Voluntary Life and AD&D Insurance

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1 Volutary Life ad AD&D Isurace Date: March 2014 To: All JMA beefit eligible members From: Wells Fargo Isurace Services Re: Volutary Life & Accidetal Death ad Dismembermet (AD&D) isurace If you choose to icrease your volutary life beefit amout, or are erollig for the first time, you will eed to fill out the attached Volutary Life applicatio. If you are erollig for ay amout over the guaratee issue amout you will also eed to fill out the Evidece of Isurability form. Please refer to the Guardia Life ad AD&D Beefit Summary ad Rates for further iformatio. The Evidece of Isurability form is also icluded i this packet. Please retur this applicatio to your maager as soo as possible. If you have ay questios, please cotact ay member of your dedicated Wells Fargo Isurace Services team or JMA. Name Phoe Number Fax Number address Jea Baptista Cary Fagudes Chris Padowa Kellie Balistreri

2 Judy Madrigal& Associates, Ic. Group Number: About Your Beefits: Life Beefit Summary Your family depeds o you i may ways ad you ve worked hard to esure their fiacial security. But if somethig happeed to you,willyourfamilybeprotected?willyourlovedoesbeabletostayitheirhome,paybills,adprepareforthefuture.life isurace provides a fiacial beefit that your family ca deped o. Ad gettig it at work is easier, more coveiet ad more affordable tha doig it o your ow. If you have fiacial depedets- a spouse, childre or agig parets, havig life isurace is a resposible ad a smart decisio. Eroll today to secure their future! What Your Beefits Cover: Employee Beefit Accidetal Death ad Dismembermet BASIC LIFE Your employer provides $25,000 Basic TermLifecoverageforallfulltime employees. Your Basic Life coverage icludes Ehaced Accidetal Death ad Dismembermet coverage equal to oe times the employee's life beefits. VOLUNTARY TERM LIFE $10,000 icremets to a maximum of $500,000. See Cost Illustratio page for details. Not available Spouse/Domestic Parter Beefit N/A 50% of employee coverage to a max of $250,000 Childbeefit: childreage14daysto26years(26if full time studet) for Volutary Life Guaratee Issue: The guaratee meas you are ot required to aswer health questios to qualify for coverage up to ad icludig the specified amout, whe you sig up for coverage durig the iitial erollmet period. Premiums Portability: Allows you to take your coverage with you if you termiate employmet. Coversio: Allows you to cotiue your coverage after your group pla has termiated. Accelerated Life Beefit: A lump sum beefit is paid to youifyouarediagosedwithatermialcoditio,as defied by the pla. WaiverofPremiums:Premiumwilloteedtobepaid if you are totally disabled. N/A Uderwritig may be required, depedig o amout ad/or age Covered by your compay if you meet eligibility requiremets Yes, with age ad other restrictios, icludig evidece of isurability Yes, with restrictios; see certificate of beefits No For employees disabled prior to age 60, with premiums waived util age 65, if coditios are met 10%ofemployeecoveragetoamaxof $10,000. Coverage limits are based o child age. We Guaratee Issue coverage up to $50,000 per employee, $25,000 for a spouse ad $5,000 for depedet childre Icrease o pla aiversary after you eter ext five-year age group Yes, with age ad other restrictios, icludig evidece of isurability Yes, with restrictios; see certificate of beefits Yes For employees disabled prior to age 60, with premiums waived util age 65, if coditios met Judy Madrigal& Associates, Ic. Classes 3& 4 Beefit Summary The Guardia Life Isurace Compay of America, 7 Haover Square, New York, NY

3 Life Assist: Provides supplemetal icome that equals 1% ofyourlifebeefittoamaximumof$2,000ifyouare ADLdisabled. Beefitsarepaidtothelesserof100 mothsortowhewaiverofpremiumeds. Beefit Reductios: Beefits are reduced by a certai percetage as a employee ages. BASIC LIFE No 50%atage70 VOLUNTARY TERM LIFE Yes 50%atage70 Subject to coverage limits Spousecoveragetermiatesatage70. Judy Madrigal& Associates, Ic. Classes 3& 4 Beefit Summary The Guardia Life Isurace Compay of America, 7 Haover Square, New York, NY

4 Volutary Life Cost Illustratio: Todetermiethemostappropriatelevelofcoverage,asaruleofthumb,youshouldcosiderabout6-10timesyouraualicome, factorigiprojectedcoststohelpmaitaiyourfamily scurretlifestyle.tohelpyouassessyoureeds,youcaalsogoto Guardia Aytime ad use our Life Isurace Explorer Tool. $10,000 Policy Electio Amout Employee $10,000 Spouse $5,000 Child $1,000 $20,000 Policy Electio Amout Employee $20,000 Spouse $10,000 Child $2,000 $30,000 Policy Electio Amout Employee $30,000 Spouse $15,000 Child $3,000 $40,000 Policy Electio Amout Employee $40,000 Spouse $20,000 Child $4,000 $50,000 Policy Electio Amout Employee $50,000 Spouse $25,000 Child $5,000 $60,000 Policy Electio Amout Employee $60,000 Spouse $30,000 Child $6,000 $70,000 Policy Electio Amout Employee $70,000 Spouse $35,000 Child $7,000 $80,000 Policy Electio Amout Employee $80,000 Spouse $40,000 Child $8,000 $90,000 Policy Electio Amout Employee $90,000 Spouse $45,000 Child $9,000 $100,000 Policy Electio Amout Employee $100,000 Spouse $50,000 $110,000 Policy Electio Amout Employee $110,000 Spouse $55,000 Mothly premiums displayed. Policy Electio Cost Per Age Bracket < $.30 $.15 $.60 $.30 $.90 $.45 $.60 $1.50 $.75 $1.80 $.90 $2.10 $1.05 $2.70 $1.35 $1.50 $3.30 $1.65 $.30 $.15 $.60 $.30 $.90 $.45 $.60 $1.50 $.75 $1.80 $.90 $2.10 $1.05 $2.70 $1.35 $1.50 $3.30 $1.65 $.40 $.20 $.80 $.40 $.60 $1.60 $.80 $2.00 $1.00 $2.80 $1.40 $3.20 $1.60 $3.60 $1.80 $4.00 $2.00 $4.40 $2.20 $.60 $.30 $.60 $1.80 $.90 $1.50 $3.60 $1.80 $4.20 $2.10 $5.40 $2.70 $6.60 $3.30 $1.00 $.50 $2.00 $1.00 $1.50 $4.00 $2.00 $5.00 $2.50 $7.00 $3.50 $8.00 $4.00 $9.00 $4.50 $10.00 $5.00 $11.00 $5.50 $1.60 $.80 $3.20 $1.60 $6.40 $3.20 $8.00 $4.00 $9.60 $11.20 $5.60 $12.80 $6.40 $14.40 $7.20 $16.00 $8.00 $17.60 $8.80 $7.20 $3.60 $9.60 $12.00 $14.40 $7.20 $16.80 $8.40 $19.20 $9.60 $21.60 $10.80 $24.00 $12.00 $26.40 $13.20 $3.90 $1.95 $7.80 $3.90 $11.70 $5.85 $15.60 $7.80 $19.50 $9.75 $23.40 $11.70 $27.30 $13.65 $31.20 $15.60 $35.10 $17.55 $39.00 $19.50 $42.90 $21.45 $5.20 $2.60 $10.40 $5.20 $15.60 $7.80 $20.80 $10.40 $26.00 $13.00 $31.20 $15.60 $36.40 $18.20 $41.60 $20.80 $46.80 $23.40 $52.00 $26.00 $57.20 $28.60 $8.00 $4.00 $16.00 $8.00 $24.00 $12.00 $32.00 $16.00 $40.00 $20.00 $48.00 $24.00 $56.00 $28.00 $64.00 $32.00 $72.00 $36.00 $80.00 $40.00 $88.00 $44.00 JudyMadrigal&Associates, Ic.-Classes3&4 The Guardia Life Isurace Compay of America, 7 Haover Square, New York, NY

5 Volutary Life Cost Illustratio cotiued $120,000 Policy Electio Amout Employee $120,000 Spouse $60,000 $130,000 Policy Electio Amout Employee $130,000 Spouse $65,000 $140,000 Policy Electio Amout Employee $140,000 Spouse $70,000 $150,000 Policy Electio Amout Employee $150,000 Spouse $75,000 $160,000 Policy Electio Amout Employee $160,000 Spouse $80,000 $170,000 Policy Electio Amout Employee $170,000 Spouse $85,000 $180,000 Policy Electio Amout Employee $180,000 Spouse $90,000 $190,000 Policy Electio Amout Employee $190,000 Spouse $95,000 $200,000 Policy Electio Amout Employee $200,000 Spouse $100,000 $210,000 Policy Electio Amout Employee $210,000 Spouse $105,000 $500,000 Policy Electio Amout Employee $500,000 Spouse $250,000 < $3.60 $1.80 $3.90 $1.95 $4.20 $2.10 $4.50 $2.25 $5.10 $2.55 $5.40 $2.70 $5.70 $2.85 $6.30 $3.15 $15.00 $7.50 $3.60 $1.80 $3.90 $1.95 $4.20 $2.10 $4.50 $2.25 $5.10 $2.55 $5.40 $2.70 $5.70 $2.85 $6.30 $3.15 $15.00 $7.50 $5.20 $2.60 $5.60 $2.80 $6.40 $3.20 $6.80 $3.40 $7.20 $3.60 $7.60 $3.80 $8.00 $4.00 $8.40 $4.20 $20.00 $10.00 $7.20 $3.60 $7.80 $3.90 $8.40 $4.20 $9.00 $4.50 $9.60 $10.20 $5.10 $10.80 $5.40 $11.40 $5.70 $12.00 $12.60 $6.30 $30.00 $15.00 $12.00 $13.00 $6.50 $14.00 $7.00 $15.00 $7.50 $16.00 $8.00 $17.00 $8.50 $18.00 $9.00 $19.00 $9.50 $20.00 $10.00 $21.00 $10.50 $50.00 $25.00 $19.20 $9.60 $20.80 $10.40 $22.40 $11.20 $24.00 $12.00 $25.60 $12.80 $27.20 $13.60 $28.80 $14.40 $30.40 $15.20 $32.00 $16.00 $33.60 $16.80 $80.00 $40.00 $28.80 $14.40 $31.20 $15.60 $33.60 $16.80 $36.00 $18.00 $38.40 $19.20 $40.80 $20.40 $43.20 $21.60 $45.60 $22.80 $48.00 $24.00 $50.40 $25.20 $ $60.00 $46.80 $23.40 $50.70 $25.35 $54.60 $27.30 $58.50 $29.25 $62.40 $31.20 $66.30 $33.15 $70.20 $35.10 $74.10 $37.05 $78.00 $39.00 $81.90 $40.95 $ $97.50 $62.40 $31.20 $67.60 $33.80 $72.80 $36.40 $78.00 $39.00 $83.20 $41.60 $88.40 $44.20 $93.60 $46.80 $98.80 $49.40 $ $52.00 $ $54.60 $ $ $96.00 $48.00 $ $52.00 $ $56.00 $ $60.00 $ $64.00 $ $68.00 $ $72.00 $ $76.00 $ $80.00 $ $84.00 $ $ Guaratee Issue Amout: Employee $50,000; Spouse $25,000; Child $5,000 Premiums for Volutary Life Icrease i five-year icremets Spouse/DP coverage premium is based o Employee age. Coverage for the spouse termiates at spouse s age 70. Beefit reductios apply. Judy Madrigal& Associates, Ic. Classes 3& 4 Beefit Summary The Guardia Life Isurace Compay of America, 7 Haover Square, New York, NY

6 Maage Your Beefits: Go to to access secure iformatio about your Guardia beefits. Your o-lie accout will be set up withi 30 days after your pla effective date. Need Assistace? Call the Guardia Helplie(888) , weekdays, 8:00 AM to 8:30 PM, EST. Refer to your member ID(social security umber) ad your pla umber: LIMITATIONS AND EXCLUSIONS: A SUMMARY OF PLAN LIMITATIONS AND EXCLUSIONS FOR LIFE AND AD&D COVERAGE: You must be workig full-time o the effective date of your coverage; otherwise, your coverage becomes effective after you have completed a specific waitig period. Employees mustbelegallyworkigitheuitedstatesiordertobeeligibleforcoverage. Uderwritig must approve coverage for employees o temporary assigmet:(a) exceedigoeyear;or(b)iaareaudertravelwarigbytheusdepartmetofstate. Subject to state specific variatios. Evidece of Isurability is required o all late erollees. This coverage will ot be effective util approved by a Guardia uderwriter. This proposal is hedged subject to satisfactory fiacial evaluatio. Please refer to certificate of coverage for full pla descriptio. Depedet life isurace will ot take effect if a depedet, other tha a ewbor, is cofiedtothehospitalorotherhealthcarefacilityorisuabletoperformtheormal activitiesofsomeoeoflikeageadsex. ApersoisADL-disabledifheorsheis(a)physicallyuabletoperformtwoormoreADLs without cotiuous physical assistace; or(b) cogitively impaired, ad requires verbal cueig to protect himself/herself or others. ADLs are bathig, dressig, toiletig, trasferrig, cotiece, ad eatig. Accelerated Life Beefit is ot paid to a employee uder the followig circumstaces: oe whoisrequiredbylawtousethebeefittopaycreditors;isrequiredbycourtordertopay thebeefittoaotherperso;isrequiredbyagovermetagecytousethepaymetto receive a govermet beefit; or loses his or her group coverage before a accelerated beefit is paid. Volutary Life Oly: Wepayobeefitsiftheisured sdeathisduetosuicidewithitwoyearsfromthe isured s origial effective date. This two year limitatio also applies to ay icrease i beefit. This exclusio may vary accordig to state law. Late etrats ad beefit icreases require uderwritig approval. GP-1-R-LB-90, GP-1-R-EOPT-96 Guaratee Issue/Coditioal Issue amouts may vary based o age ad case size. See your Pla Admiistrator for details. Late etrats ad beefit icreases require uderwritig approval. For AD&D: We pay o beefits for ay loss caused: by willful self-ijury; sickess, disease or medical treatmet; by participatig i a civil disorder or committig a feloy; Travelig oaytypeofaircraftwhilehavigdutieserothataircraft;bydeclaredorudeclaredact ofwarorarmedaggressio;whileamemberofayarmedforce(mayvarybystate);while drivig a motor vehicle without a curret, valid driver s licese; by legal itoxicatio; or by volutarily usig a o-prescriptio cotrolled substace. Cotract#GP-1-R-ADCL1-00 et al.wewo'tpaymoretha100%oftheisuraceamoutforalllossesduetothesame accidet, except as stated. The loss must occur withi 365 days of the accidet. Please see cotract for specific defiitio; defiitio of loss may vary depedig o the beefit payable. Ehaced AD&D: A loss may be defied as death, quadriplegia, loss of speech ad hearig, loss of cogitive fuctio, comatose state i excess of oe moth, hemiplegia or paraplegia. The loss must occur withi 365 days of the accidet. Please see cotract for specific defiitio; defiitio of loss may vary depedig o the beefit payable. This hadout is for illustratio purposes oly ad is a approximatio, premium amouts may be ameded. Judy Madrigal& Associates, Ic. Classes 3& 4 Beefit Summary The Guardia Life Isurace Compay of America, 7 Haover Square, New York, NY

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8 Judy Madrigal& Associates, Ic. Accidetal Death ad Dismembermet Beefit Summary Group Number: About Your Beefits: AD&D coverage provides additioal beefits followig a accidetal death or certai bodily ijuries. What Your Beefits Cover: COVERAGE OPTIONS Employee beefit ENHANCED ACCIDENTAL DEATH& DISMEMBERMENT $10,000 icremets to a maximum of $500,000. See Cost Illustratio page for details. Beefit Reductios Please be aware that your Beefit Amout may decrease as show below: Subject to coverage limits 50%atAge70 Ehaced AD&D Features Iclude: Child Educatio Beefit, Educatio& Retraiig Beefit, Seatbelt& Airbag Beefit, Day Care Expese, Repatriatio, ad Commo Carrier. Judy Madrigal& Associates, Ic. Classes 3& 4 Beefit Summary The Guardia Life Isurace Compay of America, 7 Haover Square, New York, NY

9 Accidetal Death ad Dismembermet Life Cost Illustratio: AD&D coverage provides additioal beefits followig a accidetal death or certai bodily ijuries. Employee Policy Electio Amout Mothly Premiums displayed $10,000 $0.35 $20,000 $0.70 $30,000 $1.05 $40,000 $1.40 $50,000 $1.75 $60,000 $2.10 $70,000 $2.45 $80,000 $2.80 $90,000 $3.15 $100,000 $3.50 $110,000 $3.85 $120,000 $4.20 $130,000 $4.55 $140,000 $4.90 $150,000 $5.25 $160,000 $5.60 $170,000 $5.95 $180,000 $6.30 $190,000 $6.65 $200,000 $7.00 $210,000 $7.35 $500,000 $17.50 Beefit reductios apply. Maage Your Beefits: Go to to access secure iformatio about your Guardia beefits. Your o-lie accout will be set up withi 30 days after your pla effective date. Need Assistace? Call the Guardia Helplie(888) , weekdays, 8:00 AM to 8:30 PM, EST. Refer to your member ID (social security umber) ad your pla umber: LIMITATIONS AND EXCLUSIONS: A SUMMARY OF PLAN LIMITATION AND EXCLUSIONS FOR AD&D You must be workig full-time o the effective date of your coverage; otherwise, your coverage becomes effective after you have completed a specific waitig period. EmployeesmustbelegallyworkigitheUitedStatesiordertobeeligiblefor coverage. Uderwritig must approve coverage for employees o temporary assigmet:(a)exceedigoeyear;or(b)iaareaudertravelwarigbythe US Departmet of State. Subject to state specific variatios. This proposal is hedged subject to satisfactory fiacial evaluatio. Please refer to policy booklet for full pla descriptio. We pay o beefits for ay loss caused: by willful self-ijury; sickess, disease or medical treatmet; by participatig i a civil disorder or committig a feloy; Travelig o ay type of aircraft while havig duties o that aircraft; by declared orudeclaredactofwarorarmedaggressio;whileamemberofayarmed force(may vary by state); while drivig a motor vehicle without a curret, valid driver s licese; by legal itoxicatio; or by volutarily usig a o-prescriptio cotrolled substace. Cotract#GP-1-R-ADCL1-00 et al. Wewo'tpaymoretha100%oftheIsuraceamoutforalllossesdueto the same accidet, except as stated. Thelossmustoccurwithi365daysof theaccidet.pleaseseecotractfor specific defiitio; defiitio of loss may vary depedig o the beefit payable. Ehaced AD&D: A loss may be defied as death, quadriplegia, loss of speech ad hearig, loss of cogitive fuctio, comatose state i excess of oe moth, hemiplegia or paraplegia. The loss must occur withi 365 days of the accidet. Please see cotract for specific defiitio; defiitio of loss may vary depedig o the beefit payable. This hadout is for illustratio purposes oly ad is a approximatio, premium amouts may be ameded. Judy Madrigal& Associates, Ic. Classes 3& 4 Beefit Summary The Guardia Life Isurace Compay of America, 7 Haover Square, New York, NY

10 Please prit clearly to esure accurate processig Employer: Judy Madrigal & Associates, Ic Alameda De Las Pulgas Suite 275 Sa Mateo, CA Guardia Group Pla Number: The Guardia Life Isurace Compay of America EMPLOYER USE ONLY q New Applicatio q Add Depedet(s) q Drop Depedet(s) q Chage Address q Chage Name q Drop Coverage as of: Class Classes 3 & 4 Hours Worked Divisio Beefits Effective Keep a copy for your records ad retur form to: Midwest Regioal Office, P.O. Box 8012, Appleto, WI ABOUT YOURSELF First, Middle Iitial, Last Name q Add q Chage q Drop Sex q M q F Prit clearly i black or blue ik. Date of Birth (mm/dd/yyyy) Social Security Number - - Address City State Zip Preferred Day Phoe Eve Phoe The best way to reach you: q q Day Phoe q Eve Phoe Job Title Work Status Date work status bega q Full-Time q Part-Time q Retired q COBRA/State Cotiuatio Are you married? q Yes q No If you have a domestic parter (DP), is your partership registered with the State of Califoria? q Yes q No ABOUT YOUR DEPENDENTS Spouse/DP First, Middle Iitial, Last Name q Add q Chage q Drop Sex q M q F Aual Salary/Earigs $ Do you have childre or other depedets? q Yes q No q A sheet with iformatio about additioal depedets is attached. Date of Birth (mm/dd/yyyy) Social Security Number Marriage Date (mm/dd/yyyy) - - Child 1 q Add q Chage q Drop Sex q M q F Date of Birth (mm/dd/yyyy) q Full-time studet, at (school): City/State: Attedig Sice Child 2 q Add q Chage q Drop Sex q M q F Date of Birth (mm/dd/yyyy) q Full-time studet, at (school): City/State: Attedig Sice Child 3 q Add q Chage q Drop Sex q M q F Date of Birth (mm/dd/yyyy) q Full-time studet, at (school): City/State: Attedig Sice Child 4 q Add q Chage q Drop Sex q M q F Date of Birth (mm/dd/yyyy) q Full-time studet, at (school): City/State: Attedig Sice To drop coverage for yourself or your depedets, check the box(es) to the right of the ame(s) ad select the coverage(s) to drop below. Attach a separate sheet if you wish to drop more tha oe depedet from differet coverages. q Basic Life q Volutary Life q VAD&D YOUR BASIC LIFE COVERAGE Policy Amout Employee R $25,000 If this Basic Life policy will replace your existig life isurace policy uder your curret employer, provide the amout of the previous policy $ CEF2005 Questios? Call the Guardia Helplie (888) Erollmet Kit , 0002, EN DETACH ENTIRE FORM AND RETURN TO YOUR EMPLOYER DATE FORM PUBLISHED: Feb 24,

11 LIFE INSURANCE cotiued Name your beeficiaries Primary beeficiaries must total 100%. Primary Beeficiary 1 First, Middle Iitial, Last Name Relatioship to Employee Percet % Primary Beeficiary 2 Cotiget Beeficiary % % I the evet the desigated primary beeficiaries are deceased, the cotiget beeficiary will receive the beefit. CHOOSE YOUR VOLUNTARY TERM LIFE COVERAGE Check oe box oly Employee Policy Amout You must be erolled to cover your depedets. q $10,000 q $20,000 q $30,000 q $40,000 q $50,000* q $60,000 q $70,000 q $80,000 q $90,000 q $100,000 q $110,000 q $120,000 q $130,000 q $140,000 q $150,000 q $160,000 q $170,000 q $180,000 q $190,000 q $200,000 q $210,000 q $500,000 $ *Guaratee Issue Amout q I waive this coverage Add Volutary Life for Spouse/DP q I waive this coverage Add Volutary Life for Child(re) Check oe box oly q 50% of employee's amout to maximum $250,000 The amout may ot be more tha 50% of the employee amout for Volutary Life. Check oe box oly q 10% of employee's amout to maximum $10,000 q I waive this coverage The amout may ot be more tha 10% of the employee amout for Volutary Life. CHOOSE YOUR ACCIDENTAL DEATH AND DISMEMBERMENT COVERAGE Check oe box oly Employee Policy Amout q $10,000 q $20,000 q $30,000 q $40,000 q $50,000 q $60,000 q $70,000 q $80,000 q $90,000 q $100,000 q $110,000 q $120,000 q $130,000 q $140,000 q $150,000 q $160,000 q $170,000 q $180,000 q $190,000 q $200,000 q $210,000 q $500,000 q I waive this coverage q A separate sheet for Volutary Term Life beeficiaries is attached if they are ot the same as those amed for Basic Life. For Volutary Life, a Evidece of Isurability form must be completed for ay amout above the Guaratee Issue. IMPORTANT NOTES If you waive life or disability coverage ad later decide to eroll, you will have to provide, at your ow expese, proof of each perso's isurability. Guardia reserves the right to reject your request. Childre will ot be covered util they reach 14 days. Based o your pla beefits ad your age, you may be required to complete a additioal evidece of isurability form for Volutary Life ad/or Guardia Uiversal Life. 2 DETACH ENTIRE FORM AND RETURN TO YOUR EMPLOYER

12 Guardia Group Pla Number: Please prit employee ame: SIGNATURE I hereby apply for the group beefit(s) that I have chose above. I uderstad that I must meet eligibility requiremets for all coverages that I have chose above. I uderstad that I must be actively at work or my life ad/or disability coverage will ot take effect util I have completed a waitig period (as defied i the Group Pla) of full time service. This requiremet does ot apply to eligible retirees. I uderstad that my depedet(s) caot be erolled for a coverage if I am ot erolled for that coverage. I uderstad that life isurace coverage for a depedet, other tha a ewbor child, will ot take effect if that depedet is cofied to a hospital or other health care facility, or is home cofied, or is uable to perform the ormal activities of someoe of like age ad sex. I agree that my employer may deduct premiums from my pay or add premiums to my dues; if they are required for the coverage I have chose above. I uderstad that the premium amouts show above are estimatios. If the premium amouts show above ad the deductios for premiums show o my paycheck stub do ot agree, my paycheck stub will prevail. I uderstad that the premium amouts may be ameded. I attest that the iformatio provided above is true ad correct to the best of my kowledge. Ay perso who with itet to defraud or kowig that he/she is facilitatig a fraud agaist a isurer, submits a applicatio or files a claim cotaiig a false or deceptive statemet may be guilty of isurace fraud. SIGNATURE OF EMPLOYEE X DATE Questios? Call the Guardia Helplie (888) Erollmet Kit , 0002, EN 3 DETACH ENTIRE FORM AND RETURN TO YOUR EMPLOYER

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