 700 East Gate Drive Mount Laurel, NJ 08054 Phone: 888-868-3539

• 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

116

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

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

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

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

Upon receipt of a request from you, the Bureau will arrange disclosure of any information it may have in your file. If you question the accuracy of information in the Bureau’s file, you may contact the Bureau and seek a correction in accordance with the procedure set forth in the federal Fair If you believe NPI we have about you Credit Reporting Act. The address of is incorrect, please write us. Your letter the Bureau’s information office is: 50 should include your full name, address, Braintree Hill Park, Suite 400, Braintree, telephone number and policy number if we have issued a policy. Your letter should MA 02184-8734, telephone (617) 4263660. also explain why you believe the NPI is inaccurate. If we agree with you, we will Colonial or its reinsure may also correct the NPI and notify you of the release information in its file to other correction. We will also notify any person who may have received the incorrect NPI life insurance companies to whom you from us in the past two years if you ask us may apply for life or health insurance or to whom a claim for benefits may be to contact that person. submitted. If we disagree with you, we will tell you we are not going to make the correction, We will give the reason(s) for our refusal. We will also tell you that you may submit a statement to us. Your statement should include the NPI you believe is correct. It should also include the reasons(s) why you disagree with our decision not to correct the NPI 117

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

DENTAL BENEFITS

VISION BENEFITS

TELEMEDICINE BENEFITS

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

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

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

118

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.

SCAN TO VIEW YOUR CUSTOM BENEFITS MICROSITE