$1,250 Individual/ $2,500 Family. What is the overall deductible? $2,500 Individual / $5,000 Family

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1 MESSA ABC $1,250 $2,500 Coverage Period: Beginning on or after 01/01/2014 Summary of Benefits and Coverage: What this Plan Covers & What it Costs* Coverage for: Individual / Family Plan Type: PPO This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at or by calling MESSA at Important Questions What is the overall deductible? Are there other deductibles for specific services? Is there an out of pocket limit on my expenses? What is not included in the out of pocket limit? In-Network $1,250 Individual/ $2,500 Family Answers Out-of-Network $2,500 Individual / $5,000 Family Why this Matters: You must pay all the costs up to the deductible amount before this plan begins to pay for covered services you use. Check your policy or plan document to see when the deductible starts over (usually, but not always, January 1st). See the chart starting on page 2 for how much you pay for covered services after you meet the deductible. No. No. You don t have to meet deductibles for specific services, but see the Common Medical Event chart starting on page 2 for other costs for services this plan covers. $2,250 Individual/ $4,500 Individual / The out-of-pocket limit is the most you could pay during a coverage period (usually $4,500 Family $9,000 Family one year) for your share of the cost of covered services. This limit helps you plan for Premiums, balance-billed charges, and health care this plan doesn t cover. health care expenses. Even though you pay these expenses, they don t count toward the out-of-pocket limit. Is there an overall annual limit on what the plan pays? Does this plan use a network of providers? Do I need a referral to see a specialist? Are there services this plan doesn t cover? No. Yes. For a list of in-network providers, see or call MESSA at No. Yes. The Common Medical Events chart starting on page 2 describes any limits on what the plan will pay for specific covered services, such as office visits. If you use an in-network doctor or other health care provider, this plan will pay some or all of the costs of covered services. Be aware, your in-network doctor or hospital may use an out-of-network provider for some services. Plans use the term innetwork, preferred, or participating for providers in their network. See the Common Medical Events Chart starting on page 2 for how this plan pays different kinds of providers. You can see the specialist you choose without permission from this plan. Some of the services this plan doesn t cover are listed on page 5. See your policy or plan document for additional information about excluded services. MESSA ABC, Group Number 71452, 71453; Questions: Call MESSA at or visit us at If you aren t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary at or call MESSA at to request a copy. *This plan or selected benefits within this plan are underwritten by 4 Ever Life Insurance Company, an independent licensee of the Blue Cross and Blue Shield Association and administered by Blue Cross Blue Shield of Michigan. 1 of 8

2 Common Medical Event Co-payments are fixed dollar amounts (for example, $15) you pay for covered health care, usually when you receive the service. Co-insurance is your share of the costs of a covered service, calculated as a percent of the allowed amount for the service. For example, if the plan s allowed amount for an overnight hospital stay is $1,000, your co-insurance payment of 20% would be $200. This may change if you haven t met your deductible. The amount the plan pays for covered services is based on the allowed amount. If an out-of-network provider charges more than the allowed amount, you may have to pay the difference. For example, if an out-of-network hospital charges $1,500 for an overnight stay and the allowed amount is $1,000, you may have to pay the $500 difference. (This is called balance billing.) This plan may encourage you to use in-network providers by charging you lower deductibles, co-payments and co-insurance amounts. If you visit a health care provider s office or clinic If you have a test If you need drugs to treat your illness or condition For more information about prescription drug coverage (if applicable), contact your employer. Services You May Need Primary care visit to treat an injury or illness Your cost if you use a In-Network Out-of-Network Provider Provider No Charge after deductible 20% coinsurance after deductible Specialist visit No Charge after deductible 20% coinsurance after deductible Other practitioner office visit No Charge after deductible 20% coinsurance after for Chiropractic. deductible Preventive care/screening/ immunization Diagnostic test (x-ray, blood work) Imaging (CT/PET scans, MRIs) Generic or prescribed overthe-counter drugs Formulary (preferred) brandname drugs Nonformulary (nonpreferred) brand-name drugs Limitations & Exceptions ---none none--- No Charge Not Covered ---none--- No Charge after deductible No Charge after deductible $10 co-pay after deductible for retail 34-day supply; $20 co-pay after deductible for mail order 90 day supply. $40 co-pay after deductible for retail 34-day supply; $80 co-pay after deductible for mail order 90 day supply. $40 co-pay after deductible for retail 34-day supply; $80 co-pay after deductible for mail order 90 day supply. 20% coinsurance after deductible 20% coinsurance after deductible $10 Co-pay plus an additional 25% of BCBSM approved amount for the drug. $40 Co-pay plus an additional 25% of BCBSM approved amount for the drug. $40 Co-pay plus an additional 25% of BCBSM approved amount for the drug. Limited to a maximum of 38 visits per member per calendar year. ---none--- To be eligible for coverage, these services may require approval before they are provided. For information on women s contraceptive coverage, contact your employer. Mail order drugs are not covered out-of-network Mail order drugs are not covered out-ofnetwork. Mail order drugs are not covered out-ofnetwork.

3 Common Medical Event If you have outpatient surgery Services You May Need Facility fee (e.g., ambulatory surgery center) Your cost if you use a In-Network Out-of-Network Provider Provider No Charge after deductible 20% coinsurance after deductible Physician/surgeon fees No Charge after deductible 20% coinsurance after deductible Limitations & Exceptions ---none none--- If you need immediate medical attention Emergency room services No Charge after deductible No Charge after deductible Emergency medical No Charge after deductible 20% coinsurance after transportation deductible Urgent care No Charge after deductible 20% coinsurance after deductible Co-pay waived if admitted. ---none none--- If you have a hospital stay Facility fee (e.g., hospital room) No Charge after deductible 20% coinsurance after deductible Physician/surgeon fee No Charge after deductible 20% coinsurance after deductible ---none none--- Mental/Behavioral health outpatient services No Charge after deductible 20% coinsurance after deductible ---none--- If you have mental health, behavioral health, or substance abuse needs Mental/Behavioral health inpatient services Substance use disorder outpatient services Substance use disorder inpatient services No Charge after deductible No Charge after deductible No Charge after deductible 20% coinsurance after deductible 20% coinsurance after deductible 20% coinsurance after deductible ---none none none--- 3 of 8

4 Common Medical Event If you are pregnant If you need help recovering or have other special health needs Services You May Need Prenatal and postnatal care Delivery and all inpatient services Your cost if you use a In-Network Out-of-Network Provider Provider 20% coinsurance after deductible Prenatal: No Charge Postnatal: No Charge after deductible No Charge after deductible 20% coinsurance after deductible Home health care No Charge after deductible 20% coinsurance after deductible Rehabilitation services No Charge after deductible 20% coinsurance after deductible Limitations & Exceptions ---none none none--- Habilitation services Not Covered Not Covered ---none--- Skilled nursing care No Charge after deductible 20% coinsurance after deductible Durable medical equipment No Charge after deductible 20% coinsurance after deductible Physical, Occupational, Speech therapy is limited to a combined maximum of 60 visits per member, per calendar year. Limited to a maximum of 120 days per member per calendar year. ---none--- Hospice service No Charge after deductible 20% coinsurance after deductible ---none--- If your child needs dental or eye care Eye exam Not Covered Not Covered ---none--- Glasses Not Covered Not Covered ---none--- Dental check-up Not Covered Not Covered ---none--- 4 of 8

5 Excluded Services & Other Covered Services: Services Your Plan Does NOT Cover (This isn t a complete list. Check your policy or plan document for other excluded services.) Cosmetic surgery Routine eye care (Adult) Dental care (Adult) Routine foot care Infertility treatment Weight loss programs Long-term care Other Covered Services (This isn t a complete list. Check your policy or plan document for other covered services and your costs for these services.) Acupuncture Bariatric surgery Chiropractic care Coverage provided outside the United States. See Hearing aids If you are also covered by an account-type plan such as an integrated health flexible spending arrangement (FSA), health reimbursement arrangement (HRA), and/or a health savings account (HSA), then you may have access to additional funds to help cover certain out-of-pocket expenses like the deductible, co-payments, or co-insurance, or benefits not otherwise covered. Private-duty nursing Your Rights to Continue Coverage: If you lose coverage under the plan, then, depending upon the circumstances, Federal and State laws may provide protections that allow you to keep health coverage. Any such rights may be limited in duration and will require you to pay a premium, which may be significantly higher than the premium you pay while covered under the plan. Other limitations on your rights to continue coverage may also apply. For more information on your rights to continue coverage, contact the plan by calling MESSA at You may also contact your state insurance department, the U.S. Department of Labor, Employee Benefits Security Administration at or or the U.S. Department of Health and Human Services at x61565 or Your Grievance and Appeals Rights: If you have a complaint or are dissatisfied with a denial of coverage for claims under your plan, you may be able to appeal or file a grievance. For questions about your rights, this notice, or assistance, you can contact MESSA Legal and Compliance by calling Or, you can contact Michigan Office of Financial and Insurance Regulation at or For group health coverage subject to ERISA, you may also contact Employee Benefits Security Administration at EBSA (3272). 5 of 8

6 Does this Coverage Provide Minimum Essential Coverage? The Affordable Care Act requires most people to have health care coverage that qualifies as minimum essential coverage. This plan or policy does provide minimum essential coverage. Does this Coverage Meet the Minimum Value Standard? In order for certain types of health coverage (for example, individually purchased insurance or job-based coverage) to qualify as minimum essential coverage, the plan must pay, on average, at least 60 percent of allowed charges for covered services. This is called the minimum value standard. This health coverage does meet the minimum value standard for the benefits it provides. (IMPORTANT: Blue Cross Blue Shield of Michigan is assuming that your coverage provides for all Essential Health Benefit (EHB) categories as defined by the State of Michigan. The minimum value of your plan may be affected if your plan does not cover certain EHB categories, such as prescription drugs, or if your plan provides coverage of specific EHB categories, for example prescription drugs, through another carrier. In these situations you will need to contact your plan administrator for information on whether your plan meets the minimum value standard for the benefits it provides.) Language Access Services For assistance in a language below, please call MESSA at SPANISH (Español): Para ayuda en español, llame al número de servicio al cliente [customer service] que se encuentra en este aviso ó en el reverso de su tarjeta de identificación. TAGALOG (Tagalog): Para sa tulong sa wikang Tagalog, mangyaring tumawag sa numero ng serbisyo sa mamimili [customer service] na nakalagay sa likod ng iyong pagkakakilanlan kard o sa paunawang ito. CHINESE ( 中 文 ): 要 获 取 中 文 帮 助, 请 致 电 您 的 身 份 识 别 卡 背 面 或 本 通 知 提 供 的 客 户 服 务 [customer service] 号 码 NAVAJO (Dine): Taa dineji keego shii kaa ahdool wool ninizin goo [customer service], beesh behane e naal tsoos bikii sin dahiigii binii deehgo eeh doodago di naaltsoo bikaiigii bichi hoodillnii. 4 Ever Life Insurance Company is the underwriter of this plan or selected benefits within this plan. Blue Cross Blue Shield of Michigan does not underwrite or assume any financial risk with respect to the claims liability associated with any 4 Ever Life underwritten health care products, as BCBSM is an administrator for 4 Ever Life products. 4 Ever Life Insurance Company, an independent licensee of the Blue Cross and Blue Shield Association, is a wholly owned subsidiary of BCS Financial Corporation. To see examples of how this plan might cover costs for a sample medical situation, see the next page. 6 of 8

7 About these Coverage Examples: These examples show how this plan might cover medical care in given situations. Use these examples to see, in general, how much insurance protection a sample patient might get if they are covered under different plans. This is not a cost estimator. Don t use these examples to estimate your actual costs under this plan. The actual care you receive will be different from these examples, and the cost of that care also will be different. See the next page for important information about these examples. Having a baby (normal delivery) Amount owed to providers: $7,540 Plan pays $6,120 You pay $1,420 Sample care costs: Hospital charges (mother) $2,700 Routine obstetric care $2,100 Hospital charges (baby) $900 Anesthesia $900 Laboratory tests $500 Prescriptions $200 Radiology $200 Vaccines, other preventive $40 Total $7,540 Patient pays: Deductibles $1,250 Co-pays $20 Co-insurance $0 Limits or exclusions $150 Total $1,420 Managing type 2 diabetes (routine maintenance of a well-controlled condition) Amount owed to providers: $5,400 Plan pays $3,710 You pay $1,690 Sample care costs: Prescriptions $2,900 Medical Equipment & Supplies $1,300 Office Visits & Procedures $700 Education $300 Laboratory tests $100 Vaccines, other preventive $100 Total $5,400 Patient pays: Deductibles $1,250 Co-pays $360 Co-insurance $0 Limits or exclusions $80 Total $1,690 Please note: Coverage Examples are calculated based on individual coverage. 7 of 8

8 Questions and answers about the Coverage Examples: What are some of the assumptions behind the Coverage Examples? Costs don t include premiums. Sample care costs are based on national averages supplied by the U.S. Department of Health and Human Services, and aren t specific to a particular geographic area or health plan. The patient s condition was not an excluded or preexisting condition. All services and treatments started and ended in the same coverage period. There are no other medical expenses for any member covered under this plan. Out-of-pocket expenses are based only on treating the condition in the example. The patient received all care from innetwork providers. If the patient had received care from out-of-network providers, costs would have been higher. What does a Coverage Example show? For each treatment situation, the Coverage Example helps you see how deductibles, copayments, and co-insurance can add up. It also helps you see what expenses might be left up to you to pay because the service or treatment isn t covered or payment is limited. Does the Coverage Example predict my own care needs? No. Treatments shown are just examples. The care you would receive for this condition could be different, based on your doctor s advice, your age, how serious your condition is, and many other factors. Does the Coverage Example predict my future expenses? No. Coverage Examples are not cost estimators. You can t use the examples to estimate costs for an actual condition. They are for comparative purposes only. Your own costs will be different depending on the care you receive, the prices your providers charge, and the reimbursement your health plan allows. Can I use Coverage Examples to compare plans? Yes. When you look at the Summary of Benefits and Coverage for other plans, you ll find the same Coverage Examples. When you compare plans, check the Patient Pays box in each example. The smaller that number, the more coverage the plan provides. Are there other costs I should consider when comparing plans? Yes. An important cost is the premium you pay. Generally, the lower your premium, the more you ll pay in out-ofpocket costs, such as co-payments, deductibles, and co-insurance. You should also consider contributions to accounts such as health savings accounts (HSAs), flexible spending arrangements (FSAs) or health reimbursement accounts (HRAs) that help you pay out-of-pocket expenses. Questions: Call MESSA at or visit us at If you aren t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary at or call MESSA at to request a copy. 8 of 8

9 Co-payment $6.50 Exam / $18 Lenses *Standard Lens Allowance is included. **Pre-approval from NVA required Iwf607 Schedule of Vision Benefits NVA2 Participating Provider Examination Once Every Plan Year Covered 100% After $6.50 copay Lenses Once Every Plan Year Single Vision Bifocal Trifocal Lenticular Oversized Rimless Mounting Blended Bifocal Photochromatic Transitions Polarized / Laminated* Tints / Color Coatings* Frame Once Every Plan Year Contact Lenses Once Every Plan Year Elective Contact Lenses Medically Necessary** Standard Glass or Plastic Covered 100% After $18 copay Covered 100% Covered 100% Covered 100% Covered 100% Covered 100% Covered 100% Covered 100% Non-Participating Provider Reimbursed Amount Up to $28.50 (OD) Up to $38.50 (MD) Up to $29 Up to $51 Up to $63 Up to $75 N/A N/A N/A N/A N/A Up to $47 (SV) Up to $81 (BI) Up to $101 (Tri) Up to $119(Lent) Up to $33 (SV) Up to $61 (Bi) Up to $75 (Tri) Up to $89 (Lent) Retail Allowance Up to $65 Up to $44 In lieu of Lenses & Frame Up to $90 Retail Covered 100% In lieu of Lenses & Frame Up to $90 Up to $175 Additional professional services related to contact lenses (also known as fitting fees) would be included in the contact lens allowance shown above. Lens options purchased from a participating NVA provider will be provided to the member at the amounts listed in the fixed option pricing list below: $10 Standard Scratch-Resistant Coating $55 High Index $12 Ultraviolet Coating $25 Polycarbonate (Single Vision) $40 Standard Anti-Reflective $30 Polycarbonate (Multi-Focal) $50 Progressive Lenses Standard Options not listed will be priced by NVA providers at their R&C retail price less 20%. Every Day Low Prices will be provided at Retail Locations where available. Doctors affiliated with Retail Locations are not employees; therefore, participation for exams varies. Insurance coverage provided by National Guardian Life Insurance Company (NGLIC), 2E Gilman, Madison, WI Policy NVIGRP2002. NGLIC is not affiliated with the Guardian Life Insurance Company of America, a/k/a The Guardian or Guardian Life. A full description of your coverage, its limitations, exclusions and conditions is contained in the Insurance Policy issued to your Plan Sponsor at its place of business. That full description in the form of a Certificate of Coverage can be made available to you by requesting it from your Plan Sponsor. This document is intended as a program overview only and is not a certified document of the individual plan parameters. National Vision Administrators, L.L.C. Utica Community Schools New Vision Administrator Effective July 1, 2008 Plan Year July 1st Summary of Vision Care Benefits National Vision Administrators, L.L.C. (NVA) has been contracted by your group to offer a comprehensive vision care plan to you and your eligible family members. Founded in January of 1979, NVA manages vision benefit services for more than seven million lives nationwide. How Your Vision Care Program Works When scheduling your appointment, please notify the NVA participating provider of your choice that your vision coverage is administered by NVA. The provider will contact NVA to verify eligibility. At the time of your appointment, simply present your NVA identification card to the provider or indicate clearly that your benefit is administered by NVA. A vision claim form is not required at an NVA participating provider. The provider will inform you of your eligibility status prior to rendering services. Be sure to inform the provider of your medical history and any prescription or over-the-counter medications you may be taking. To verify your benefit eligibility prior to calling or visiting your eye care provider, please visit our website at or contact NVA s Customer Service Department toll-free at Eligibility: Eligible members and dependents are entitled to receive a vision examination and one (1) pair of lenses and a frame or contact lenses and contact lens evaluation/fitting once every plan year. Customer Service: To verify eligibility, locate a participating provider and receive answers to all your vision care related inquiries, please call NVA s Customer Service Department toll-free at (TDD: ). NVA s Interactive Voice Response (IVR) system is available twenty-four (24) hours per day, seven (7) days per week. The IVR allows you to locate a participating provider in your area, check eligibility as well as the status of your claim(s). An NVA Customer Service Representative can be contacted Monday - Friday 8:00am - 6:00pm (EST) & Saturdays 8:30am - 5:00pm (EST) National Vision Administrators, L.L.C. PO Box 2187 Clifton, NJ Web: Toll-Free: This document has been printed on recycled paper. NVA is a registered mark of National Vision Administrators, L.L.C

10 Benefits at Participating Providers: Highlights of your vision care benefit: The option of receiving services in- or out-of-network Extensive national provider network Enhanced in-network benefits: 100% covered Vision examination (after copay if applicable) 100% covered standard spectacle lenses (after copay if applicable) Frame allowance covers countless fashionable frames in full Allowance towards the cost of contact lenses and fitting fees No claim forms. NVA participating providers submit their claims directly to NVA. In the event you obtain services from a non-participating provider, you must submit your itemized receipt along with a completed reimbursement form to NVA to acquire reimbursement. You may obtain a Direct Reimbursement Claim Form from the NVA Web-Site: Examinations: A comprehensive eye examination is covered which includes a case history, examination for pathology or anomalies, visual acuity (clearness of vision), refraction, and Tonometry testing (glaucoma). Comprehensive eye examinations can aid in the early detection of ocular diseases and other serious medical conditions. Lenses: NVA provides coverage in full for standard glass or plastic eyeglass lenses of any size. Frames: Select any frame from the participating provider s inventory. Any amount in excess of your plan allowance is the member s responsibility. Frame choices vary from office to office. Contact Lenses: Elective contact lenses are covered in lieu of all other materials (i.e. spectacle lenses and frames). Additional professional services related to contact lenses (also known as fitting fees) are covered under the contact lens allowance. The contact lens benefit includes all types of contact lenses such as hard, soft, gas permeable and disposable lenses. Medically necessary contact lenses may be covered with prior authorization when prescribed for: post cataract surgery, correction of extreme visual acuity problems that cannot be corrected to 20/70 with spectacle lenses, Anisometropia or Keratoconus. Discounts: There will be a twenty-percent (20%) discount off additional purchases of lenses and frames, excluding contacts at the time of service. Non-Participating Providers: You will be responsible for one hundred percent (100%) of the cost at the time of service at a non-participating provider. To obtain direct reimbursement according to your plan design, you can print a claim form from Please complete this form and submit along with an original or copy of the itemized receipt. If you cannot print the claim form you may submit receipts along with a letter containing the member s full name, patient s full name, address, ID# and sponsoring organization to NVA s Clifton, NJ office. Remember, obtaining vision care services from a non-participating provider will result in greater out-of-pocket expense. Exclusions / Limitations: No payment is made for Medical or surgical treatments / Rx drugs or OTC medications / non-prescription lenses / two pair of glasses in lieu of bifocals / subnormal visual aids / vision examination or materials required for employment / replacement of lost, stolen, broken or damaged lenses/contact lenses or frames except at normal intervals when service would otherwise be available / services or materials provided by Federal, State, local government or Worker's compensation / examination, procedures training or materials not listed as a covered service / industrial safety lenses and safety frames with or without side shields / parts or repair of frame / sunglasses. Participating providers are not contractually obligated to offer sale prices in addition to outlined coverage. Regardless of medical or optical necessity, vision benefits are not available more frequently than specified in your policy. Laser Eye Surgery: If you are nearsighted, farsighted or affected by astigmatism, and are interested in laser eye surgery, NVA offers a network of providers and significant discounts off reasonable and customary charges. The benefit is easy to use and there are: No claims forms to fill out No deductibles to meet No waiting period for coverage No need for reimbursements Laser surgery providers can be located online at Contact Fill: NVA provides you with the convenience and savings of Contact Fill, our mail order contact lens replacement service. You may access Contact Fill s services online at or by calling them toll-free at Contact Fill provides contact lens wearers with significant savings packaged with the convenience of home delivery. Plan discounts applicable at participating retail locations do not apply to purchases made through Contact Fill due to the already low prices. Plan Specific Details Online: The NVA website is easy to use and provides the most up to date information for program participants: Locate a nearby participating provider by name, zip code, or City/State Verify eligibility for you or a dependent View benefit program and specific details Review claims Print ID cards (when allowable) Nominate a non-participating provider to join the NVA network If you are not a registered subscriber, you can still search our providers online by selecting the Find a Provider link on our home page. Be sure to choose the NVA Network 2 vision plan from the drop down box and enter in your search parameters. It s that easy! The following providers are not in the network Sears, Target, JC Penny, Pearle Vision, Optical Boutique at Macy s, 20 / 20 Vision Center, Service Optical, Tropical Optical and Boscov s Optical. Iwf607

11 GROUP LIFE AND ACCIDENTAL DEATH AND DISMEMBERMENT INSURANCE PROGRAM

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13 GROUP LIFE INSURANCE

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15 CERTIFICATE OF INSURANCE We certify that you (provided you belong to a class described on the Schedule of Benefits) are insured, for the benefits which apply to your class, under Group Policy No. GL issued to Utica Community Schools, the Policyholder. When loss of life covered under the Policy occurs, we will pay the amount stated on the Schedule of Benefits to the named beneficiary, subject to provisions entitled Beneficiary and Facility of Payment. This Certificate is not a contract of insurance. It contains only the major terms of insurance coverage and payment of benefits under the Policy. It replaces all certificates that may have been issued to you earlier. Secretary President GROUP LIFE INSURANCE CERTIFICATE This Group Life Certificate replaces any previous Group Life Certificates and is dated November 7, LRS-6441 Ed. 11/84

16 TABLE OF CONTENTS Page SCHEDULE OF BENEFITS DEFINITIONS GENERAL PROVISIONS EFFECTIVE DATE AND TERMINATION CONVERSION PRIVILEGE BENEFICIARY AND FACILITY OF PAYMENT SETTLEMENT OPTIONS CLAIMS PROVISIONS EXTENSION OF COVERAGE UNDER THE FAMILY AND MEDICAL LEAVE ACT AND UNIFORMED SERVICES EMPLOYMENT AND REEMPLOYMENT RIGHTS ACT (USERRA) GROUP TERM LIFE INSURANCE LIVING BENEFIT RIDER

17 EFFECTIVE DATE: May 1, 2011 SCHEDULE OF BENEFITS ELIGIBLE CLASSES: Each active, Full-time Employee who is a member of the Utica Federation of Teachers, except any person employed on a temporary or seasonal basis. INDIVIDUAL EFFECTIVE DATE: The first of the month following the day you become eligible. INDIVIDUAL REINSTATEMENT: Not Applicable AMOUNT OF INSURANCE: Basic Life: $10,000. The Life amount will be reduced by any benefit paid under the Living Benefit Rider. CHANGES IN AMOUNT OF INSURANCE: Increases and decreases in the Amount of Insurance because of changes in age, class or earnings (if applicable) are effective on the first of the Policy month coinciding with or next following the date of the change. With respect to increases in the Amount of Insurance, you must be Actively At Work on the date of the change. If you are not Actively At Work when the change should take effect, the change will take effect on the day after you have been Actively At Work for one full day. CONTRIBUTIONS: You are not required to contribute toward the cost of the Basic Insurance. LRS Ed. 9/89 Page 1.0

18 DEFINITIONS "We," "us" and "our" means Reliance Standard Life Insurance Company. "You," "your" and "yours" means a person who meets the eligibility requirements of the Policy and is enrolled for this insurance. "Actively at work" and "active work" means actually performing on a Fulltime basis each and every duty pertaining to your job in the place where and the manner in which the job is normally performed. This includes approved time off such as vacation, jury duty and funeral leave, but does not include time off as a result of injury or illness. "Full-time" means working for the Policyholder for the number of hours set by the Policyholder for a regular work day for an Insured in an eligible class. "The date you retire" or "retirement" means the effective date of your: (1) retirement pension benefits under any plan of a federal, state, county or municipal retirement system, if such pension benefits include any credit for employment with the Policyholder; (2) retirement pension benefits under any plan which the Policyholder sponsors, or makes or has made contributions; (3) retirement benefits under the United States Social Security Act of 1935, as amended, or under any similar plan or act. LRS Ed. 06/01 Page 2.0

19 GENERAL PROVISIONS INCONTESTABILITY Any statements made by you, or on your behalf to persuade us to provide coverage, will be deemed a representation, not a warranty. This provision limits our use of these statements in contesting the amount of insurance for which you are covered. The following rules apply to each statement: (1) No statement will be used in a contest unless: (a) it is in a written form signed by you, or on your behalf; and (b) a copy of such written instrument is or has been furnished to you, your beneficiary or legal representative. (2) If the statement relates to your insurability, it will not be used to contest the validity of insurance which has been in force, before the contest, for at least two (2) years during your lifetime. ASSIGNMENT Ownership of any benefit provided under the Policy may be transferred by assignment. An irrevocable beneficiary must give written consent to assign this insurance. Written request for assignment must be made in duplicate at our Administrative Offices. Once recorded by us, an assignment will take effect on the date it was signed. We are not liable for any action we take before the assignment is recorded. LRS Ed. 12/93 Page 3.0

20 EFFECTIVE DATE AND TERMINATION EFFECTIVE DATE OF INDIVIDUAL INSURANCE: If the Policyholder pays the entire premium, your insurance will go into effect on the date stated on the Schedule of Benefits. If you pay a part of the premium, you must apply in writing for the insurance to go into effect. You will become insured on the later of: (1) the Individual Effective Date stated on the Schedule of Benefits, if you apply on or before that date; or (2) the first of the month following the date you apply, if you apply within thirty-one (31) days from the date you first met the eligibility requirements; or (3) the first of the month following the date we approve any required proof of good health. We require proof of good health if you apply: (a) after thirty-one (31) days from the date you first become eligible; or (b) after you terminated this insurance but you remained in a class eligible for this insurance; or (c) for an Amount of Insurance greater than the Amount of Insurance shown on the Schedule of Benefits as not subject to our approval of a person's good health; or (d) for an Amount of Insurance greater than you were insured for under the prior group life insurance plan carrier, if applicable; or (e) after being eligible for coverage under a prior group life insurance plan for more than thirty-one (31) days but did not elect to be covered under that prior plan; or (4) the date premium is remitted. Changes in your amount of insurance are effective as shown on the Schedule of Benefits. If you are not actively at work on the day your insurance is to go into effect, the insurance will go into effect on the day you return to active work for one full day. LRS Ed. 11/07 Page 4.0

21 TERMINATION OF INSURANCE: Your insurance will terminate on the first of the following to occur: (1) the date the Policy terminates; or (2) the date you cease to be in a class eligible for this insurance; or (3) the end of the period for which premium has been paid for you; or (4) the date you enter military service (not including Reserve or National Guard). CONTINUATION OF INSURANCE: Your insurance may be continued by payment of premium beyond the date you cease to be eligible for this insurance, but not longer than: (1) twelve (12) months, if due to illness or injury; or (2) the end of the month temporary lay-off or approved leave of absence occurred, if due to temporary lay-off or approved leave of absence. REINSTATEMENT: Your insurance may be reinstated if it was terminated while you were: (1) on an approved leave of absence, or (2) on a temporary lay-off. You must return to active work within the period of time shown on the Schedule of Benefits. You must also be a member of a class eligible for this insurance. You will not be required to fulfill the eligibility requirements of the Policy again. The insurance will go into effect on the day you return to active work. If you return after having resigned or having been discharged, you will be required to fulfill the eligibility requirements of the Policy again. If you return after terminating at your own request or for failure to pay premium when due, proof of good health must be approved by us before you may be reinstated. LRS Ed. 11/07 Page 4.1

22 CONVERSION PRIVILEGE You can use this privilege when your insurance is no longer in force. It has several parts. They are: A. If the insurance ceases due to termination of employment or membership in any of the Policy's classes, an individual Life Insurance Policy may be issued. You are entitled to a policy without disability or supplemental benefits. You must make written application for the policy within thirty-one (31) days after you terminate. The first premium must also be paid within that time. The issuance of the policy is subject to the following conditions: (1) The policy will, at your option, be on any one of our forms, except for term life insurance. It will be the standard type issued by us for the age and amount applied for; (2) The policy issued will be for an amount not over what you had before you terminated; (3) The premium due for the policy will be at our usual rate. This rate will be based on the amount of insurance, class of risk and your age at date of policy issue; and (4) Proof of good health is not required. B. If the insurance ceases due to the termination or amendment of the Policy, an individual Life Insurance Policy can be issued. You must have been insured for at least five (5) years under the Policy. The same rules as in A above will be used, except that the face amount will be the lesser of: (1) The amount of your Group Life benefit under the Policy. This amount will be less any amount you are entitled to under any group life policy issued by us or another insurance company; or (2) $5,000. C. If the insurance reduces, as may be provided in the Policy, an individual Life Insurance Policy can be issued. The same rules as in A above will be used, except that the face amount will not be greater than the amount which ceased due to the reduction. D. If you die during the time in which you are entitled to apply for an LRS Ed. 9/83 Page 5.0

23 individual policy, we will pay the benefit under the Group Policy that you were entitled to convert. This will be done whether or not you applied for the individual policy. E. Any policy issued with respect to A, B or C above will be put in force at the end of the thirty-one (31) day period in which application must be made. LRS Ed. 9/83 Page 5.1

24 BENEFICIARY AND FACILITY OF PAYMENT BENEFICIARY: The beneficiary will be as named in writing by you to receive benefits at your death. This beneficiary designation must be on file with us or the Plan Administrator and will be effective on the date you sign it. Any payment made by us before receiving the designation shall fully discharge us to the extent of that payment. If you name more than one beneficiary to share the benefit, you must state the percentage of the benefit that is to be paid to each beneficiary. Otherwise, they will share the benefit equally. The beneficiary's consent is not needed if you wish to change the designation. His/her consent is also not needed to make any changes in the Policy. If the beneficiary dies at the same time as you, or within fifteen (15) days after your death but before we received written proof of your death, payment will be made as if you survived the beneficiary, unless noted otherwise. If you have not named a beneficiary, or the named beneficiary is not surviving at your death, any benefits due shall be paid to the first of the following classes to survive you: (1) your legal spouse; (2) your surviving children (including legally adopted children), in equal shares; (3) your surviving parents, in equal shares; (4) your surviving siblings, in equal shares; or, if none of the above, (5) your estate. We will not be liable for any payment we have made in good faith. FACILITY OF PAYMENT: If a beneficiary, in our opinion, cannot give a valid release (and no guardian has been appointed), we may pay the benefit to the person who has custody or is the main support of the beneficiary. Payment to a minor shall not exceed $1,000. If you have not named a beneficiary, or the named beneficiary is not surviving at your death, we may pay up to $2,500 of the benefit to the person(s) who, in our opinion, have incurred expenses in connection with your last illness, death or burial. LRS Ed. 11/00 Page 6.0

25 The balance of the benefit, if any, will be held by us, until an individual or representative: (1) is validly named; or (2) is appointed to receive the proceeds; and (3) can give valid release to us. The benefit will be held with interest at a rate set by us. We will not be liable for any payment we have made in good faith. LRS Ed. 11/00 Page 6.1

26 SETTLEMENT OPTIONS You may elect a different way in which payment of the Amount of Insurance can be made. You must provide a written request to us, for our approval, at our Administrative Office. If the option covers less than the full amount due, we must be advised of what part is to be under an option. Amounts under $2,000 or option payments of less than $20.00 each are not eligible. If no instructions for a settlement option are in effect at your death, the beneficiary may make the election, with our consent. Settlement Options are described in the Policy. LRS Ed. 3/82 Page 7.0

27 CLAIMS PROVISIONS NOTICE OF CLAIM: Written notice must be given to us within 31 days after the Loss occurs, or as soon as reasonably possible. The notice should be sent to us at our Administrative Offices or to our authorized agent. The notice should include your name and the Policy Number. CLAIM FORMS: When we receive written notice of a claim, we will send claim forms to the claimant within 15 days. If we do not, the claimant will satisfy the requirements of written proof of loss by sending us written proof as shown below. The proof must describe the occurrence, extent and nature of the loss. PROOF OF LOSS: For any covered Loss, written proof must be sent to us within 90 days. If it is not reasonably possible to give proof within 90 days, the claim is not affected if the proof is sent as soon as reasonably possible. In any event, proof must be given within 1 year, unless the claimant is legally incapable of doing so. PAYMENT OF CLAIMS: Payment will be made as soon as proper proof is received. All benefits will be paid to you, if living. Any benefits unpaid at the time of death, or due to death, will be paid to the beneficiary. PHYSICAL EXAMINATION: At our own expense, we will have the right to have you examined as reasonably necessary when a claim is pending. We can have an autopsy made unless prohibited by law. LEGAL ACTION: No legal action may be brought against us to recover on the Policy within 60 days after written proof of loss has been given as required by the Policy. No action may be brought after three (3) years (Kansas, five (5) years; South Carolina and Michigan, six (6) years) from the time written proof of loss is required to be submitted. LRS Ed. 4/94 Page 8.0

28 EXTENSION OF COVERAGE UNDER THE FAMILY AND MEDICAL LEAVE ACT AND UNIFORMED SERVICES EMPLOYMENT AND REEMPLOYMENT RIGHTS ACT (USERRA) Family and Medical Leave of Absence: We will continue your coverage and that of any Insured Dependent, if applicable, in accordance with the Policyholder's policies regarding leave under the Family and Medical Leave Act of 1993, as amended, or any similar state law, as amended, if: (1) the premium for you and your Insured Dependents, if applicable, continues to be paid during the leave; and (2) the Policyholder has approved your leave in writing and provides a copy of such approval within thirty-one (31) days of our request. As long as the above requirements are satisfied, we will continue coverage until the later of: (1) the end of the leave period required by the Family and Medical Leave Act of 1993, as amended; or (2) the end of the leave period required by any similar state law, as amended. Military Services Leave of Absence: We will continue your coverage and that of any Insured Dependents, if applicable, in accordance with the Policyholder's policies regarding Military Services Leave of Absence under USERRA if the premium for you and your Insured Dependents, if applicable, continues to be paid during the leave. As long as the above requirement is satisfied, we will continue coverage until the end of the period required by USERRA. The Policy, while coverage is being continued under this Military Services Leave of Absence extension, does not cover any loss which occurs while on active duty in the military if such loss is caused by or arises out of such military service, including but not limited to war or any act of war, whether declared or undeclared. While you are on a Family and Medical Leave of Absence for any reason other than your own illness, injury or disability or Military Services Leave of Absence you will be considered Actively at Work. Any changes such as revisions to coverage due to age, class or salary changes, as LRS Ed. 06/08 Page 9.0

29 applicable, will apply during the leave except that increases in the amount of insurance, whether automatic or subject to election, will not be effective if you are not considered Actively at Work until you have returned to Active Work for one (1) full day. A leave of absence taken in accordance with the Family and Medical Leave Act of 1993 or USERRA will run concurrently with any other applicable continuation of insurance provision in the Policy. Your coverage and that of any Insured Dependents, if applicable, will cease under this extension on the earliest of: (1) the date the Policy terminates; or (2) the end of the period for which premium has been paid for you; or (3) the date such leave should end in accordance with the Policyholder's policies regarding Family and Medical Leave of Absence and Military Services Leave of Absence in compliance with the Family and Medical Leave Act of 1993, as amended and USERRA. Should the Policyholder choose not to continue your coverage during a Family and Medical Leave of Absence and/or Military Services Leave of Absence, your coverage as well as any dependent coverage, if applicable, will be reinstated. LRS Ed. 06/08 Page 9.1

30 GROUP TERM LIFE INSURANCE LIVING BENEFIT RIDER THIS RIDER ADDS AN ACCELERATED BENEFIT PROVISION. RECEIPT OF THIS ACCELERATED BENEFIT WILL REDUCE THE DEATH BENEFIT AND MAY BE TAXABLE. INSUREDS SHOULD SEEK ASSISTANCE FROM THEIR PERSONAL TAX ADVISOR. Attached to Group Policy Number: GL Issued to Group Policyholder: Utica Community Schools This Rider is attached to and made a part of the Policy indicated above. Your Certificate is hereby amended, in consideration of the application for this coverage, by the addition of the following benefit. In this Rider, Reliance Standard Life Insurance Company will be referred to as we", us", our". DEFINITIONS: This section gives the meaning of terms used in this Rider. The Definitions of the Policy and Certificate also apply unless they conflict with Definitions given here. "Certified" or "Certification" refers to a written statement, made by a Physician on a form provided by us, as to the Insured s Terminal Illness. "Certificate" means the document, issued to each Insured, which explains the terms of his coverage under the Group Life Insurance Policy. "Death Benefit" means the insurance amount payable under the Certificate at death of the Insured, subject to all Certificate provisions dealing with changes in the amount of insurance and reductions or termination for age or retirement. It does not include any amount that is only payable in the event of Accidental Death. "Insured" means only a primary Insured. Dependents are not eligible for coverage under this Living Benefit Rider. "Physician" means a duly licensed practitioner, acting within the scope of his license, who is recognized by the law of the state in which diagnosis is received. The Physician may not be the Insured or a member of his immediate family. "Policy" means the Group Life Insurance Policy issued to the Group Policyholder under which the Insured is covered. "Terminally Ill" or "Terminal Illness" refers to an Insured s illness or physical condition that is Certified by a Physician to reasonably be expected to result in death in less than 12 months. LRS Page 10.0

31 "Written Request" means a request made, in writing, by the Insured to us. All pronouns include either gender unless the context indicates otherwise. DESCRIPTION OF COVERAGE: This benefit is payable to the Insured if, after having been covered under this Rider for at least 60 days, an Insured is Certified as Terminally Ill. In order for this benefit to be paid: (1) the Insured must make a Written Request; and (2) we must receive from any assignee or irrevocable beneficiary their signed acknowledgment and agreement to payment of this benefit. We may, at our option, confirm the terminal diagnosis with a second medical exam performed at our own expense. AMOUNT OF THE LIVING BENEFIT: The Living Benefit will be an amount equal to 75% of the Death Benefit applicable to the Insured under the Policy on the date of the Certification of Terminal Illness, subject to a maximum benefit of $500,000. This benefit may be paid as a single lump sum or in installment payments mutually agreed to by us and the Insured. The Living Benefit is payable one time only for any Insured under this Rider. EFFECT OF BENEFIT: If an Insured becomes eligible for, and elects to receive this benefit, it will have the following effects: (1) The Death Benefit payable for such Insured will be reduced by an amount equal to the Living Benefit paid to such Insured. The amount of the Living Benefit plus the corresponding Death Benefit will not exceed the amount that would have been paid as the Death Benefit in the absence of this Rider. (2) Any amount of insurance that would otherwise be continued under a Waiver of Premium provision will be reduced proportionately, as will the maximum Face Amount available under the Conversion Privilege. MISSTATEMENT OF AGE OR SEX: The Living Benefit will be adjusted to reflect the amount of benefit that would have been purchased by the actual premium paid at the correct age and sex. TERMINATION OF AN INDIVIDUAL S COVERAGE UNDER THIS RIDER: The coverage of any Insured under this Rider will terminate on LRS Page 10.1