Manage your Liberty Mutual group benefits online.

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1 Manage your Liberty Mutual group benefits online. MyLibertyConnection.com offers convenient access to online tools to help you manage your group benefits. To get started, visit and register by clicking the "New User" link next to the Login tab. Use the Company Code: MUSCP and answer the prompted questions. Once registered, you may then submit an evidence of insurability application and access additional tools to help you manage your benefits. MyLibertyConnection.com Saves Time: There are no paper forms to fax or mail Convenient: Information is available day or night, whenever you need it Secure: You must sign in with the University Medical Associates Service ID: MUSCP. Your information is sent directly to Liberty Mutual. Group products offered by Liberty Life Assurance Company of Boston, a member of the Liberty Mutual Group. Home Office: Boston, MA. Coverage is provided subject to the terms and conditions of the policy.

2 Who s Eligible? Group Short-Term Disability and Life Insurance Enrollment Guide All active, full-time employees working a minimum of 30 hours per week are eligible to participate in the University Medical Associates Group Short-Term Disability (STD) and Life Insurance plan underwritten by Liberty Life Assurance Company of Boston. What are my Coverage Options for Short Term Disability? The University Medical STD Insurance plan is sponsored by your employer. If you purchase this coverage, become disabled (as defined in the plan), and remain disabled through the elimination period, you will receive your elected weekly benefit amount, less other deductible sources of income (e.g. state mandated benefits, sick pay, etc. See your plan booklet for details). You may choose a weekly benefit amount of either: 200, 300, 400, 500, 600, 700 or 800. This amount may not exceed 66.7% of your basic weekly earnings. You also have the option to choose whether your insurance provides benefits after 7 days or 14 days of initial disability. This initial benefit wait period is referred to as an Elimination Period. What is the Cost for Short-Term Disability Insurance? The cost of this program is paid for by you and the rate is based on your age as of January 1, To calculate your cost, find the rate that matches your age and desired elimination period. Multiply this rate by 2 for a 200 benefit, 3 for a 300 benefit, etc. 7 Day Elimination Period Bi-Weekly Cost per 100 of Benefit 14 Day Elimination Period Bi-Weekly Cost per 100 of Benefit < Example: A 42 year old requesting 400 of benefits to begin after 14 days (14-Day Elimination Period) would have a bi-weekly deduction amount of The information above and below provides highlights of the insurance program. It does not and is not intended to cover the program in detail. Please refer to the policy for a complete description of the coverage, limitations and exclusions.

3 What are my Coverage Options for Life Insurance? Term Life Coverage Options Employee Dependents Basic Term Life and AD&D: Coverage is equal to 1 times your base annual salary. This amount may not exceed 50,000. Coverage is employer-paid. Optional Term Life: You may purchase increments of 25,000 to a maximum of 300,000. The biweekly rate is based on amount selected and your age as of January 1, Optional Spouse Life: You may purchase increments of 5,000 to a maximum of the lesser of 150,000 or 100% of the Optional Employee Term Life amount. The biweekly rate is based on amount selected and your spouse s age as of January 1, Optional Child Life: You may purchase an amount equal to 10,000. What is the Cost for Optional and Dependent Term Life Insurance? The cost of this program is paid for by you. The cost for Child coverage in the amount of 10,000 is 0.23 per bi-weekly pay period. Use the rate tables below to calculate the employee and spouse cost. Employee Rate Bi-weekly cost per 1,000 Spouse Rate Bi-weekly cost per 1,000 < < The following example calculates the biweekly cost for a 36-year old employee who would like to purchase 100,000 in Optional Life insurance coverage. Calculate Your Cost Example You Step 1 Using the table above, enter the rate that corresponds with your age Step 2 Enter the desired coverage amount in dollars 100,000 Step 3 Divide Step 2 1, Step 4 Calculate the biweekly cost. Multiply Step 1 by Step Cost of insurance may change in the future due to age and/or coverage amount elected. Rates are subject to change.

4 Employer Name University Medical Associates Enrollment Form Group Life and Disability Insurance Please return completed form to your benefits department University Medical Associates Employer Address (City, State, Zip Code) 1180 Sam Rittenberg Blvd. Charleston, SC Group Policy Number Coverage Effective Date Employee Name (Last, First, Middle) Address (City, State, Zip Code) Social Security Number Date of Birth (MM/DD/YY) Gender Marital Status Male Female Hire Date (MM/DD/YY) Annual Salary Type of Enrollment Coverage Elections Single Married Divorced Widowed New Employee Annual/Open Enrollment Qualified Life Event Rehire Rehire Date: Please indicate your coverage elections below. The Employee must enroll in Optional Life coverage to elect Optional Dependent Life coverage. The Optional Spouse Benefit cannot be greater than 100% of the Employee Optional Benefit. All dependent children will be covered. Evidence of Insurability may be required. Please see your plan booklet for additional information. Type of Coverage Selection Coverage Amount Elected Optional Short-Term Disability Decline 7-Day Elimination Period 14-Day Elimination Period *Enter an amount equal to 200, 300, 400, 500, 600, 700 or 800. This amount may not exceed 66.7% of your basic weekly earnings. Employee Optional Life Yes No *Must be increment of 25,000 up to 300,000. Statement of Health required for amounts above 150,000 (see instructions below) Spouse Optional Life Yes No *Must be increment of 5,000. Cannot exceed 150,000 or 100% of Employee Optional Amount. Statement of Health required for amounts above 50,000 (see instructions below) Child(ren) Optional Life Yes No 10,000 Statement of Health Instructions If you are requesting an amount of Employee Optional Life Insurance above 150,000 or an amount of Spouse Optional Life Insurance above 50,000, you must complete the Statement of Health by going to You will need to register to the site using the company code MUSCP and then complete the application that is initiated by clicking the Complete Statement of Health button.

5 If electing for Dependent Coverage (Spouse and Child), please complete the following: Spouse Name: Dependent Child(ren) coverage is available to eligible dependent child(ren) under 19 years of age, or 25 if a full-time student. Employee Signature and Authorization ACCEPT: I declare that all information given in this enrollment form is true and complete to the best of my knowledge and belief. I request coverage under my employer s plan of benefits as indicated above. I authorize my employer to deduct from my earnings my contributions for the coverage(s) selected. I understand that with respect to coverages I have declined, Liberty Mutual Insurance has the right to require Evidence of Insurability in order to consider any later request to change this decision and that my request may be denied. I am an employee in active employment working at the employer s regular place of business. DECLINE: I hereby decline all optional coverage as offered by my Employer. I certify that I have been given the opportunity by my Employer to enroll for coverage. I understand that Liberty has the right to require Evidence of Insurability in order to consider any later request to change this decision and that my request may be denied. I am an employee in active employment working at the Employer s regular place of business. Employee Signature: Date: Completion of this enrollment form does not guarantee coverage. Evidence of Insurability may be required. Please see your plan booklet for additional information. Submit completed form to your employer and retain a copy for your records. Group disability income and life insurance policies are issued by Liberty Life Assurance Company of Boston, a member of the Liberty Mutual