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EMPLOYEE BENEFITS GUIDE 2025 PLAN YEAR:

JULY 1, 2025 - JUNE 30, 2026

HENRY COUNTY PUBLIC SCHOOLS

WWW.PIERCEGROUPBENEFITS.COM

EMPLOYEE SERVICES: 800-387-5955

TABLE OF CONTENTS

EMPLOYEE BENEFITS GUIDE TABLE OF CONTENTS Welcome to Henry County 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, employee-paid benefits unless otherwise noted.

ENROLLMENT DATES: March 24, 2025 - April 18, 2025 PLAN YEAR & EFFECTIVE DATES: July 1, 2025 - June 30, 2026

Important Contact Information............................... 3 Eligibility Requirements......................................... 4 Overview Of Benefits............................................. 5 Important Notices................................................. 6 Mid-Year Events..................................................... 7 Enrollment Information.......................................... 9 BenSelect Enrollment Instructions......................... 10 Health Insurance................................................... 12 Dental Insurance................................................... 32 Vision Insurance.................................................... 37 Flexible Spending Account..................................... 40 Dependent Care Account....................................... 42 The FSA Store....................................................... 46 Long Term Care Benefits........................................ 47 Cancer Benefits..................................................... 51 Critical Illness Benefits.......................................... 61 Short-Term Disability Benefits................................ 72 Accident Benefits.................................................. 84 Medical Bridge Benefits......................................... 90 Term Life Insurance............................................... 99 Whole Life Insurance............................................. 103 Authorization For Colonial Life Insurance Form....... 108 Protected Health Information Privacy Practices...... 109 Additional Benefits................................................ 113 Required Health Care Notices................................ 114 COBRA Continuation Of Coverage.......................... 119 Privacy Notices..................................................... 121 Continuation Of Coverage...................................... 122

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.

HENRY COUNTY PUBLIC SCHOOLS 2025 Benefits Plan

July 1, 2025 - June 30, 2026

All information in this guide, including premiums quoted, is subject to change. All policy descriptions are for informational purposes only. Your actual policies may be different than those in this guide. Rev: 2/27/2025

IMPORTANT CONTACT INFORMATION Carrier

Phone/Fax

Website

Health Insurance

Anthem Health

P: 800-331-1476

www.anthem.com

Flexible Spending Accounts

Flexible Benefit Administrators

P: 1-800-437-3539 F: 757-431-1155

FlexDivision@flex-admin.com

fba.wealthcareportal.com

Dental Insurance

Delta Dental of VA

P: 800-237-6060

www.deltadentalVA.com

Vision Insurance

Superior Vision

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

www.superiorvision.com

Long Term Care Benefits

CHUBB

P: 833-542-2013 F: 312-351-7120

CWBclaimsteam@chubb.com

chubbworkplacebenefits.com

Student Loan Assistance Program

GradFin

P: 844-472-3346

www.gradfin.com

BenSelect Online Enrollment

BenSelect

P: 888-662-7500

harmony.benselect.com/ henryschools

To View Your Benefits Online

Pierce Group Benefits

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

service@ piercegroupbenefits.com

www.PierceGroupBenefits.com/ HenryCountyPublicSchools

www.coloniallife.com

Customer Service & Wellness Screenings

Supplemental Benefits

Colonial Life

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

800-798-4040

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

ELIGIBILITY REQUIREMENTS CURRENT EMPLOYEE? ANNUAL ENROLLMENT DATES: March 24, 2025 - April 18, 2025

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

ELIGIBILITY • Full-time employees working 30 or more hours per week, School Nutrition employees working more than 30 hours per week, and Grandfathered Bus Drivers are eligible for all benefits. • Part-time School Nutrition employees working 25 hours per week are eligible for dental and vision only.

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 - Please call PGB’s Employee Services within 30 days of your date of hire and a PGB Benefits Representative will help you enroll in benefits. The Employee Services number is located in the contact section of this guide. All Other Benefits - Please call PGB’s Employee Services within 30 days of your date of hire and a PGB Benefits Representative will help you enroll in benefits. The Employee Services number is located in the contact section of this guide. You also have the option to self-enroll, if you choose, within 30 days of your date of hire. Please see the self-enrollment instructions in this guide for more information. 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/HenryCountyPublicSchools 4

OVERVIEW OF BENEFITS POST – TAX BENEFITS

PRE – TAX BENEFITS

Disability Benefits Colonial Life

Health Insurance Anthem Health

Critical Illness Benefits Colonial Life

Flexible Spending Accounts Flexible Benefit Administrators - Medical Reimbursement: $3,300/year Max - Dependent Care Reimbursement: $5,000/year Max

Life Insurance Colonial Life

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

- Term Life Insurance - Whole Life Insurance

Long Term Care Benefits CHUBB

Dental Insurance Delta Dental of VA

ADDITIONAL BENEFITS Vision Insurance Superior Vision

Student Loan Assistance Program GradFin

Cancer Benefits Colonial Life

Accident Benefits Colonial Life

Medical Bridge Benefits Colonial Life

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, Anthem Health, Flexible Benefit Administrator Flexible Spending Accounts, Delta Dental of VA, Superior Vision, and CHUBB Long Term Care Benefits runs from July 1, 2025, through June 30, 2026. When do my deductions start? Deductions for Anthem Health, Delta Dental of VA, and Superior Vision start June 2025 for enrolled employees. Deductions for Colonial Life Insurance Products, Flexible Benefits Administrator Flexible Spending Accounts, and CHUBB Long Term Care Benefits start July 2025 for enrolled employees. Why have my Accident or Medical Bridge benefits not started yet? The Health Screening Rider on the Colonial Accident and Colonial Medical Bridge plan has a 30-day waiting period for new enrollees. Coverage, therefore, will not begin until July 31, 2025. 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 60 days days to submit claims for incurred qualified spending account expenses (or 60 days days after employment termination date). If employment is terminated before the plan year ends, the spending account also ends. Failure to use all allotted funds in the FSA account will result in a “Use It or Lose It” scenario. Your plan includes a grace period which is an additional 2.5 months (running July 1, 2026, through September 15, 2026), during which you can incur eligible expenses that can be reimbursed. Therefore, you have from July 1, 2025, through September 15, 2026, to incur qualified expenses eligible for reimbursement. If you do not incur qualified expenses by September 15, 2026, and/or file by September 30, 2026, any contributions are forfeited under the “Use It or Lose It” rule. My spouse is enrolled in an Health Savings Account (HSA), am I eligible for an FSA? As a married couple, one spouse cannot be enrolled in a Medical Reimbursement FSA at the same time the other opens or contributes to an HSA. How do Dependent Care Account (DCA) funds work and when do they need to be used? Dependent Care Accounts are like FSA accounts and allow you to request reimbursement up to your current balance. However, you cannot receive more reimbursement than what has been deducted from your pay. Any remaining funds in your DCA account must be utilized before the deadline. Failure to use all allotted funds in the DCA account will result in a “Use It or Lose It” scenario. When will I get my card? If you will be receiving a new debit card, whether you are a new participant or to replace your expired card, please be aware that it may take up to 30 days following your plan effective date for your card to arrive. Your card will be delivered by mail in a plain white envelope. During this time you may use manual claim forms for eligible expenses. Please note that your debit card is good through the expiration date printed on the card. I want to sign my family up for benefits as well, what information will I need? If signing up for any coverage on your spouse and/or children, please have their dates of birth and social security numbers available when speaking with the Benefits Representative. What does Pre-Tax vs. Post-Tax Change? Pre-Tax benefits take funds directly from your paycheck to cover benefits before going through State and Federal taxing process. Post-Tax collects funds for benefits after taxes have been taken out. Please be aware there are certain coverages that may be subject to federal and state tax when premium is paid by pretax deduction or employee contribution. Can I change my benefit elections outside of the enrollment period? Elections made during this enrollment period CANNOT BE CHANGED AFTER THE ENROLLMENT PERIOD unless there is a family status change, otherwise known as a qualifying life event (Mid-Year Events), as defined by the Internal Revenue Code. Examples of Mid-Year Events can be found in the chart on the next page. Once a Mid-Year Event has occurred, an employee has 30 days to notify PGB’s VA Employee Services at 1-800-387-5955 to request a change in elections. I have a pre-existing condition. Will I still be covered? Some policies may include a pre-existing condition clause. Please read your policy carefully for full details. Important Information About Your Dental Plan: Preventative dental is part of the annual maximum. In order have the carry over, employees must have preventative service done that year.

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

ANNUAL ENROLLMENT PERIOD:

MARCH 24, 2025 - APRIL 18, 2025 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 Care 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/HenryCountyPublicSchools 9

BENSELECT ENROLLMENT INSTRUCTIONS

• • • •

Below is a series of instructions outlining the enrollment process. Please have the following information available before you begin: Username, pin, and enrollment website URL from this page 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 800-3875955 between 8:30am and 5:00pm for assistance. • If you are an existing employee and unable to log into the online system, please contact PGB Employee Services at 800-387-5955, or speak with the Benefits Representative assigned to your location.

1. LOGGING IN Enter your Username: Social Security Number with or without dashes (ex. 123-45-6789 or 123456789) Enter your Pin: Last 4 numbers of your Social Security Number followed by last 2 numbers of your Date of Birth year (ex. 678970)

To login, visit: harmony.benselect.com/henryschools

1. 2. NEW PIN The screen prompts you to create a NEW PIN.

3. SECURITY QUESTIONS Choose a security question and enter answer.

4. CONFIRM Confirm (or enter) an email address.

5. SAVE NEW PIN Click on ‘Save New PIN’ to continue to the enrollment welcome screen.

6. CLICK NEXT

7. PERSONAL INFORMATION

From the welcome screen click ‘Next’.

The screen shows ‘Personal Information’. Verify that the information is correct and enter the additional required information (marital status, work phone, e-mail address). Click ‘Next’. Enrollment instructions continued on next page >>>

BENSELECT ENROLLMENT INSTRUCTIONS

8. ADDING FAMILY MEMBER

9. BENEFIT SUMMARY

The screen allows you to add family members. It is only necessary to enter family member information if adding or including family members in your coverage. Click ‘Next’.

The screen shows ‘Benefit Summary’. Review your current benefits and make changes, and selections for the upcoming plan year.

11. REVIEW

10. SIGN & SUBMIT Click ‘Sign & Submit’ once you have decided which benefits to enroll in.

Review your coverage. If any items are ‘Pending’, you will need to decide whether to enroll or decline this benefit.

13. SIGN FORM

12. NEXT Click ‘Next’ to review and electronically sign the authorization for your benefit elections.

Review the confirmation, then if you are satisfied with your elections, enter your PIN and click ‘Sign Form’.

14. DOWNLOAD & PRINT Click ‘Download & Print’ to print a copy of your elections, or download and save the document. Please do not forget this important step! Click ‘Log Out’. 11

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

HEALTH INSURANCE

Henry County Public Schools July 1, 2025 - June 30, 2026 Anthem KeyCare 30 1000/20%/4500

Plan Year Deductible

In-Network

Individual Family (two or more people)

$1,000 $2,000

Plan Year Out-of-Pocket Expense Limit

In-Network

Individual Out-of-Pocket Maximum Family Out-of-Pocket Maximum

$4,500 $9,000

Lifetime Maximum

Unlimited

Covered Services

In-Network Benefits Only

Doctor's Visits (Outpatient or In-Office) Primary Care Physician Visits -

$30 Copayment

Specialist Visits -

$50 Copayment

Live Health Online Medical Visit

$0 Copayment

Chiropractic, Spinal Manipulations (visit limits apply) Chiropractic, Spinal Manipulations (visit limits apply)

No Charge

Labs (Office or Preferred Reference Lab) Diagnostic Tests, Labs, Advanced Diagnostic Imaging and X-Rays

20% Coinsurance, after deductible Covered at 100%

Preventive Care Visits

Hospital & Other Services Pre-certification may be required

20% Coinsurance, after deductible

Emergency Room Visits

$50 Copayment

Urgent Care Copay Inpatient Hospital Services (includes Maternity, Mental and

20% Coinsurance, after deductible

Outpatient Hospital Services

20% Coinsurance, after deductible

Physical Therapy/OCC Therapy/Speech Therapy (visit

20% Coinsurance, after deductible

Substance Use Disorder)

limits apply)

Essential Formualry

Prescription Drug Benefit

Retail Pharmacy (up to a 31-day supply)

A 90 day supply is available at most retail pharmacies Tier 1

$10 Copayment

Tier 2

$30 Copayment

Tier 3

$50 Copayment

Tier 4

20% up to $200 per prescription

Henry County Public Schools July 1, 2025 - June 30, 2026 Contribution Schedule KeyCare 1000/20%/4500 Employee Only

Employee + Child

Employee + Children

Employee +Spouse

Employee +Family

Balanced Family

Total Monthly Premium

$723.17

$1,293.49

$1,475.08

$1,497.21

$2,036.95

$2,109.26

Employer Monthly Contribution

$723.17

$763.17

$783.17

$843.17

$1,566.34

Employee Monthly Contribution

$0.00

$530.32

$691.91

$714.04

$1,193.78

$542.92

BENEFIT BANK Henry County Public Schools’ Benefit Bank offers up to $723.17 to employees who do not enroll in the health plan* as a credit to enroll in ancillary benefits. Ancillary benefits may include dental, vision, medical bridge, cancer, accident, disability, and critical care. Benefit Bank’s funds cannot be used for Colonial Term Life, Colonial Whole Life, CHUBB Long Term Care, FSA or DCA. *For families where both spouses work for Henry County Public Schools, both spouses would need to decline the health plan to receive the Benefit Bank credit.

Anthem® BlueCross and BlueShield Your Plan: Anthem KeyCare 30 1000/20%/4500 Your Network: KeyCare This summary of benefits is a brief outline of coverage, designed to help you with the selection process. This policy has exclusions and limitations to benefits and terms under which the policy may be continued in force or discontinued. For costs and complete details of the coverage, contact your insurance agent or contact us. If there is a difference between this summary and the contract of coverage, the contract of coverage will prevail. This benefit summary is not to be distributed without also providing access to the applicable Anthem enrollment brochure. Cost if you use an In-Network Provider

Cost if you use a Non-Network Provider

Overall Deductible See notes section to understand how your deductible works. Your plan may also have a separate Prescription Drug Deductible. See Prescription Drug Coverage section.

$1,000 person / $2,000 family

$2,000 person / $4,000 family

Out-of-Pocket Limit When you meet your out-of-pocket limit, you will no longer have to pay costshares during the remainder of your benefit period. See notes section for additional information regarding your out of pocket maximum.

$4,500 person / $9,000 family

$9,000 person / $18,000 family

Preventive care/screening/immunization In-network preventive care is not subject to deductible, if your plan has a deductible.

No charge

40% coinsurance after medical deductible is met

Primary Care Visit to treat an injury or illness

$30 copay per visit medical deductible does not apply

40% coinsurance after medical deductible is met

Specialist Care Visit

$50 copay per visit medical deductible does not apply

40% coinsurance after medical deductible is met

Covered Medical Benefits

Doctor Home and Office Services

Page 1 of 13

Cost if you use an In-Network Provider

Cost if you use a Non-Network Provider

20% coinsurance after medical deductible is met

40% coinsurance after medical deductible is met

Retail Health Clinic

$30 copay per visit medical deductible does not apply

40% coinsurance after medical deductible is met

On-line Medical Visit Live Health Online is the preferred telehealth solutions. (www.livehealthonline.com).

$20 copay per visit medical deductible does not apply

40% coinsurance after medical deductible is met

Chiropractic Services Coverage for Rehabilitation and Habilitation is limited to 30 visits combined per benefit period. Limit is combined In-Network and NonNetwork. Visit limits are combined both across outpatient and other professional visits.

$30 copay per visit medical deductible does not apply

40% coinsurance after medical deductible is met

Allergy Testing

$30 copay per visit medical deductible does not apply

40% coinsurance after medical deductible is met

Chemo/Radiation Therapy

20% coinsurance after medical deductible is met

40% coinsurance after medical deductible is met

Hemodialysis

20% coinsurance after medical deductible is met

40% coinsurance after medical deductible is met

Prescription Drugs For the drugs itself dispensed in the office through infusion/injection.

20% coinsurance after medical deductible is met

40% coinsurance after medical deductible is met

Covered Medical Benefits Prenatal and Post-natal Care In-Network preventive prenatal and postnatal services are covered at 100%. Other Practitioner Visits:

Other Services in an Office:

Page 2 of 13

Cost if you use an In-Network Provider

Cost if you use a Non-Network Provider

Office

No charge

40% coinsurance after medical deductible is met

Preferred Reference Lab

No charge

40% coinsurance after medical deductible is met

Outpatient Hospital

20% coinsurance after medical deductible is met

40% coinsurance after medical deductible is met

Office

20% coinsurance after medical deductible is met

40% coinsurance after medical deductible is met

Outpatient Hospital

20% coinsurance after medical deductible is met

40% coinsurance after medical deductible is met

Office

20% coinsurance after medical deductible is met

40% coinsurance after medical deductible is met

Outpatient Hospital

20% coinsurance after medical deductible is met

40% coinsurance after medical deductible is met

Urgent Care Center Office Visit

$50 copay per visit medical deductible does not apply

40% coinsurance after medical deductible is met

Emergency Room Facility Services

20% coinsurance after medical deductible is met

Covered as InNetwork

Covered Medical Benefits Diagnostic Services Lab:

X-Ray:

Advanced Diagnostic Imaging (for example, MRI/PET/CAT scans):

Emergency and Urgent Care

Page 3 of 13

Cost if you use an In-Network Provider

Cost if you use a Non-Network Provider

Emergency Room Doctor and Other Services

20% coinsurance after medical deductible is met

Covered as InNetwork

Ambulance Transportation

20% coinsurance after medical deductible is met

Covered as InNetwork

$30 copay per visit medical deductible does not apply

40% coinsurance after medical deductible is met

Facility Fees

20% coinsurance after medical deductible is met

40% coinsurance after medical deductible is met

Doctor Services

20% coinsurance after medical deductible is met

40% coinsurance after medical deductible is met

Hospital

20% coinsurance after medical deductible is met

40% coinsurance after medical deductible is met

Freestanding Surgical Center

20% coinsurance after medical deductible is met

40% coinsurance after medical deductible is met

20% coinsurance after medical deductible is met

40% coinsurance after medical deductible is met

Covered Medical Benefits

Outpatient Mental Health and Substance Use Disorder Doctor Office Visit and Online Visit Facility visit:

Outpatient Surgery Facility Fees:

Doctor and Other Services: Hospital

Page 4 of 13

Cost if you use an In-Network Provider

Cost if you use a Non-Network Provider

Facility fees (for example, room & board) Coverage for Inpatient Rehabilitation and Skilled Nursing services is limited to 100 days combined per admission.

20% coinsurance after medical deductible is met

40% coinsurance after medical deductible is met

Doctor and other services

20% coinsurance after medical deductible is met

40% coinsurance after medical deductible is met

20% coinsurance after medical deductible is met

40% coinsurance after medical deductible is met

Office Coverage for rehabilitative and habilitative physical therapy and occupational therapy combined is limited to 30 visits per benefit period. Limit is combined for In-Network and Non-Network. Visit limits are combined both across outpatient and other professional visits. Coverage for rehabilitative and habilitative speech therapy is limited to 30 visits per benefit period. Visit limits are combined both across outpatient and other professional visits. Limit is combined for In-Network and NonNetwork. Visit limit does not apply when performed as part of Hospice, Home Health, Early Intervention or Autism service.

20% coinsurance after medical deductible is met

40% coinsurance after medical deductible is met

Outpatient Hospital Coverage for rehabilitative and habilitative physical therapy and occupational therapy combined is limited to 30 visits per benefit period. Limit is combined for In-Network and Non-Network. Visit limits are combined both across outpatient and other professional visits. Coverage for rehabilitative and habilitative speech therapy is limited to 30 visits per benefit period. Visit limits are combined both across outpatient and other professional visits. Limit is combined for In-Network and NonNetwork. Visit limit does not apply when performed as part of Hospice, Home Health, Early Intervention or Autism service.

20% coinsurance after medical deductible is met

40% coinsurance after medical deductible is met

Covered Medical Benefits Hospital Stay (all Inpatient stays including Maternity, Mental and Substance Use Disorder):

Recovery & Rehabilitation Home Health Care Coverage is limited to 100 visits per benefit period. Limit is combined InNetwork and Non-Network. Visit limit does not apply to Home Infusion Therapy or Home Dialysis. Rehabilitation services (for example, physical/speech/occupational therapy):

Page 5 of 13

Cost if you use an In-Network Provider

Cost if you use a Non-Network Provider

20% coinsurance after medical deductible is met

40% coinsurance after medical deductible is met

Outpatient Hospital Coverage for rehabilitative and habilitative physical therapy and occupational therapy combined is limited to 30 visits combined per benefit period. Visit limits are combined both across outpatient and other professional visits. Coverage for rehabilitative and habilitative speech therapy is limited to 30 visits per benefit period. Visit limits are combined both across outpatient and other professional visits. Limit is combined for In-Network and Non-Network. Visit limit does not apply when performed as part of Hospice, Home Health, Early Intervention or Autism service.

20% coinsurance after medical deductible is met

40% coinsurance after medical deductible is met

Office Visit

20% coinsurance after medical deductible is met

40% coinsurance after medical deductible is met

Outpatient Hospital

20% coinsurance after medical deductible is met

40% coinsurance after medical deductible is met

Skilled Nursing Care (in a facility) Coverage for Inpatient rehabilitation and skilled nursing services is limited to 100 days combined per admission. Limit is combined In-Network and NonNetwork.

20% coinsurance after medical deductible is met

40% coinsurance after medical deductible is met

Hospice

20% coinsurance after medical deductible is met

40% coinsurance after medical deductible is met

Covered Medical Benefits Habilitation services (for example, physical/speech/occupational therapy):

Cardiac rehabilitation

Page 6 of 13

Cost if you use an In-Network Provider

Cost if you use a Non-Network Provider

Durable Medical Equipment

20% coinsurance after medical deductible is met

40% coinsurance after medical deductible is met

Prosthetic Devices Coverage for wigs needed after cancer treatment is limited to 1 items per benefit period. Limit is combined In-Network and Non-Network.

20% coinsurance after medical deductible is met

40% coinsurance after medical deductible is met

Covered Medical Benefits

Page 7 of 13

Covered Prescription Drug Benefits

Cost if you use an In-Network Provider

Cost if you use a Non-Network Provider

Pharmacy Deductible

Not applicable

Pharmacy Out of Pocket

Combined with medical out of pocket maximum

Tier 1 - Typically Generic Covers up to a 30 day supply (retail pharmacy). Covers up to a 90 day supply (home delivery program). Covers up to 90 day supply (retail maintenance pharmacy). No coverage for non-formulary drugs. Coverage is also provided for up to a 12-month supply of FDA-approved, self-administered hormonal contraceptives, when dispensed or furnished at one time.

$10 copay per prescription, deductible does not apply (retail) and $10 copay per prescription, deductible does not apply (home delivery)

40% coinsurance (retail) and Not covered (home delivery)

Tier 2 – Typically Preferred Brand Covers up to a 30 day supply (retail pharmacy). Covers up to a 90 day supply (home delivery program). Covers up to 90 day supply (retail maintenance pharmacy). No coverage for non-formulary drugs. Coverage is also provided for up to a 12-month supply of FDA-approved, self-administered hormonal contraceptives, when dispensed or furnished at one time.

$30 copay per prescription, deductible does not apply (retail) and $60 copay per prescription, deductible does not apply (home delivery)

40% coinsurance (retail) and Not covered (home delivery)

Tier 3 - Typically Non-Preferred Brand Covers up to a 30 day supply (retail pharmacy). Covers up to a 90 day supply (home delivery program). Covers up to 90 day supply (retail maintenance pharmacy). No coverage for non-formulary drugs. Coverage is also provided for up to a 12-month supply of FDA-approved, self-administered hormonal contraceptives, when dispensed or furnished at one time.

$50 copay per prescription, deductible does not apply (retail) and $150 copay per prescription, deductible does not

40% coinsurance (retail) and Not covered (home delivery)

Prescription Drug Coverage National Drug List This product has a 90-day Retail Pharmacy Network available. A 90 day supply is available at most retail pharmacies.

Page 8 of 13

Cost if you use an In-Network Provider

Covered Prescription Drug Benefits

Cost if you use a Non-Network Provider

apply (home delivery) Tier 4 - Typically Specialty (brand and generic) Covers up to a 30 day supply (retail pharmacy). Covers up to a 90 day supply (home delivery program). No coverage for non-formulary drugs. Coverage is also provided for up to a 12-month supply of FDA-approved, self-administered hormonal contraceptives, when dispensed or furnished at one time.

20% coinsurance up to $200 per prescription (retail and home delivery)

40% coinsurance (retail) and Not covered (home delivery)

Page 9 of 13

Notes: • All medical services subject to a coinsurance are also subject to the annual medical deductible, if deductible is applicable to plan. • If your plan includes a hospital stay copay and you are readmitted within 72 hours of a prior admission for the same diagnosis, your hospital stay copay for your readmission is waived. • Human Organ and Tissues Transplants require precertification and are covered as any other service in your summary of benefits. • If your plan includes out of network benefits, all services with calendar/plan year limits are combined both in and out of network. • If your plan includes out of network benefits and you use a non-participating provider, you are responsible for any difference between the covered expense and the actual non-participating providers charge. • Your copays, coinsurance and deductible count toward your out of pocket amount. • To view your prescription formulary list log on to www.anthem.com/health-insurance/customer-care/formslibrary • In-network preventive care is not subject to deductible, if you plan has a deductible. • This plan includes Home Delivery (Mail Order). Home Delivery copays are different than the Retail Pharmacy Copays. • If your plan includes out of network benefits and you use a non-participating provider, you are responsible for any difference between the covered expense and the actual non-participating providers charge. When receiving care from providers out of network, members may be subject to balance billing in addition to any applicable copayments, coinsurance and/or deductible. This amount does not apply to the out of network out of pocket limit. • For additional information on this plan, please visit sbc.anthem.com to obtain a "Summary of Benefit Coverage". • The family deductible and out-of-pocket maximum are embedded meaning the cost shares of one family member will be applied to the individual deductible and individual out-of-pocket maximum; in addition, amounts for all family members apply to the family deductible and family out-of-pocket maximum. No one member will pay more than the individual deductible and individual out-of-pocket maximum. • The representations of benefits in this document are subject to Division of Insurance approval and are subject to change.

Anthem Health Plans of Virginia, Inc. trades as Anthem Blue Cross and Blue Shield in Virginia, and its service area is all of Virginia except for the City of Fairfax, the Town of Vienna, and the area east of State Route 123. Independent licensee of the Blue Cross and Blue Shield Association. ® ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association.

Questions: (833) 592-9956 or visit us at www.anthem.com VA/LG/Anthem KeyCare 30 1000/20%/4500 /42FJ/01-01-2020 24

Page 11 of 13

Language Access Services: Get help in your language Curious to know what all this says? We would be too. Here’s the English version: If you have any questions about this document, you have the right to get help and information in your language at no cost. To talk to an interpreter, call (833) 592-9956

Separate from our language assistance program, we make documents available in alternate formats for members with visual impairments. If you need a copy of this document in an alternate format, please call the customer service telephone number on the back of your ID card. (TTY/TDD: 711) . (833) 592-9956 հայերեն). Եթե այս փաստաթղթի հետ կապված հարցեր ունեք, դուք իրավունք ունեք Armenian (հ անվճար ստանալ օգնություն և տեղեկատվություն ձեր լեզվով: Թարգմանչի հետ խոսելու համար զանգահարեք հետևյալ հեռախոսահամարով՝ (833) 592-9956: Chinese(中中文)：：如果您對本文件有任何疑問，您有權使用您的語言免費獲得協助和資訊。如需與譯員通話，請致電(833) 592-9956。 (833) 592-9956 French (Français) : Si vous avez des questions sur ce document, vous avez la possibilité d’accéder gratuitement à ces informations et à une aide dans votre langue. Pour parler à un interprète, appelez le (833) 592-9956. Haitian Creole (Kreyòl Ayisyen): Si ou gen nenpòt kesyon sou dokiman sa a, ou gen dwa pou jwenn èd ak enfòmasyon nan lang ou gratis. Pou pale ak yon entèprèt, rele (833) 592-9956. Italian (Italiano): In caso di eventuali domande sul presente documento, ha il diritto di ricevere assistenza e informazioni nella sua lingua senza alcun costo aggiuntivo. Per parlare con un interprete, chiami il numero (833) 5929956.

(833) 592-9956 Korean (한국어): 본 문서에 대해 어떠한 문의사항이라도 있을 경우, 귀하에게는 귀하가 사용하는 언어로 무료 도움 및 정보를 얻을 권리가 있습니다. 통역사와 이야기하려면(833) 592-9956로 문의하십시오.

Page 12 of 13 25

Language Access Services:

(833) 592-9956. Polish (polski): W przypadku jakichkolwiek pytań związanych z niniejszym dokumentem masz prawo do bezpłatnego uzyskania pomocy oraz informacji w swoim języku. Aby porozmawiać z tłumaczem, zadzwoń pod numer: (833) 5929956. (833) 592-9956

(833) 592-9956. Spanish (Español): Si tiene preguntas acerca de este documento, tiene derecho a recibir ayuda e información en su idioma, sin costos. Para hablar con un intérprete, llame al (833) 592-9956. Tagalog (Tagalog): Kung mayroon kang anumang katanungan tungkol sa dokumentong ito, may karapatan kang humingi ng tulong at impormasyon sa iyong wika nang walang bayad. Makipag-usap sa isang tagapagpaliwanag, tawagan ang (833) 592-9956. Vietnamese (Tiếng Việt): Nếu quý vị có bất kỳ thắc mắc nào về tài liệu này, quý vị có quyền nhận sự trợ giúp và thông tin bằng ngôn ngữ của quý vị hoàn toàn miễn phí. Để trao đổi với một thông dịch viên, hãy gọi (833) 592-9956. It’s important we treat you fairly That’s why we follow federal civil rights laws in our health programs and activities. We don’t discriminate, exclude people, or treat them differently on the basis of race, color, national origin, sex, age or disability. For people with disabilities, we offer free aids and services. For people whose primary language isn’t English, we offer free language assistance services through interpreters and other written languages. Interested in these services? Call the Member Services number on your ID card for help (TTY/TDD: 711). If you think we failed to offer these services or discriminated based on race, color, national origin, age, disability, or sex, you can file a complaint, also known as a grievance. You can file a complaint with our Compliance Coordinator in writing to Compliance Coordinator, P.O. Box 27401, Mail Drop VA2002-N160, Richmond, VA 23279. Or you can file a complaint with the U.S. Department of Health and Human Services, Office for Civil Rights at 200 Independence Avenue, SW; Room 509F, HHH Building; Washington, D.C. 20201 or by calling 1-800-368-1019 (TDD: 1- 800-537-7697) or online at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf. Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

Page 13 of 13 26

A caring team to help guide you Anthem Health Guide is a concierge service for your health and health care

Health care benefits can seem complicated or confusing at times. To make the most of your benefits, you need to understand them. That is why you have a team of concierge-level customer service experts — ready to answer questions, advocate for your health and explain how to use your benefits. You can call a health guide or chat from your mobile device using our Sydney Health app.

Anthem health guides are here to help Health guides are team members hand-picked for their kindness and understanding, their ability to listen and find a solution, all while also helping you feel less overwhelmed. They are experts at: 

One-call resolution. Our guides use advanced technology to see your whole health care picture while talking to you or advocating for you. They understand you are busy and may not have time for multiple conversations so they find the solution in the first call. Health guides take a comprehensive and personal approach, not only to help with your immediate needs but also anticipate future questions.



Advocating for you. Health guides bring knowledge and experience to help make sure you are receiving the care you need. They will help break down barriers and eliminate “homework” for you, like calling providers about billing discrepancies, so you can focus on your health. If you need help finding a provider, guides can match you with an in-network provider that suits your needs. They can also help you save money by comparing costs for care at different hospitals and save on your prescription drugs, by switching to generic from brand-name, if available.



Coordinating care for better health. Many people see more than one doctor. Health guides can connect you to health professionals who will help coordinate with doctors and other members of your care team. They can remind you of important preventive care, and even help schedule appointments for you, when possible. They also have in-depth knowledge about the programs and preventive care services that are part of your benefits, and they work closely with nurses, health coaches and social workers to provide support uniquely suited to you.

Anthem Health Guide is here to give you personalized help when you need it most. That way you can focus on what is most important: your health.

Reach out to an Anthem Health Guide Connect from your Anthem Blue Cross and Blue Shield Sydney Health mobile app or by logging in at anthem.com. Then choose Customer Support, then Contact Us.

Sydney Care is offered through an arrangement with CareMarket, Inc. Sydney Health and Sydney Care are service marks of CareMarket Inc., ©2020. Health and wellness programs are not covered services under the health plan, but are additions; these programs’ features are not guaranteed under your health plan certificate and could be discontinued at any time. Anthem Blue Cross and Blue Shield is the trade name of Anthem Health Plans of Virginia, Inc. Anthem Blue Cross and Blue Shield, and its affiliate HealthKeepers, Inc., serving all of Virginia except for the City of Fairfax, the Town of Vienna, and the area east of State Route 123, are independent licensees of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc. 40157VAMENBVA VPOD Rev. 05/20

Call us at 833 621 0308, Monday to Friday.

59742742-132294663

LiveHealth Online What you need to know about video visits with a doctor, 24/7 What is LiveHealth Online?

LiveHealth Online should not be used for emergency care. If you have a medical emergency, call 911 right away.

LiveHealth Online lets you have a video visit with a boardcertified doctor using your smartphone, tablet or computer with a webcam. No appointments, no driving and no waiting at an urgent care center. Doctors are available 24/7 to assess your condition and, if it’s needed, they can send a prescription to your local pharmacy.*

When is LiveHealth Online available? Doctors are available 24/7, 365 days a year. How does LiveHealth Online work?

Use LiveHealth Online if you have pinkeye, a cold, the flu, a fever, rashes, infections, allergies or another common health condition. It’s faster, easier and more convenient than a visit to an urgent care center.

When you need to see a doctor, simply go to livehealthonline.com or use the LiveHealth Online mobile app. Pick the state you’re in and answer a few questions.

Why would I use LiveHealth Online instead of going to visit my doctor in person?

Setting up an account allows you to securely store your personal and health information. Plus, you can easily connect with doctors in the future, share your health history and set up online visits at times that fit your schedule.

LiveHealth Online isn’t meant to replace your primary care doctor. It’s a convenient option for care when your doctor isn’t available. LiveHealth Online connects you with a doctor in minutes. Plus, you can get a LiveHealth Online visit summary from the MyHealth tab at livehealthonline.com to print, email or fax to your primary care doctor.

59965MUMENABS_M VPOD 03/17

Once connected, you can talk with the doctor as if you were in a private exam room.

How much does it cost to use LiveHealth Online? Your Anthem plan includes benefits for video visits using LiveHealth Online, so you’ll just pay your share of the costs — usually $49 or less for a doctor visit. Will I be charged more if I use LiveHealth Online on weekends, holidays or at night? No, the cost is the same. How do I pay for a LiveHealth Online visit? You can use PayPal, American Express, Visa, MasterCard and Discover cards to pay for an online doctor visit. Keep in mind that charges for prescriptions aren’t included in the cost of your visit. Is there a LiveHealth Online app that I can download to my smartphone? Yes, search for “LiveHealth Online” in the App Store® or on Google Play . To learn what mobile devices are supported and get instructions, go to livehealthonline.com and select Frequently asked questions under the How it works tab. TM

Can I get online care from a doctor if I’m traveling or in another state?

What type of computer do I need to use LiveHealth Online? You’ll need high-speed Internet access, a webcam or built-in camera with audio. To learn what computer hardware and software you need, go to livehealthonline.com and select Frequently asked questions under the How it works tab.

Yes, just select the state you’re in under My Location on livehealthonline.com or with the app, and you’ll only see doctors licensed to treat you in that state. Don’t forget to change the state back when you get home.

Do doctors have access to my health information?

What if I still have questions about using LiveHealth Online?

It depends on whether or not you set up an account. With a LiveHealth Online account, you can allow doctors to access and review your health information from past visits. Also, to help keep track of your own health information, you can record it at livehealthonline.com. Once you sign in, go to the MyHealth tab and then select Health Record.

Send an email to customersupport@livehealthonline.com or call toll free at 1-888-548-3432.

How long is a LiveHealth Online visit? A typical LiveHealth Online visit with a doctor lasts about 10 minutes.

* Prescription availability is defined by physician judgment and state regulations. Visit the home page of livehealthonline.com to view the service map by state. LiveHealth Online is the trade name of Health Management Corporation, a separate company providing telehealth services on behalf of Anthem. If you’re a retiree or have coverage that complements your Medicare benefits, your employer sponsored health plan may not include coverage for online visits using LiveHealth Online. Check your plan documents for details. You can still use LiveHealth Online, but you may have to pay the full cost of a visit. Online visits using LiveHealth Online may not be a covered benefit for HRA and HIA+ members. Anthem Blue Cross and Blue Shield is the trade name of: In Colorado: Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc. Copies of Colorado network access plans are available on request from member services or can be obtained by going to anthem.com/co/networkaccess. In Connecticut: Anthem Health Plans, Inc. In Indiana: Anthem Insurance Companies, Inc. In Kentucky: Anthem Health Plans of Kentucky, Inc. In Maine: Anthem Health Plans of Maine, Inc. In Missouri (excluding 30 counties in the Kansas City area): RightCHOICE® Managed Care, Inc. (RIT), Healthy Alliance® Life Insurance Company (HALIC), and HMO Missouri, Inc. RIT and certain affiliates administer non-HMO benefits underwritten by HALIC and HMO benefits underwritten by HMO Missouri, Inc. RIT and certain affiliates only provide administrative services for self-funded plans and do not underwrite benefits. In Nevada: Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc., dba HMO Nevada. In New Hampshire: Anthem Health Plans of New Hampshire, Inc.; HMO plans are administered by Anthem Health Plans of New Hampshire, Inc. and underwritten by Matthew Thornton Health Plan, Inc. In Ohio: Community Insurance Company. In Virginia: Anthem Health Plans of Virginia, Inc. trades as Anthem Blue Cross and Blue Shield in Virginia, and its service area is all of Virginia except for the City of Fairfax, the Town of Vienna, and the area east of State Route 123. In Wisconsin: Blue Cross Blue Shield of Wisconsin (BCBSWi), underwrites or administers PPO and indemnity policies and underwrites the out of network benefits in POS policies offered by Compcare Health Services Insurance Corporation (Compcare) or Wisconsin Collaborative Insurance Corporation (WCIC). Compcare underwrites or administers HMO or POS policies; WCIC underwrites or administers Well Priority HMO or POS policies. Independent licensees of the Blue Cross and Blue Shield Association. ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association.

Nine months. Many questions. Future Moms can help — any time, any day Ever wish you had a go-to source for all of your questions about pregnancy? Now, you do. Future Moms is a program that can answer your questions, help you make good choices and follow your health care provider’s plan of care. And it can help you have a safe delivery and a healthy child. Sign up as soon as you know you’re pregnant. Just call us toll free at 800-828-5891. One of our registered nurses will help you get started. You’ll get: }

A toll-free number so you can talk to a nurse coach 24/7 about your pregnancy. A nurse may also call you from time to time to see how you’re doing.

}

The Mayo Clinic Guide to a Healthy Pregnancy book that shows changes you can expect for you and your baby during the next nine months.

}

A screening to check your health risk for depression or early delivery.

}

Other useful tools to help you, your doctor and your Future Moms nurse keep track of your pregnancy and help you make healthier choices.

}

Free phone calls with pharmacists, nutritionists and other specialists, if needed.

}

A booklet with tips to help keep you and your new baby safe and well.

}

It’s easy to join

Other helpful information on labor and delivery, including options and how to prepare.

Visit with a lactation consultant online Using Future Moms with Breastfeeding Support on LiveHealth Online, you can make appointments for free video visits with a certified lactation consultant, counselor or registered dietitian at no extra cost to you! These professionals can provide personalized support to help you with breastfeeding techniques, learn about milk production, baby hunger cues, foods to avoid, nutrition while breastfeeding and more.

Once your baby is born, get lactation support with LiveHealth Online. Sign up now for livehealthonline.com or use the free mobile app and enter your health plan information. Once you’ve created an account, select Future Moms with Breastfeeding Support to view the available lactation consultants, counselors and registered dietitians. Appointments are available 7 days a week and evenings, too. Schedule your appointment at any time by logging in to LiveHealth Online.

Health and wellness programs are not covered services under the health plan, but are additions; these programs’ features are not guaranteed under your health plan certificate and could be discontinued at any time. Anthem Health Plans of Virginia, Inc. trades as Anthem Blue Cross and Blue Shield in Virginia, and its service area is all of Virginia except for the City of Fairfax, the Town of Vienna, and the area east of State Route 123. Anthem Blue Cross and Blue Shield and its affiliate HealthKeepers, Inc. are independent licensees of the Blue Cross Blue Shield Association. ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. 62150VAMENBVA VPOD Rev. 8/16

Say hi to Sydney Anthem’s new app is simple, smart — and all about you With Sydney, you can find everything you need to know about your Anthem benefits -- personalized and all in one place. Sydney makes it easier to get things done, so you can spend more time focused on your health.

Get started with Sydney Download the app today!

Ready for you to use quickly, easily, seamlessly — with one-click access to benefits info, Member Services, wellness resources and more.

Sydney acts like a personal health guide, answering your questions and connecting you to the right resources at the right time. And you can use the chatbot to get answers quickly.

With just one click, you can:  Find care and check costs  Check all benefits  See claims

Get alerts, reminders and tips directly from Sydney. Get doctor suggestions based on your needs. The more you use it, the more Sydney can help you stay healthy and save money.

Already using one of our apps?  Get answers even faster with

our chatbot  View and use digital ID cards

It’s easy to make the switch. Simply download the Sydney app and log in with your Anthem username and password.

Anthem Blue Cross and Blue Shield is the trade name of: In Colorado: Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc. In Connecticut: Anthem Health Plans, Inc. In Georgia: Blue Cross Blue Shield Healthcare Plan of Georgia, Inc. In Indiana: Anthem Insurance Companies, Inc. In Kentucky: Anthem Health Plans of Kentucky, Inc. In Maine: Anthem Health Plans of Maine, Inc. In Missouri (excluding 30 counties in the Kansas City area): RightCHOICE® Managed Care, Inc. (RIT), Healthy Alliance® Life Insurance Company (HALIC), and HMO Missouri, Inc. RIT and certain affiliates administer non-HMO benefits underwritten by HALIC and HMO benefits underwritten by HMO Missouri, Inc. RIT and certain affiliates only provide administrative services for self-funded plans and do not underwrite benefits. In Nevada: Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc., dba HMO Nevada. In New Hampshire: Anthem Health Plans of New Hampshire, Inc. HMO plans are administered by Anthem Health Plans of New Hampshire, Inc. and underwritten by Matthew Thornton Health Plan, Inc. In Ohio: Community Insurance Company. In Virginia: Anthem Health Plans of Virginia, Inc. trades as Anthem Blue Cross and Blue Shield in Virginia, and its service area is all of Virginia except for the City of Fairfax, the Town of Vienna, and the area east of State Route 123. In Wisconsin: Blue Cross Blue Shield of Wisconsin (BCBSWI), underwrites or administers PPO and indemnity policies and underwrites the out of network benefits in POS policies offered by Compcare Health Services Insurance Corporation (Compcare) or Wisconsin Collaborative Insurance Corporation (WCIC). Compcare underwrites or administers HMO or POS policies; WCIC underwrites or administers Well Priority HMO or POS policies. Independent licensees of the Blue Cross and Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc. 115993MUMENABS 06/19

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

DENTAL INSURANCE

July 1, 2023

Continued on next page



Delta Dental – 12 month Employee Only Employee + Child Employee + Spouse Employee + Family



Low Plan $28.12 $51.56 $67.91 $74.93

July 1, 2023

Continued on next page



Delta Dental – 12 month Employee Only Employee + Child Employee + Spouse Employee + Family



High Plan $36.59 $67.07 $88.36 $97.48

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

VISION INSURANCE

superiorvision.com | 1 (800) 507-3800

Vision Care Plan for Henry County 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:

$15

Contact lens fitting2 copay (standard and specialty):

Materials1 Materials copay:

$15

Monthly Premiums

$30

Specialty In-network allowance:

$50

Frames In-network allowance:

$130

Contacts4 in lieu of glasses

Employee only:

$9.07

Employee + spouse:

$14.28

Employee + child(ren):

$14.50

Employee + family:

$23.19

In-network allowance:

$130

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

Factory scratch coat

Covered-in-full

Not covered

Polycarbonate

Covered-in-full

Not covered

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

Lens Add-Ons5

Your Cost

Ultraviolet coating

$12

Tints - solid / gradient

$15 / $18

Blue light filtering

$15

Digital single vision

$30

Multiple discounts on laser vision

Progressive lenses (standard / premium / ultra / ultimate)

$55 / $110 / $150 / $225

available to you. To learn more,

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

correction procedures may be 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

Additional Out-of-Network Reimbursements

Amount

With the free Superior Vision app

Eye exam (MD)

Up to $34

devices), you can create an

Eye exam (OD)

Up to $26

Frame

Up to $61

Contact lens fitting (standard / specialty)2

Not covered

Contact lenses

Up to $100

(available for Android and Apple

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.

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

FLEXIBLE SPENDING ACCOUNT

Henry County Public Schools Get reimbursed for out-of-pocket healthcare and child/aged adult day care expenses with tax free dollars! MAXIMIZE YOUR INCOME!

THE HEALTHCARE ACCOUNT IS A PRE-FUNDED ACCOUNT

Flexible Spending Accounts (FSAs) allow you to pay certain healthcare and dependent care expenses with pre-tax money. (The key to the Flexible Benefit Plan is that your eligible expenses are paid for with Tax Free Dollars!) You will not pay any federal, state or social security taxes on funds placed in the Plan. You will save approximately $27.65 to $37.65 on every $100 you place in the Plan. The amount of your savings will depend on your federal tax bracket.

This means that you can submit a claim for medical expenses in excess of your account balance. You will be reimbursed your total eligible expense up to your annual election. The funds that you are pre-funded will be recovered as deductions are deposited into your account throughout the Plan Year. Contribution Limits: The maximum you may place in this account for the Plan Year is $3,300.

ELIGIBILITY

HEALTHCARE REIMBURSEMENT

Participation in the Plan begins on July 1, 2025 and ends on June 30, 2026. If you are a full time employee who works at least 30 hours or more per week, you are eligible to participate in the plan upon your date of hire or, if you are hired after the 15th of the month, you will be eligible to join the plan the first day of the next month. Those employees having a qualifying event are eligible to enroll within 30 days of the qualifying event. Deductions begin on the first pay period following your Plan start date. You must complete an enrollment to participate in the Flexible Spending Accounts each year during the enrollment period. If an enrollment is not completed during open enrollment, you will not be enrolled in the Plan and you will not be able to join until the next Plan Year or if you have a qualifying event.

With this account, you can pay for your out-of-pocket healthcare expenses for yourself, your spouse and all of your tax dependents for healthcare services that are incurred during your Plan Year and while an active participant. Eligible expenses are those incurred “for the diagnosis, cure, mitigation, treatment, or prevention of disease, or for the purpose of affecting any structure or function of the body. “

EXAMPLES OF ELIGIBLE HEALTH CARE EXPENSES Fees/Co-Pays/Deductibles For: • Surgery • Dental/ Orthodontic fees • Obstetrician • X-Rays • Eye exams • Prescription drugs • Artificial limbs & teeth • Orthopedic shoes/ inserts • Therapeutic care for drug and alcohol addiction • Vaccinations & immunizations • Mileage

REIMBURSEMENT SCHEDULE All manual or paper claims received in the office of Flexible Benefit Administrators, Inc. will be processed within one week via check or direct deposit. You may also use your Benefits Card to pay for expenses. Please refer to the Benefits Card section for details.

• Acupuncture • Prescription eyeglasses/ reading glasses/ Contact lens and supplies/ Eye exams/ Laser eye surgery • Physician • Ambulance • Psychiatrist • Psychologist • Anesthetist • Hospital • Chiropractor • Laboratory/ diagnostic • Fertility treatments

ONLINE ACCESS

OVER-THE-COUNTER EXPENSES

ELECTION CHANGES Election changes are only allowed if you experience one of the following qualifying events: • Marriage or divorce • Birth or adoption • Involuntary loss of spouse’s medical or dental coverage

• Death of dependent (child or spouse) • Unpaid FMLA or Non-FMLA leave • Change in Dependent Care Providers

• Take-home screening kits • Diabetic supplies • Routine physicals • Oxygen • Physical therapy • Hearing aids and batteries • Medical equipment • Antacids • Pain relivers • Allergy & Sinus Medication

Examples of medications and drugs that may be purchased in reasonable quantities with a prescription:

Flexible Benefit Administrators, Inc. provides on-line account access for all FSA participants. Please visit their website at:

• Acne Treatment • Humidifiers • Multivitamins

https://fba.wealthcareportal.com/ to view the following features: • FSA Login – view balances, check status and view claims history-download participation forms. • FSA Educational Tools – FSA calculator: estimate how much you can save by utilizing an FSA.

• Herbal Supplements • Baby Formula • Fiber Supplements

DAY CARE/AGED ADULT CARE REIMBURSEMENT

HOW TO RECEIVE REIMBURSEMENT

The Day Care/Aged Adult Care FSA allows you to pay for day care exTo obtain a reimbursement from your Flexible Spending Account, penses for your qualified dependent/child with pre-tax dollars. Eliyou must complete a Claim Form. This form is available to you on our gible Day Care/Aged Adult Care expenses are those you must pay website. You must attach a receipt or bill from the service provider for the care of an eligible depenwhich includes all the pertinent inHOW THE FLEXIBLE BENEFIT PLAN WORKS dent so that you and your spouse formation regarding the expense: can work. Eligible dependents, as Without With revised under Section 152 of the Flex Benefits Flex Benefits • Date of service Code by the Working Families Tax $ 2,500.00 $ 2,500.00 • Patient’s name Act of 2005, are defined as either Gross Monthly Income dependent children or dependent Eligible Pre-Tax employer medical insurance $ 0.00 $ 200.00 • Amount charged relatives that you claim as depen- Eligible Pre-Tax Medical Expenses $ 0.00 $ 100.00 • Provider’s name 0.00 $ 300.00 dents on your taxes. Refer to the Em- Eligible Pre-Tax Dependent Child Care Expenses$ ployee Guide for more details. Eligible Taxable Income • Nature of the expense $ 2500.00 $ 1900.00 dependents are further defined as: • Amount covered by • Under age 13 • Physically or mentally unable to care for themselves such as: - Disabled spouse - Children who became disabled prior to age 19. - Elderly parents that live with you

Contribution Limits: The annual maximum contribution may not exceed the lesser of the following:

Federal Tax (15%) State Tax (5.75%) FICA Tax (7.65%)

$ 375.00 $ 143.75 $ 191.25

$ 285.00 $ 109.25 $ 145.35

After-Tax employer medical insurance After-Tax medical expenses After-Tax dependent child care expenses

$ 200.00 $ 100.00 $ 300.00

$ $ $

Monthly Spendable Income

$ 1190.00

$ 1360.40

0.00 0.00 0.00

By taking advantage of the Flexible Benefit Plan this employee was able to increase his/her spendable income by $170.40 every month! This means an annual tax savings of $2,044.80. Remember, with the FLEXIBLE BENEFIT PLAN, the better you plan the more you save!

insurance (if applicable)

Canceled checks, bankcard receipts, credit card receipts and credit card statements are NOT acceptable forms of documentation. You are responsible for paying your healthcare or dependent care provider directly.

FORFEITING FUNDS

• $5,000 ($2,500 if married filing separately) • Your wages for the year or your spouse’s if less than above • Maximum is reduced by spouse’s contribution to a Day Care/ Aged Adult Care FSA

Plan carefully! Unused funds will be forfeited back to your employer as governed by the IRS’s “use-it-or-lose-it” rule. Your employer has elected to adopt the IRS offered 2 month 15-day grace period. Please see the Employee Guide for more info.

ELIGIBLE DAY CARE/AGED ADULT CARE EXPENSES

Step 1 Carefully estimate your eligible Healthcare and Day Care/Aged Adult Care expenses for the upcoming Plan Year. Then use our online FSA Educational Tools located at https://fba.wealthcareportal.com/ to help you determine your total expenses for the Plan Year.

HOW TO ENROLL IN OUR FSA PLAN • Au Pair • Nannies • Before and After Care • Day Camps • Babysitters

• Daycare for an Elderly Dependent

• Nursery School

• Daycare for a Disabled Dependent

• Sick Child Center

• Private Pre School • Licensed Day Care Centers

Ineligible Expenses • Overnight Camps • Babysitting for Social Events • Tuition Expenses Including Kindergarten • Food Expenses (if separate from dependent care expenses) • Care Provided By Children Under 19 (or by anyone you claim as a dependent) • Days Your Spouse Doesn’t Work (though you may still have to pay the provider) • Kindergarten expenses are ineligible as an expense because it is primarily educational, regardless if it is half or full day, private, public, state mandated or voluntary. • Transportation, books, clothing, food, entertainment and registration fees are ineligible if these expenses are shown separately on your bill.

Step 2 Complete your enrollment during the open enrollment period, which instructs payroll to deduct a certain amount of money for your expenses. This amount will be contributed on a pre-tax basis from your paychecks to your FSA. Remember the amount you elect will be set aside before any federal, social security, and state taxes are calculated.

BENEFITS CARD The Benefits Card can be used as a direct payment method for eligible expenses incurred at approved service providers and merchants. Using your card allows you instant access to your funds with no out-of-pocket expense. Please keep all your itemized receipts. Flexible Benefit Administrators, Inc. may request documentation to substantiate Benefits Card transactions to determine eligibility of an expense. Benefits Cards are available upon request of the account holder for dependents over the age of 18. Please contact Flexible Benefit Administrators, Inc. to order additional cards.

• Expenses incurred while on a Leave of Absence or Vacation.

P.O. Drawer 8188 • Virginia Beach, VA 23450 • Toll Free (800) 437-3539 • Phone (757) 340-4567 • Fax (757) 431-1155 42 www.flex-admin.com

Managing your Benefit Account is easy with the FBA Participant Portal! The FBA Participant Portal provides powerful self-service account access plus education and decision-support tools that help put you in the driver’s seat when it comes to your healthcare finances.

Features A single digital experience – optimal viewing experience across all browsers and devices, including touchscreens Personalized content – resources and messages are tailored to your individual preferences and account settings Full account details at your fingertips – intuitive online access to plan details, account balances and transaction history (including prior years) Self-service convenience – check balances, submit claims and receipt documentation, pay bills, manage investments and more Comprehensive decision-support tools – educational and interactive tools to help you make critical spending and saving decisions throughout the plan year Communication when you need it – manage your preferences with access to more than 25 alerts to keep you connected to your account Value-add services and offers – to help you get the most value from your healthcare dollars

Get Started Today!

Go to https://fba.wealthcareportal.com/ to register for online access today. 43

Make better healthcare spending and saving decisions with the FBA Mobile App! The FBA Mobile App offers a personalized, real-time and self-guided experience that allows you to easily manage your Benefit Account and delivers tools to help save you money.

Features Virtual medicine cabinet – find ways to save on your prescriptions Download on iTunes

Find care – search for providers or procedure and drug prices Funding calculator – learn how to save for future healthcare needs Access accounts – check balances, view transaction history and more

Download on Google Play

Manage claims – submit new claims, upload receipts and check claims status Track and pay expenses – track medical claims and other expenses, plus pay bills electronically Access cards – manage card details, access your PIN and initiate card replacement for lost or stolen cards Receive alerts – view important account messages Update your profile – update personal information, including your email and mobile phone

Get Started Today!

Download the Mobile App at the App Store or Google Play. Log in using your Participant Portal user ID. If you do not have a user ID, follow the prompts to complete the registration process. 44

Get CONNECTED with your account... Wherever, whenever. Introducing... our convenient participant web site! With the online WealthCare Portal you can view your account status, submit claims and report your benefits card lost/stolen right from your computer. Once your account is established, you can use the same user name and password to access your account via our Mobile App!

Follow the simple steps below to establish your secure user account. Get started by visiting https://fba.wealthcareportal.com/ and click the register button in the top-right corner of the homepage. You will be directed to the registration page. Follow the prompts to create your account. First Name Last Name Zip Code Verification Code Verify Email/Create Username & Password Once completed, please proceed to your account.

Getting Started is Easy!

If you are having difficulty creating your user account or you have forgotten your password to an existing account, please contact us at 800-437-3539 or flexdivision@flex-admin.com.

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

$20 OFF *Limit one per customer

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

Shop Now

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

Eligibility List

FSA Calculator

Search comprehensive list of eligible products and services.

Estimate how much you can save with an FSA.

Learning Center

Savings Center

Easy tips and resources for utilizing an FSA.

Your funds go further with the FSA Store rewards program.

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

Your Health, Your Funds, Your Choice Take control of your health and wellness with guaranteed FSA-eligible essentials. Pierce Group Benefits partners with the FSA store to provide one convenient location for Flexible Spending Account holders. 46

Click or Scan to Shop Now

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

LONG TERM CARE BENEFITS

Workplace Benefits

Discover the Unmatched Advantages of LifeTime Benefit Term With Long Term Care Learn more about our 7702(b) Qualified Long Term Care offering, with favorable interest rates and benefits to ensure your clients are better protected.

Life Insurance and So Much More 7702(b) Qualification

Interest Rates at 3%

LBT provides a tax-qualified LTC Benefit that complies with this provision of the tax code and may satisfy future state mandates as Qualified Long Term Care.

Based on a 3% interest rate and mortality assumptions, the full death benefit is designed to last through age 99 for non-tobacco users and age 95 for tobacco users.

Paid-up Benefits After 10 years, paid-up benefits begin to accrue. At any point thereafter, if you stop paying the premium, a reduced paid-up benefit is issued and can never lapse.

Our Life Insurance premiums never change and are only due until age 100. And as long as premiums are paid, coverage won’t lapse, lasting until employees reach their 121st birthday.

Long Term Care (LTC) Benefits

Guaranteed Portability

Pays benefits for Long Term Care services including home health care, assisted living, adult day care and nursing home care.

Employees can take these benefits with them, even if they change jobs.

Example

Life Situation

Death Benefit

As Life Insurance

The employee leads a full life and does not need Long Term Care (LTC).

$100,000

As LTC Insurance

The employee leads a full life and needs assisted living or nursing home care.

Or Split the Death Benefit for LTC & Life Insurance

Life Insurance Premiums Are Guaranteed Never to Increase

Long Term Care

LTC Extension

$100,000

The employee leads a full life but also needs some LTC funds (example: 4% of $100,000 for 12 months).

$52,000

Total Benefits

$100,000

$48,000

Additional Coverage for Long Term Care and Death Benefits Extra Long Term Care for up to 50 Additional Months

The employee leads a full life and needs extended benefits for assisted living or nursing home care.

Restore Your Death Benefit

If the employee depletes their entire Death Benefit due to LTC, we restore their Death Benefit to 50% of their original death benefit

$200,000

$50,000

$200,000

$50,000 Option 1, 2 or 3 = Total Coverage of $350,000

Chubb is the marketing name used to refer to subsidiaries of Chubb Limited providing insurance and related services. This insurance product is underwritten by Combined Insurance Company of America, Chicago, IL, a Chubb company. www.chubbworkplacebenefits.com

LifeTime Benefit Term

Choose Chubb Chubb’s Workplace Benefits product series is designed to empower you with innovative and flexible benefits solutions to better meet your customer’s needs. Innovation that Pays More—Guaranteed For about the same premium, LifeTime Benefit Term (LBT) provides higher death benefits than permanent life insurance and lasts to age 121. Plus offers additional benefits. Valuable Family Protection Plus Benefits for Long Term Care LBT’s innovative design provides life time guarantees at a fraction of the cost of permanent life insurance. And flexibility allows you to customize benefits for Long Term Care (LTC) and double or triple the policy value. Guaranteed Benefits—During the Working Years Death Benefit is guaranteed 100% when it is needed most—during the working years when a family is relying on income. While the policy is in force, the death benefit is 100% guaranteed. The full death benefit is designed to last through age 99 for nontobacco users and age 95 for tobacco users based on the current interest rate and mortality assumptions.

Let LifeTime Benefit Term be Your Champion As Life Insurance LifeTime Benefit Term protects families with money that can be used any way they need. Often it is used to pay for mortgage or rent, education for children and grandchildren, family debt and final expenses. For Long Term Care Long Term Care is expensive, and LifeTime Benefit Term can help. It pays death benefits in advance for home health care, assisted living, adult day care and nursing home and waives life insurance premiums. And with Extension of Long Term Care, benefits can last for more than 6 years, in essence, tripling the policy value Additional Benefits Long Term Care Acceleration* When employees need LTC, death benefits can be paid early for home health care, assisted living, adult day care and nursing home care. Early payments equal 4% of the death benefit per month for up to 25 months. Premiums are waived while this benefit is being paid. Long Term Care Extension* Once the full death benefit has been paid in advance for LTC, payments can be extended. Choose between 25 and 50 months of LTC Benefit Extension to double or triple the value. Restoration of Death Benefit Accelerating the life coverage for LTC benefits can reduce the death benefit to $0. This rider restores the life coverage to either 25% or 50% of the death benefit on which the LTC benefits were based, therefore assuring a death benefit available up to the insured’s age 121.

Optional Benefits Guaranteed Premiums Life insurance premiums will never increase and are guaranteed through age 100.

Waiver of Premium Benefit & Payor Waiver of Premium Benefit Waives premium if employee becomes totally disabled.

Paid-up Benefits After 10 years, paid-up benefits begin to accrue. At any point thereafter, if premiums stop, a reduced paid up benefit is guaranteed. Flexibility is perfect for retirement. Terminal Illness Benefit After coverage has been in force for two years, employees can receive 50% of their death benefit immediately, up to $100,000, if they are diagnosed as terminally ill.

Features Affordable Financial Security Lifelong protection with premiums beginning as low as $3 per week. Dependable Guarantees Guaranteed life insurance premium and death benefits last a lifetime.

Highly Competitive Rates For the same premium, LifeTime Benefit Term provides higher benefits than permanent life Insurance and lasts to age 121.

This document is only a brief description of Group Policy Form No. P34544. See the policy for complete details about features, benefits, exclusions and limitations that may vary by state. The availability of this product, riders or optional benefits are subject to underwriting approval.

Fully Portable and Guaranteed Renewable for Life Employee coverage cannot be cancelled as long as premiums are paid as due.

* LTC and Extension of Benefits premiums may be adjusted based upon the experience of the group or other group characteristics that may affect results. Premiums will not be increased solely because of an independent claim.

CWB-LBT-LTC-BR-0523

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

CANCER BENEFITS

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

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

CANCER ASSIST

One family’s journey

DOCTOR’S SCREENING

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

SECOND OPINION

SURGERY

Wellness benefit

Travel expenses

Out-of-pocket costs

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

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

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

For illustrative purposes only

With cancer insurance: ■ Coverage options are available for you

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

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

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

change jobs or retire.

ONLY of ALL

CANCERS are

hereditary.

American Cancer Society, Cancer Facts & Figures, 2013

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

TREATMENT

RECOVERY

Experimental care

Follow-up evaluations

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

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

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

(inpatient or outpatient)

Surgery benefits ■ Surgical procedures

■ Radiation/chemotherapy

■ Anesthesia

■ Anti-nausea medication

■ Reconstructive surgery

■ Medical imaging studies

■ Outpatient surgical center

■ Supportive or protective care drugs

■ Prosthetic device/artificial limb

and colony stimulating factors ■ Second medical opinion

Travel benefits

■ Blood/plasma/platelets/

■ Transportation

immunoglobulins ■ Bone marrow or peripheral stem

■ Companion transportation ■ Lodging

LIFETIME RISK OF DEVELOPING CANCER

MEN 1 in 2

cell donation ■ Bone marrow or peripheral stem

cell transplant ■ Egg(s) extraction or harvesting/

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

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

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

Additional benefits WOMEN

■ Family care

1 in 3

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

American Cancer Society, Cancer Facts & Figures, 2013

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

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.

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Cancer Insurance Level 4 Benefits BENEFIT DESCRIPTION

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

BENEFIT AMOUNT

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

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

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

Anesthesia

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

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

per prescription filled

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

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

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

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

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

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

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

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

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

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

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

For more information, talk with your benefits counselor.

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

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

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

Hospice (initial or daily care)

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

CANCER ASSIST – LEVEL 4

BENEFIT DESCRIPTION

BENEFIT AMOUNT

Hospital confinement

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

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

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

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

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

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

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

Radiation/chemotherapy

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

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

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.

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

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

CANCER BENEFIT PREMIUMS LEVEL 1 - Composite Rates Employee

Employee/Spouse

One-Parent Family

Two-Parent Family

$18.25

$28.75

One-Parent Family

Two-Parent Family

$21.95

$34.15

One-Parent Family

Two-Parent Family

$27.10

$44.85

One-Parent Family

Two-Parent Family

$36.20

$60.00

One-Parent Family

Two-Parent Family

$1.75

$1.25

$1.75

$2.50

$1.60

$2.60

$7.80

$17.05

Level 1 with $100 Cancer Wellness/Health Screening 12-Pay Premium

$18.10

$28.60 LEVEL 2 - Composite Rates

Employee

Employee/Spouse

Level 2 with $100 Cancer Wellness/Health Screening 12-Pay Premium

$21.65

$33.85 LEVEL 3 - Composite Rates

Employee

Employee/Spouse

Level 3 with $100 Cancer Wellness/Health Screening 12-Pay Premium

$26.65

$44.40 LEVEL 4 - Composite Rates

Employee

Employee/Spouse

Level 4 with $100 Cancer Wellness/Health Screening 12-Pay Premium

$35.60

$59.40 OPTIONAL RIDERS

Employee

Employee/Spouse

Specified Disease Hospital Confinement Rider 12-Pay Premium

$1.25

Initial Diagnosis of Cancer Rider (per $1,000) 12-Pay Premium

$1.50

Initial Diagnosis of Cancer Progressive Payment Rider 12-Pay Premium

$7.80

$17.05

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

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

CRITICAL ILLNESS BENEFITS

Group Critical Illness Insurance Plan 1

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

An unexpected moment changes life forever

Coverage amount: ____________________________

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

Critical illness benefit

HOW CHRIS’S COVERAGE HELPED

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

For illustrative purposes only.

COVERED CONDITION¹

PERCENTAGE OF APPLICABLE COVERAGE AMOUNT

Benign brain tumor

100%

Coma

100%

End stage renal (kidney) failure

100%

Heart attack (myocardial infarction)

100%

Loss of hearing

100%

Loss of sight

100%

Loss of speech

100%

Major organ failure requiring transplant

100%

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

100%

Permanent paralysis due to a covered accident

100%

Stroke

100%

Sudden cardiac arrest

100%

Coronary artery disease

25%

GCI6000 – PLAN 1 – CRITICAL ILLNESS

KEY BENEFITS

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

For more information, talk with your benefits counselor.

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

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

Additional covered conditions for dependent children PERCENTAGE OF APPLICABLE COVERAGE AMOUNT

COVERED CONDITION¹

Cerebral palsy

100%

Cleft lip or palate

100%

Cystic fibrosis

100%

Down syndrome

100%

Spina bifida

100%

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

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

EXCLUSIONS AND LIMITATIONS FOR CRITICAL ILLNESS

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

ColonialLife.com

PRE-EXISTING CONDITION LIMITATION

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

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Group Critical Illness Insurance Plan 2

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

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

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

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

Special needs daycare

Coverage amount: ____________________________

Critical illness and cancer benefits COVERED CRITICAL ILLNESS CONDITION¹

Benign brain tumor

100%

Coma

100%

End stage renal (kidney) failure

100%

Heart attack (myocardial infarction)

100%

Loss of hearing

100%

Loss of sight

100%

Loss of speech

100%

Major organ failure requiring transplant

100%

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

100%

Permanent paralysis due to a covered accident

100%

Stroke

100%

Sudden cardiac arrest

100%

Coronary artery disease

25%

COVERED CANCER CONDITION¹ For illustrative purposes only.

PERCENTAGE OF APPLICABLE COVERAGE AMOUNT

Invasive cancer (including all breast cancer)

100%

Non-invasive cancer

25%

Skin cancer initial diagnosis ............................................................ $400 per lifetime 64

GCI6000 – PLAN 2 – CRITICAL ILLNESS AND CANCER

KEY BENEFITS

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

Additional covered conditions for dependent children PERCENTAGE OF APPLICABLE COVERAGE AMOUNT

COVERED CONDITION¹

Cerebral palsy

100%

Cleft lip or palate

100%

Cystic fibrosis

100%

Down syndrome

100%

Spina bifida

100%

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

For more information, talk with your benefits counselor.

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

EXCLUSIONS AND LIMITATIONS FOR CRITICAL ILLNESS

EXCLUSIONS AND LIMITATIONS FOR CANCER

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

PRE-EXISTING CONDITION LIMITATION

ColonialLife.com

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

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Group Critical Illness Insurance First Diagnosis Building Benefit Rider

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

First diagnosis building benefit Payable once per covered person per lifetime

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

For more information, talk with your benefits counselor.

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

ColonialLife.com

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

GCI6000 – FIRST DIAGNOSIS BUILDING BENEFIT RIDER | 5-20 | 387381

Group Critical Illness Insurance Infectious Diseases Rider

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

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

PERCENTAGE OF APPLICABLE COVERAGE AMOUNT

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

For more information, talk with your benefits counselor.

ColonialLife.com

Antibiotic resistant bacteria (including MRSA)

50%

Cerebrospinal meningitis (bacterial)

50%

Diphtheria

50%

Encephalitis

50%

Legionnaires’ disease

50%

Lyme disease

50%

Malaria

50%

Necrotizing fasciitis

50%

Osteomyelitis

50%

Poliomyelitis

50%

Rabies

50%

Sepsis

50%

Tetanus

50%

Tuberculosis

50%

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

25%

GCI6000 – INFECTIOUS DISEASES RIDER

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

EXCLUSIONS AND LIMITATIONS FOR INFECTIOUS DISEASES RIDER

ColonialLife.com

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

PRE-EXISTING CONDITION LIMITATION

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

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Group Critical Illness Insurance Progressive Diseases Rider

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

COVERED PROGRESSIVE DISEASE¹

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

For more information, talk with your benefits counselor.

ColonialLife.com

Amyotrophic Lateral Sclerosis (ALS)

25%

Dementia (including Alzheimer’s disease)

25%

Huntington’s disease

25%

Lupus

25%

Multiple sclerosis (MS)

25%

Muscular dystrophy

25%

Myasthenia gravis (MG)

25%

Parkinson’s disease

25%

Systemic sclerosis (scleroderma)

25%

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

EXCLUSIONS AND LIMITATIONS FOR PROGRESSIVE DISEASES RIDER

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

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

GCI6000 – PROGRESSIVE DISEASES RIDER | 5-20 | 387594

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

Issue Age

Deduction

Named Insured

Employee & Spouse

One-Parent Family

Two Parent Family

Non-Tobacco 17-24

12-Pay Premium

$0.22

$0.31

$0.22

$0.31

25-29

12-Pay Premium

$0.30

$0.43

$0.30

$0.43

30-34

12-Pay Premium

$0.38

$0.55

$0.38

$0.55

35-39

12-Pay Premium

$0.57

$0.85

$0.57

$0.85

40-44

12-Pay Premium

$0.77

$1.14

$0.77

$1.14

45-49

12-Pay Premium

$1.08

$1.65

$1.08

$1.65

50-54

12-Pay Premium

$1.44

$2.23

$1.44

$2.23

55-59

12-Pay Premium

$1.90

$2.94

$1.90

$2.94

60-64

12-Pay Premium

$2.60

$4.02

$2.60

$4.02

65-69

12-Pay Premium

$2.84

$4.38

$2.84

$4.38

70-74

12-Pay Premium

$3.27

$5.04

$3.27

$5.04

One-Parent Family $6.65

Two Parent Family $10.35

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

12-Pay Premium

Named Insured $6.65

Employee & Spouse $10.35

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

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

Issue Age

Deduction

Named Insured

Employee & Spouse

One-Parent Family

Two Parent Family

Non-Tobacco 17-24

12-Pay Premium

$0.40

$0.57

$0.40

$0.57

25-29

12-Pay Premium

$0.57

$0.83

$0.57

$0.83

30-34

12-Pay Premium

$0.75

$1.09

$0.75

$1.09

35-39

12-Pay Premium

$1.15

$1.70

$1.15

$1.70

40-44

12-Pay Premium

$1.55

$2.30

$1.55

$2.30

45-49

12-Pay Premium

$2.21

$3.32

$2.21

$3.32

50-54

12-Pay Premium

$2.86

$4.34

$2.86

$4.34

55-59

12-Pay Premium

$3.76

$5.71

$3.76

$5.71

60-64

12-Pay Premium

$5.13

$7.79

$5.13

$7.79

65-69

12-Pay Premium

$6.29

$9.57

$6.29

$9.57

70-74

12-Pay Premium

$6.29

$9.57

$6.29

$9.57

One-Parent Family $6.65

Two Parent Family $10.35

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

12-Pay Premium

Named Insured $6.65

Employee & Spouse $10.35

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

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

SHORT-TERM DISABILITY BENEFITS

Educator Disability Income Insurance

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

$_________________

$_________________ Total $_________________

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

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

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

On-Job

Off-Job

First 3 months

$_____________/month

Next 9 months

$_____________/month

First 6 months

$_____________/month

Next 6 months

$_____________/month

= Total Disability

Educator Disability 1.0-VA

Option A Option B = Partial Disability Up to 3 months

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

After a Sickness: ___________ days

How much will it cost? Your cost will vary based on the level of coverage you select. 73

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 74

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

Additional Features l

Waiver of Premium

Worldwide Coverage

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

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

Hospital Confinement Benefit for Accident or Sickness l

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

Accidental Death and Dismemberment Benefits l

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

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

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

Here are some

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

What if I change employers?

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

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

When am I considered totally disabled?

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

Totally disabled means you are: l

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

What is a covered accident or a covered sickness?

Under the regular and appropriate care of a doctor.

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

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

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

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

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

Colonial Life and Making benefits count are registered service marks of Colonial Life &71381-1 Accident Insurance Company. 100252 76

Educator Disability 1.0-VA

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

What is a pre-existing condition?

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

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

Benefit Amount

Elimination Period

First 3 months

Next 9 Months

Units

0/7

0/14

14/14

0/30

30/30

400

200

$18.40

$16.00

$15.00

$14.80

$12.80

600

300

$24.30

$20.70

$19.20

$18.90

$15.90

800

400

$30.20

$25.40

$23.40

$23.00

$19.00

1000

500

$36.10

$30.10

$27.60

$27.10

$22.10

1200

600

$42.00

$34.80

$31.80

$31.20

$25.20

1400

700

$47.90

$39.50

$36.00

$35.30

$28.30

1600

800

$53.80

$44.20

$40.20

$39.40

$31.40

1800

900

$59.70

$48.90

$44.40

$43.50

$34.50

2000

1000

$65.60

$53.60

$48.60

$47.60

$37.60

2200

1100

$71.50

$58.30

$52.80

$51.70

$40.70

2400

1200

$77.40

$63.00

$57.00

$55.80

$43.80

2600

1300

$83.30

$67.70

$61.20

$59.90

$46.90

2800

1400

$89.20

$72.40

$65.40

$64.00

$50.00

3000

1500

$95.10

$77.10

$69.60

$68.10

$53.10

3200

1600

$101.00

$81.80

$73.80

$72.20

$56.20

3400

1700

$106.90

$86.50

$78.00

$76.30

$59.30

3600

1800

$112.80

$91.20

$82.20

$80.40

$62.40

3800

1900

$118.70

$95.90

$86.40

$84.50

$65.50

4000

2000

$124.60

$100.60

$90.60

$88.60

$68.60

4200

2100

$130.50

$105.30

$94.80

$92.70

$71.70

4400

2200

$136.40

$110.00

$99.00

$96.80

$74.80

4600

2300

$142.30

$114.70

$103.20

$100.90

$77.90

4800

2400

$148.20

$119.40

$107.40

$105.00

$81.00

5000

2500

$154.10

$124.10

$111.60

$109.10

$84.10

Spouse and Dependent Premiums Rider

Monthly Premium

Spouse Accident & Sickness Benefit Coverage

$5.50

Child(ren) Accident & Sickness Benefit Coverage

$7.50

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

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

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

Benefit Amount

Elimination Period

First 3 months

Next 9 Months

Units

0/7

0/14

14/14

0/30

30/30

400

200

$23.60

$21.40

$19.40

$18.80

$16.00

600

300

$32.10

$28.80

$25.80

$24.90

$20.70

800

400

$40.60

$36.20

$32.20

$31.00

$25.40

1000

500

$49.10

$43.60

$38.60

$37.10

$30.10

1200

600

$57.60

$51.00

$45.00

$43.20

$34.80

1400

700

$66.10

$58.40

$51.40

$49.30

$39.50

1600

800

$74.60

$65.80

$57.80

$55.40

$44.20

1800

900

$83.10

$73.20

$64.20

$61.50

$48.90

2000

1000

$91.60

$80.60

$70.60

$67.60

$53.60

2200

1100

$100.10

$88.00

$77.00

$73.70

$58.30

2400

1200

$108.60

$95.40

$83.40

$79.80

$63.00

2600

1300

$117.10

$102.80

$89.80

$85.90

$67.70

2800

1400

$125.60

$110.20

$96.20

$92.00

$72.40

3000

1500

$134.10

$117.60

$102.60

$98.10

$77.10

3200

1600

$142.60

$125.00

$109.00

$104.20

$81.80

3400

1700

$151.10

$132.40

$115.40

$110.30

$86.50

3600

1800

$159.60

$139.80

$121.80

$116.40

$91.20

3800

1900

$168.10

$147.20

$128.20

$122.50

$95.90

4000

2000

$176.60

$154.60

$134.60

$128.60

$100.60

4200

2100

$185.10

$162.00

$141.00

$134.70

$105.30

4400

2200

$193.60

$169.40

$147.40

$140.80

$110.00

4600

2300

$202.10

$176.80

$153.80

$146.90

$114.70

4800

2400

$210.60

$184.20

$160.20

$153.00

$119.40

5000

2500

$219.10

$191.60

$166.60

$159.10

$124.10

Spouse and Dependent Premiums Rider

Monthly Premium

Spouse Accident & Sickness Benefit Coverage

$5.50

Child(ren) Accident & Sickness Benefit Coverage

$7.50

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

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

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

Benefit Amount

Elimination Period

First 3 months

Next 9 Months

Units

0/7

0/14

14/14

0/30

30/30

400

200

$27.00

$23.60

$21.80

$21.60

$17.80

600

300

$37.20

$32.10

$29.40

$29.10

$23.40

800

400

$47.40

$40.60

$37.00

$36.60

$29.00

1000

500

$57.60

$49.10

$44.60

$44.10

$34.60

1200

600

$67.80

$57.60

$52.20

$51.60

$40.20

1400

700

$78.00

$66.10

$59.80

$59.10

$45.80

1600

800

$88.20

$74.60

$67.40

$66.60

$51.40

1800

900

$98.40

$83.10

$75.00

$74.10

$57.00

2000

1000

$108.60

$91.60

$82.60

$81.60

$62.60

2200

1100

$118.80

$100.10

$90.20

$89.10

$68.20

2400

1200

$129.00

$108.60

$97.80

$96.60

$73.80

2600

1300

$139.20

$117.10

$105.40

$104.10

$79.40

2800

1400

$149.40

$125.60

$113.00

$111.60

$85.00

3000

1500

$159.60

$134.10

$120.60

$119.10

$90.60

3200

1600

$169.80

$142.60

$128.20

$126.60

$96.20

3400

1700

$180.00

$151.10

$135.80

$134.10

$101.80

3600

1800

$190.20

$159.60

$143.40

$141.60

$107.40

3800

1900

$200.40

$168.10

$151.00

$149.10

$113.00

4000

2000

$210.60

$176.60

$158.60

$156.60

$118.60

4200

2100

$220.80

$185.10

$166.20

$164.10

$124.20

4400

2200

$231.00

$193.60

$173.80

$171.60

$129.80

4600

2300

$241.20

$202.10

$181.40

$179.10

$135.40

4800

2400

$251.40

$210.60

$189.00

$186.60

$141.00

5000

2500

$261.60

$219.10

$196.60

$194.10

$146.60

Spouse and Dependent Premiums Rider

Monthly Premium

Spouse Accident & Sickness Benefit Coverage

$5.50

Child(ren) Accident & Sickness Benefit Coverage

$7.50

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

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

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

Elimination Period

First 3 months

Next 9 Months

Units

0/7

0/14

14/14

0/30

30/30

400

200

$14.45

$12.05

$10.85

$10.05

$9.25

600

300

$19.35

$15.75

$13.95

$12.75

$11.55

800

400

$24.25

$19.45

$17.05

$15.45

$13.85

1000

500

$29.15

$23.15

$20.15

$18.15

$16.15

1200

600

$34.05

$26.85

$23.25

$20.85

$18.45

1400

700

$38.95

$30.55

$26.35

$23.55

$20.75

1600

800

$43.85

$34.25

$29.45

$26.25

$23.05

1800

900

$48.75

$37.95

$32.55

$28.95

$25.35

2000

1000

$53.65

$41.65

$35.65

$31.65

$27.65

2200

1100

$58.55

$45.35

$38.75

$34.35

$29.95

2400

1200

$63.45

$49.05

$41.85

$37.05

$32.25

2600

1300

$68.35

$52.75

$44.95

$39.75

$34.55

2800

1400

$73.25

$56.45

$48.05

$42.45

$36.85

3000

1500

$78.15

$60.15

$51.15

$45.15

$39.15

3200

1600

$83.05

$63.85

$54.25

$47.85

$41.45

3400

1700

$87.95

$67.55

$57.35

$50.55

$43.75

3600

1800

$92.85

$71.25

$60.45

$53.25

$46.05

3800

1900

$97.75

$74.95

$63.55

$55.95

$48.35

4000

2000

$102.65

$78.65

$66.65

$58.65

$50.65

4200

2100

$107.55

$82.35

$69.75

$61.35

$52.95

4400

2200

$112.45

$86.05

$72.85

$64.05

$55.25

4600

2300

$117.35

$89.75

$75.95

$66.75

$57.55

4800

2400

$122.25

$93.45

$79.05

$69.45

$59.85

5000

2500

$127.15

$97.15

$82.15

$72.15

$62.15

Spouse and Dependent Premiums Rider

Monthly Premium

Spouse Accident & Sickness Benefit Coverage

$5.50

Child(ren) Accident & Sickness Benefit Coverage

$7.50

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

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

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

Elimination Period

First 3 months

Next 9 Months

Units

0/7

0/14

14/14

0/30

30/30

400

200

$19.65

$16.05

$14.45

$12.85

$11.65

600

300

$27.15

$21.75

$19.35

$16.95

$15.15

800

400

$34.65

$27.45

$24.25

$21.05

$18.65

1000

500

$42.15

$33.15

$29.15

$25.15

$22.15

1200

600

$49.65

$38.85

$34.05

$29.25

$25.65

1400

700

$57.15

$44.55

$38.95

$33.35

$29.15

1600

800

$64.65

$50.25

$43.85

$37.45

$32.65

1800

900

$72.15

$55.95

$48.75

$41.55

$36.15

2000

1000

$79.65

$61.65

$53.65

$45.65

$39.65

2200

1100

$87.15

$67.35

$58.55

$49.75

$43.15

2400

1200

$94.65

$73.05

$63.45

$53.85

$46.65

2600

1300

$102.15

$78.75

$68.35

$57.95

$50.15

2800

1400

$109.65

$84.45

$73.25

$62.05

$53.65

3000

1500

$117.15

$90.15

$78.15

$66.15

$57.15

3200

1600

$124.65

$95.85

$83.05

$70.25

$60.65

3400

1700

$132.15

$101.55

$87.95

$74.35

$64.15

3600

1800

$139.65

$107.25

$92.85

$78.45

$67.65

3800

1900

$147.15

$112.95

$97.75

$82.55

$71.15

4000

2000

$154.65

$118.65

$102.65

$86.65

$74.65

4200

2100

$162.15

$124.35

$107.55

$90.75

$78.15

4400

2200

$169.65

$130.05

$112.45

$94.85

$81.65

4600

2300

$177.15

$135.75

$117.35

$98.95

$85.15

4800

2400

$184.65

$141.45

$122.25

$103.05

$88.65

5000

2500

$192.15

$147.15

$127.15

$107.15

$92.15

Spouse and Dependent Premiums Rider

Monthly Premium

Spouse Accident & Sickness Benefit Coverage

$5.50

Child(ren) Accident & Sickness Benefit Coverage

$7.50

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

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

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

Elimination Period

First 3 months

Next 9 Months

Units

0/7

0/14

14/14

0/30

30/30

400

200

$22.25

$17.45

$16.05

$14.25

$12.65

600

300

$31.05

$23.85

$21.75

$19.05

$16.65

800

400

$39.85

$30.25

$27.45

$23.85

$20.65

1000

500

$48.65

$36.65

$33.15

$28.65

$24.65

1200

600

$57.45

$43.05

$38.85

$33.45

$28.65

1400

700

$66.25

$49.45

$44.55

$38.25

$32.65

1600

800

$75.05

$55.85

$50.25

$43.05

$36.65

1800

900

$83.85

$62.25

$55.95

$47.85

$40.65

2000

1000

$92.65

$68.65

$61.65

$52.65

$44.65

2200

1100

$101.45

$75.05

$67.35

$57.45

$48.65

2400

1200

$110.25

$81.45

$73.05

$62.25

$52.65

2600

1300

$119.05

$87.85

$78.75

$67.05

$56.65

2800

1400

$127.85

$94.25

$84.45

$71.85

$60.65

3000

1500

$136.65

$100.65

$90.15

$76.65

$64.65

3200

1600

$145.45

$107.05

$95.85

$81.45

$68.65

3400

1700

$154.25

$113.45

$101.55

$86.25

$72.65

3600

1800

$163.05

$119.85

$107.25

$91.05

$76.65

3800

1900

$171.85

$126.25

$112.95

$95.85

$80.65

4000

2000

$180.65

$132.65

$118.65

$100.65

$84.65

4200

2100

$189.45

$139.05

$124.35

$105.45

$88.65

4400

2200

$198.25

$145.45

$130.05

$110.25

$92.65

4600

2300

$207.05

$151.85

$135.75

$115.05

$96.65

4800

2400

$215.85

$158.25

$141.45

$119.85

$100.65

5000

2500

$224.65

$164.65

$147.15

$124.65

$104.65

Spouse and Dependent Premiums Rider

Monthly Premium

Spouse Accident & Sickness Benefit Coverage

$5.50

Child(ren) Accident & Sickness Benefit Coverage

$7.50

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

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

ACCIDENT BENEFITS

Accident Insurance

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

Sports-related accidental injury Broken bone Burn Concussion Laceration

Back or knee injuries

l l l l

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

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

What additional features are included? l

Worldwide coverage

Portable

Accident 1.0-Preferred-VA

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

Compliant with Healthcare Spending Account (HSA) guidelines

Can my premium change?

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

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

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

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

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

Initial Care l

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

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

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

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

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

Non-Surgical

Surgical

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

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

Non-Surgical

Surgical

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

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

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

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

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

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

l l

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

Requires Surgery l

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

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

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

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

Surgical Care l

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

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

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

Blood/Plasma/Platelets ................................................................................................................................$300 86

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

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

Accident Hospital Care l

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

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

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

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

Accident Follow-Up Care l l

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

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

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

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

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

Accidental Dismemberment l

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

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

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

Loss of one hand and one foot

Loss of the sight of both eyes

Loss of both hands or both feet

Loss of the hearing of both ears

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

Loss of the ability to speak

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

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

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

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

Accidental Death Accidental Death

Common Carrier

Named Insured

$25,000

$100,000

Spouse

$25,000

$100,000

Child(ren)

$5,000

$20,000

Health Screening Benefit

l $50 per covered person per calendar year

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

Tests include: l.

Blood test for triglycerides

Hemoccult stool analysis

Bone marrow testing

Mammography

Breast ultrasound

Pap smear

CA 15-3 (blood test for breast cancer)

PSA (blood test for prostate cancer)

CA125 (blood test for ovarian cancer)

Carotid doppler

Serum cholesterol test to determine level of HDL and LDL

Serum protein electrophoresis (blood test for myeloma)

Stress test on a bicycle or treadmill

Skin cancer biopsy

Thermography

ThinPrep pap test

Virtual colonoscopy

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

Chest x-ray

Colonoscopy

Echocardiogram (ECHO)

Electrocardiogram (EKG, ECG)

Fasting blood glucose test

Flexible sigmoidoscopy

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

Spouse Only

One-Parent Family, with Spouse

Employee & Spouse Two-Parent Family

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

Off -Job Only Benefits

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

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

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

74231-2

Accident 1.0-Preferred with Health Screening Benefit-VA

One-Parent Family, with Employee

One Child Only

ACCIDENT BENEFIT PREMIUMS Preferred with HealthScreening - On/Off-Job Accident Coverage 12-Pay Premium Named Insured

$21.15

Employee & Spouse

$28.97

One-Parent Family

$32.67

Two-Parent Family

$40.48

Preferred with HealthScreening - Off-Job Only Accident Coverage 12-Pay Premium Named Insured

$17.92

Employee & Spouse

$23.96

One-Parent Family

$26.56

Two-Parent Family

$32.61

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

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

MEDICAL BRIDGE BENEFITS

Hospital Confinement Indemnity Insurance Plan 2

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

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

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

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

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

For more information, talk with your benefits counselor.

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

Tier 1 outpatient surgical procedures Breast

Gynecological

– Axillary node dissection – Breast capsulotomy – Lumpectomy

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

Cardiac

Liver

– Pacemaker insertion

– Paracentesis

Digestive

Musculoskeletal system

– Colonoscopy – Fistulotomy – Hemorrhoidectomy – Lysis of adhesions

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

Skin – Laparoscopic hernia repair – Skin grafting

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

IMB7000 – PLAN 2

Tier 2 outpatient surgical procedures Breast

Gynecological

– Breast reconstruction – Breast reduction

– Hysterectomy – Myomectomy

Cardiac

Musculoskeletal system

– Angioplasty – Cardiac catheterization

Digestive – Exploratory laparoscopy – Laparoscopic appendectomy – Laparoscopic cholecystectomy

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

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

Thyroid – Excision of a mass

Urologic

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

– Lithotripsy

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

5-18 | 101578-1-NC

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

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

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

Waiver of premium

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

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

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

For more information, talk with your benefits counselor.

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

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

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

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

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

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

Tier 1 outpatient surgical procedures Breast

Gynecological

Cardiac

Liver

Digestive

Musculoskeletal system

– Axillary node dissection – Breast capsulotomy – Lumpectomy

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

– Pacemaker insertion

– Paracentesis

– Colonoscopy – Fistulotomy – Hemorrhoidectomy – Lysis of adhesions

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

Skin

– Laparoscopic hernia repair – Skin grafting

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

Tier 2 outpatient surgical procedures Breast

Gynecological

Cardiac

Musculoskeletal system

– Breast reconstruction – Breast reduction

– Hysterectomy – Myomectomy

– Angioplasty – Cardiac catheterization

Digestive

– Exploratory laparoscopy – Laparoscopic appendectomy – Laparoscopic cholecystectomy

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

Thyroid

– Excision of a mass

Eye

ColonialLife.com

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

Urologic

– Lithotripsy

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

$36.75 $48.35 $61.30 $78.85

$44.60 $58.90 $75.85 $98.05

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

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

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

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

TERM LIFE INSURANCE

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

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

Talk with your Colonial Life benefits counselor to learn more.

ColonialLife.com

Spouse coverage options

Dependent coverage options

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

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

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

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

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

100

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 £ Critical illness accelerated death benefit rider £ Waiver of premium benefit rider

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

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 ridesharing 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.

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 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

1 Any payout would reduce the death benefit. Benefits may be taxable as income. Individuals should consult with their l egal or tax counsel when deciding to apply for accelerated benefits. 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.

101

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

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

$6.64 $7.06 $7.57 $7.98 $9.17 $11.72 $16.17 $23.36

$10.60 $11.65 $12.94 $13.96 $16.92 $23.29 $34.44 $52.39

$10.21 $10.21 $11.25 $14.04 $18.62 $25.58 $36.37 $53.96

$16.42 $16.42 $18.50 $24.08 $33.25 $47.16 $68.75 $103.91

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

Pay Premium

$10,000.00

$25,000.00

$50,000.00

$100,000.00

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

$6.71 $7.12 $7.69 $8.23 $9.68 $12.67 $18.06 $26.84

$10.77 $11.81 $13.23 $14.58 $18.21 $25.69 $39.14 $61.10

$10.54 $10.54 $11.58 $15.42 $21.79 $31.58 $46.33 $72.00

$17.08 $17.08 $19.17 $26.83 $39.58 $59.16 $88.66 $139.99

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

102

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. 104

WHOLE LIFE PLUS (IWL5000)

Benefits worksheet

Additional coverage options (Continued)

For use with your benefits counselor

Accidental death benefit rider

How much coverage do you need?

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 farepaying 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.

 YOU $_______________________ 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

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.

$ _____________face amount for _________-year term period

 Children’s term rider

$ ______________ face amount

 Accidental death benefit rider  Critical illness accelerated death benefit rider

 Guaranteed purchase option rider

 Waiver of premium benefit rider

* 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. 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.

To learn more, talk with your benefits counselor.

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

105

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

$10,000.00 $9.87 $11.92 $14.96 $19.35 $25.57 $34.87

$25,000.00 $24.69 $29.79 $37.39 $48.37 $63.93 $87.18

$50,000.00 $49.37 $59.58 $74.79 $96.75 $127.87 $174.37

$100,000.00 $98.75 $119.16 $149.58 $193.49 $255.74 $348.74

$200,000.00 $197.49 $238.32 $299.15 $386.98 $511.48 $697.47

$100,000.00 $92.00 $104.58 $125.16 $155.08 $198.83 $250.99 $324.49 $429.57

$200,000.00 $183.99 $209.16 $250.32 $310.15 $397.65 $501.98 $648.97 $859.13

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

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

$10,000.00 $9.20 $10.46 $12.52 $15.51 $19.88 $25.10 $32.45 $42.96

$25,000.00 $23.00 $26.14 $31.29 $38.77 $49.71 $62.75 $81.12 $107.39

$50,000.00 $46.00 $52.29 $62.58 $77.54 $99.41 $125.49 $162.24 $214.78

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

106

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

_____________ (Social Security Number)

___________________ (Signature)

__________________ (Date Signed)

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

________________________________ (Printed name of legal representative)

_____________________________ (Signature of legal representative)

108

___________ (Date Signed)

Protected Health Information Privacy Practices

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ADDITIONAL BENEFITS

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

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

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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.

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

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

ALASKA - MEDICAID

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

INDIANA - MEDICAID

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

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

ARKANSAS - MEDICAID

IOWA - MEDICAID AND CHIP (HAWKI)

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

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

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

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

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

KENTUCKY - MEDICAID

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

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

FLORIDA - MEDICAID

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

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

LOUISIANA - MEDICAID

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

COBRA CONTINUATION OF COVERAGE INTRODUCTION: You’re getting this notice because you recently gained coverage under a group plan. This notice has important information about your right to COBRA continuation coverage, which is a temporary extension of coverage under the Plan. This notice explains COBRA continuation coverage, when it may become available to you and your family, and what you need to do to protect your right to get it. When you become eligible for COBRA, you may also become eligible for other coverage options that may cost less than COBRA continuation coverage. The right to COBRA continuation coverage was created by a federal law, the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA). COBRA continuation coverage can become available to you and other members of your family when group health coverage would otherwise end. For more information about your rights and obligations under the Plan and under federal law, you should review the Plan’s Summary Plan Description or contact the Plan Administrator.

A, Part B, or both); or • You become divorced or legally separated from your spouse. Your dependent children will become qualified beneficiaries if they lose coverage under the Plan because of the following qualifying events: • The parent-employee dies; • The parent-employee’s hours of employment are reduced; • The parent-employee’s employment ends for any reason other than his or her gross misconduct; • The parent-employee becomes entitled to Medicare benefits (Part A, Part B, or both); • The parents become divorced or legally separated; or • The child stops being eligible for coverage under the Plan as a “dependent child.”

You may have other options available to you when you lose group health coverage. For example, you may be eligible to buy an individual plan through the Health Insurance Marketplace. By enrolling in coverage through the Marketplace, you may qualify for lower costs on your monthly premiums and lower out-of-pocket costs. Additionally, you may qualify for a 30-day special enrollment period for another group health plan for which you are eligible (such as a spouse’s plan), even if that plan generally doesn’t accept late enrollees.

Sometimes, filing a proceeding in bankruptcy under title 11 of the United States Code can be a qualifying event. If a proceeding in bankruptcy is filed with respect to Henry County 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: Henry County 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, or a second qualifying event during the initial period of coverage,

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

account of Medicare entitlement, even if you enroll in the other part of Medicare after the date of the election of COBRA coverage.

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

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

Disability extension of 18-month period of COBRA continuation coverage: If you or anyone in your family covered under the Plan is determined by Social Security to be disabled and you notify the Plan Administrator in a timely fashion, you and your entire family may be entitled to get up to an additional 11 months of COBRA continuation coverage, for a maximum of 29 months. The disability would have to have started at some time before the 60th day of COBRA continuation coverage and must last at least until the end of the 18-month period of COBRA continuation coverage. 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.

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 Henry County Public Schools 330 Kings Mountain Road Collinsville, VA 24078 ATTN: Christy Landon clandon@henry.k12.va.us

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

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

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

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

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

Upon receipt of a request from you, the Bureau will arrange disclosure of any information it may have in your file. If you question the accuracy of information in the Bureau’s file, you may contact the Bureau and seek a correction in accordance with the procedure set forth in the federal Fair If you believe NPI we have about you Credit Reporting Act. The address of is incorrect, please write us. Your letter the Bureau’s information office is: 50 should include your full name, address, Braintree Hill Park, Suite 400, Braintree, telephone number and policy number if we have issued a policy. Your letter should MA 02184-8734, telephone (617) 4263660. also explain why you believe the NPI is inaccurate. If we agree with you, we will Colonial or its reinsure may also correct the NPI and notify you of the release information in its file to other correction. We will also notify any person who may have received the incorrect NPI life insurance companies to whom you from us in the past two years if you ask us may apply for life or health insurance or to whom a claim for benefits may be to contact that person. submitted. If we disagree with you, we will tell you we are not going to make the correction, We will give the reason(s) for our refusal. We will also tell you that you may submit a statement to us. Your statement should include the NPI you believe is correct. It should also include the reasons(s) why you disagree with our decision not to correct the NPI 121

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

DENTAL BENEFITS

VISION BENEFITS

TELEMEDICINE BENEFITS

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

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

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

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

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