A B. C Plan C: It s Time to Choose Your 2015 Health Benefits. Plan A

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1 HABLAMOS ESPANOL! Open Enrollment ends March 27. It s Time to Choose Your 2015 Health Benefits choose one... A B Plan A Wellness + Preventive $7.83 / week Plan B Plan A + Hospital Indemnity + Sickness, Dr. Office Visits + Rx + Accident, X-Ray + Hospitalization Benefits $23.48 / week optional purchase to add to coverage C Plan C: Optional Benefits + Life +Dental + Short-Term Disability see pages 5-6 Enroll Today. Time is Limited. PLAN A or B COMPLETE + FAX THE ENCLOSED ENROLLMENT FORM OR CALL US TOLL-FREE AT OPEN ENROLLMENT ENDS MARCH 27, 2015

2 Health Care for Everyone AVOID THE PENALTY By purchasing either Plan A or Plan B, you can avoid the ACA tax penalty that goes into effect on January 1, The tax penalty in 2015 is the greater of 2% of your adjusted household income or $325 per adult plus $ per child. These penalties increase again in However, as long as you have qualifying coverage, you will not be subject to these tax penalties. PLAN A PREVENTIVE SERVICES Plan A&B covers 64 preventive services required per the government list of Preventive and Wellness Benefits. This list includes diabetes and cholesterol screenings, prenatal visits for pregnant women, and more. These benefits are covered at 100% when you visit a network provider. The benefits drop to 40% if you use an out-of-network provider. A full list of the covered services is on page 3. Plan A is minimum essential coverage. PLAN B COVERED BENEFITS Our plans offer coverage for things like doctor s office visits, laboratory services and X-rays. Plan B does include limited benefits. Those are shown on page 4. The dollar amounts shown in the chart are what the insurance company pays for each covered benefit for hospitalization and surgical expenses. In addition, there is a lump sum benefit of $2,500 (25% of that benefit for enrolled dependents) if you are diagnosed with a covered critical illness. Plan B is minimum essential coverage. NATIONAL PPO, NATIONAL DISCOUNTS It is important that you use network doctors and medical facilities. If you use an out-of-network medical provider, the plan pays less benefits. You can find in-network doctors and medical facilities at or by calling First Staff Benefits at MEDICAL ID CARDS As a member, you will receive a medical ID Card that needs to be presented to your medical provider at your time of service.

3 Plan A WELLNESS + PREVENTIVE ONLY COVERED PREVENTIVE SERVICES FOR ADULTS (AGES 18 AND OLDER) 1 Abdominal Aortic Aneurysm one time screening for age Alcohol Misuse screening and counseling Aspirin use for men ages and women ages to prevent CVD 3 when prescribed by a physician 4 Blood Pressure screening 5 Cholesterol screening for adults 6 Colorectal Cancer screening for adults starting at age 50 limited to one every 5 years 7 Depression screening 8 Type 2 Diabetes screening 9 Diet counseling 10 HIV screening 11 Immunization vaccines (Hepatitis A & B, Herpes Zoster, Human Papillomavirus, Influenza (Flu Shot), Measles, Mumps Rubella, Meningococcal, Pneumococcal, Tetanus, Diptheria, Pertussis) 12 Obesity screening and counseling 13 Sexually Transmitted Infection (STI) prevention counseling 14 Tobacco Use screening and cessation interventions 15 Syphillis screening COVERED PREVENTIVE SERVICES FOR WOMEN (INCLUDING PREGNANT WOMEN) 1 Anemia screening on a routine basis for pregnant women 12 Gestational diabetes screening 26 2 Bacteriuria Urinary Tract or other infection screening for pregnant women 3 BRCA counseling and genetic testing for women at higher risk Breast Cancer Mammography screenings every year for women age 40 4 and over 5 Breast Cancer Chemo Prevention counseling for women 6 Breastfeeding comprehensive support and counseling from trained providers as well as access to breastfeeding supplies for pregnant and nursing women. Non-network services will be payable as network services. 7 Cervical Cancer screening 8 Chlamydia Infection screening 9 Contraception: Food and Drug Administration approved contraceptive methods, sterilization procedures, and patient education and counseling, not including abortifacient drugs 10 Domestic interpersonal violence screening and counseling for all women. 11 Folic acid supplements for women who may become pregnant when prescribed by a physician. 13 Gonorrhea screening 14 Hepatitis B screening for pregnant women 15 Human Immunodeficiency Virus (HIV) screening and counseling 16 Human Papillomavirus (HPV) DNA test: HPV DNA testing every three years for women with normal cytology results who are 30 or older. 17 Osteoporosis screening over age Routine prenatal visits for pregnant women Rh Incompatibility screening for all pregnant women and follow-up testing Tobacco Use screening and interventions for all women and expanded counseling for pregnant tobacco users 21 Sexually Transmitted Infections (STI) counseling 22 Syphillis screening COVERED PREVENTIVE SERVICES FOR CHILDREN 23 Well-woman visits to obtain recommended preventive services 1 Alcohol and Drug Use assessments Autism screening for children limited to two screenings up to 24 2 months Behavioral assessments for children limited to five assessments up 3 to age Blood Pressure Screening 5 Cervical Dysplasia screening 6 Congenital Hypothyroidism screening for newborns 7 Depression Screening for adolescents ages 12 and older 8 Developmental Screening for children under age 3 and surveillance throughout childhood 9 Dyslipidemia screening for children 10 Fluoride Chemoprevention supplements for children without flouride in their water source when prescribed by a physician 16 HIV screening for adolescents Immunization Vaccines for children from birth to age 18 - Doses, recommended ages, and recommended populations vary: Hepatitis A, Hepatitis B, Human Papillomavirus, Influenza (Flu Shot), Meningococcal, Rotavirus, Diptheria, Tetanus, Pertussis, Inactivated Poliovirus, Measles, Mumps Rubella, Pneumococcal, Varicella Iron supplements for children up to 12 months when prescribed by a physician 19 Lead screening for children 20 Medical History for all children throughout development Ages: 0-11 months; 1-4 years; 5-10 years; years; years 21 Obesity screening and counseling 22 Oral Health risk assessment for young children up to age Gonorrhea preventive medication for the eyes of all newborns 12 Hearing screening for all newborns 13 Height, weight and body mass index measurements for children 14 Hematocrit or Hemoglobin screening for children 15 Hemoglobinopathies or Sickle Cell screening for newborns 23 Phenylketonuria (PKU) screening in newborns 24 Sexually Transmitted Infection (STI) prevention counseling and screening for adolescents 25 Tuberculin testing for children 26 Vision screening for all children under the age of 5 This plan provides no coverage for sickness/hospitalization/surgical benefits. Refer to Plan B for those benefits. Additional benefits including surgical/hospitalization/sickness benefits are available to you in addition to Plan A.

4 Plan B Plan B includes the benefits of Plan A In addition to the well care and preventive benefits provided under Plan A, if you purchase Plan B you will receive limited medical benefits for sickness, accident, hospitalization and surgery. Plan A + Limited Medical Benefits Limited Medical Benefits (Includes the benefits of Plan A) In Hospital Benefits (The amounts listed below are what the insurance company pays) Daily In-Hospital Indemnity Benefit $200 per day / 31 days maximum Inpatient Surgical Indemnity Benefit Rider $500 per day / 1 day maximum Off-the-Job Accident Benefit $100 per day / 5 days max Outpatient Physician Sickness Office Visit Indemnity Benefit $50 per visit / 6 per year Outpatient Diagnostic X-Ray and Lab Indemnity Benefit $20 / 2 days maximum Outpatient Select Diagnostic Test Indemnity Benefit Rider $100 / 2 days maximum Outpatient Advanced Studies Diagnostic Test Indemnity Rider $400 / 1 day maximum Outpatient Surgical Indemnity Benefit Rider $250 per procedure (per schedule) / 1 day maximum Calendar Year Maximum Prescription Drug Benefit PPO Network Life & AD&D* PPO Network 20% Anesthesia $10 Generic / $20 Brand Name 1 per day/ 12 days max MultiPlan Employee: $10,000 Benefit Spouse: $5,000 Benefit Child(ren): $2,500 Benefit Multiplan Weekly Cost - Plan A Contact your employer to enroll dependents in Plan A Weekly Cost - Plan B Plan A + Hospital Indemnity Employer Contribution Employee Contribution Employer Contribution Employee Contribution Employee $6.00 $7.83 Employee + Spouse $6.00 $13.59 Employee + Child (ren) $6.00 $30.90 Family $6.00 $36.65 Employee $6.00 $23.48 Employee + Spouse $6.00 $42.12 Employee + Child (ren) $6.00 $54.21 Family $6.00 $70.19 Please refer to your plan document for a detailed description of all exclusions. Plan A is administered by Key Benefit Administrators, P.O. Box 129, Fort Mill, SC 29716

5 C ADDED COVERAGE: Purchase Optional Benefits SHORT-TERM DISABILITY INCOME INSURANCE - WEEKLY COST You You must must enroll enroll in Plan in A Plan + Limited B to Medical purchase to purchase Short-Term short-term Disability disability Insurance insurance Elimination Period for Accident and Sickness 14 days Maximum Disability Period 6 months Maximum Benefit Per Month $800 Employee Only $ 4.95 DENTAL INSURANCE You must enroll You must in Plan enroll A + Limited in Plan Medical B to purchase to Dental dental Insurance insurance. Maximum Available Allowance $1,000 DENTAL WEEKLY COST Employee $4.75 $ Coinsurance Deductible Waiting Period Diagnostic and Preventive Services: 80% Basic Restorative Services: 50% Major Restorative Services: 50% $50 Waived for Diagnostic and Preventive Services. No Family Maximum No waiting period for Diagnostic and Preventive and Basic Restorative Services; 12 months for Major Restorative Services. Employee + Spouse $9.24 $ Employee + Child(ren) $ $10.03 Family $15.50 $ What Is It? Life insurance helps provide immediate and future financial security for your family following your death. Term life insurance gives you coverage for a specified period of time, or term such as 10 years. OPTIONAL GROUP TERM LIFE INSURANCE No medical questions asked! This policy is portable - you can take it with you if you leave the group Provide income for your family after you are gone Pick your benefit levels in increments of $25,000 or $50,000 Call to enroll or fill out enclosed enrollment form You can enroll in the life insurance even if you don t select other benefits Policy Description Voluntary Term Life Insurance Benefit Levels Evidence of Insurability Portable Convertible to Whole Life Policy Terminal Illness Rider - Pick in increments of $25,000 or $50,000 - Guaranteed issue up to $50,000 - NO MEDICAL QUESTIONS ASKED! (up to age 65) - Spouse guaranteed issue up to $15,000 (call for pricing) - Eligible dependent children issue is up to $10,000 Guaranteed Issue - NO MEDICAL QUESTIONS ASKED! You can take this plan with you if you leave the group! Opportunity to convert to permanent 1 life insurance upon termination of insurance. You can access a percent of this benefit if you are diagnosed for the first time with a terminal illness that will result in death within 12 months. Once you die, your family receives the remainder of the benefit to provide them with income after you are gone. Waiver of Premium Due to

6 C ADDED COVERAGE: Purchase Optional Benefits OPTIONAL GROUP TERM LIFE INSURANCE - WEEKLY COST Non-Tobacco Weekly Premiums $25,000 $50,000 AGE PREMIUM PREMIUM Age $0.88 $1.77 Age $0.90 $1.79 Age $0.91 $1.82 Age 26 $0.93 $1.86 Age 27 $0.96 $1.93 Age 28 $0.98 $1.97 Age 29 $1.01 $2.01 Age 30 $1.02 $2.04 Age 31 $1.04 $2.09 Age 32 $1.06 $2.12 Age 33 $1.08 $2.16 Age 34 $1.13 $2.26 Age 35 $1.20 $2.40 Age 36 $1.27 $2.55 Age 37 $1.39 $2.79 Age 38 $1.45 $2.90 Age 39 $1.55 $3.11 Age 40 $1.65 $3.30 Age 41 $1.77 $3.53 Age 42 $1.88 $3.76 Age 43 $2.00 $4.01 Age 44 $2.18 $4.37 Age 45 $2.35 $4.70 Age 46 $2.51 $5.02 Age 47 $2.67 $5.35 Age 48 $2.86 $5.73 Age 49 $3.06 $6.13 Age 50 $3.25 $6.51 Age 51 $3.43 $6.87 Age 52 $3.59 $7.18 Age 53 $3.78 $7.55 Age 54 $3.96 $7.92 Age 55 $4.28 $8.57 Age 56 $4.69 $9.39 Age 57 $5.03 $10.06 Age 58 $5.42 $10.85 Age 59 $5.82 $11.64 Age 60 $6.28 $12.57 Age 61 $6.80 $13.60 Age 62 $7.31 $14.62 Age 63 $7.82 $15.65 Age 64 $8.39 $16.78 Age 65 $9.33 $18.67 WEEKLY Amounts below this line do not include the Waiver Riders Tobacco Weekly Premiums $25,000 $50,000 AGE PREMIUM PREMIUM Age $1.30 $2.61 Age $1.31 $2.63 Age $1.32 $2.65 Age 26 $1.33 $2.67 Age 27 $1.41 $2.83 Age 28 $1.44 $2.88 Age 29 $1.51 $3.03 Age 30 $1.56 $3.13 Age 31 $1.60 $3.20 Age 32 $1.62 $3.26 Age 33 $1.69 $3.38 Age 34 $1.77 $3.54 Age 35 $1.88 $3.76 Age 36 $2.05 $4.10 Age 37 $2.21 $4.42 Age 38 $2.38 $4.77 Age 39 $2.64 $5.29 Age 40 $2.92 $5.85 Age 41 $3.23 $6.47 Age 42 $3.49 $6.98 Age 43 $3.78 $7.55 Age 44 $4.06 $8.13 Age 45 $4.35 $8.70 Age 46 $4.65 $9.29 Age 47 $5.10 $10.20 Age 48 $5.49 $11.00 Age 49 $5.88 $11.76 Age 50 $6.28 $12.57 Age 51 $6.72 $13.45 Age 52 $7.17 $14.34 Age 53 $7.71 $15.42 Age 54 $8.44 $16.88 Age 55 $9.27 $18.53 Age 56 $9.76 $19.53 Age 57 $10.73 $21.46 Age 58 $11.73 $23.46 Age 59 $12.55 $25.11 Age 60 $13.70 $27.40 Age 61 $14.43 $28.86 Age 62 $15.45 $30.91 Age 63 $16.88 $33.76 Age 64 $18.48 $36.97 Age 65 $20.47 $40.94 WEEKLY

7 Call to enroll in Plan A or Plan B Please complete and fax this enrollment form to PERSONAL INFORMATION Group Name ID# Location Personnel Rita Staffing Solutions Plus Employee (Last, First, M.I.) Male Female Spouse (Last, First, M.I.) Male Female Date of Hire Avg hrs worked per week Annual Salary Address Employee ID HOME ADDRESS Street Apt# City State Zip Code Home Phone Work phone/ext CHILD/DEPENDENT INFORMATION Child Name FT Student Non-Student Male Female Child Name FT Student Non-Student Male Female Child Name FT Student Non-Student Male Female Child Name FT Student Non-Student Male Female Primary Beneficiary (Last, First, M.I.) Relationship Contingent Beneficiary (Last, First, M.I.) Relationship BENEFIT OPTIONS - Questions 1-3 pertain to Plan C ONLY 1. Is anyone proposed for coverage covered by any Title XIIX program (e.g. Medicaid)? Yes No If Yes, please list name(s), who will be excluded from coverage: 2. Are you actively at work on a full-time basis and able to perform the regular duties of your occupation? Yes No If No, you and your dependents are not eligible for coverage 3. If applying for spouse and/or child(ren) coverage, is/are any of the proposed insured currently disabled? Yes No If Yes, list name(s), who will be excluded from coverage. PLAN A ONLY Weekly Premiums Basic Coverage Employee Only $7.83 $ 5.00 Employee + Spouse $13.59 $ Employee + Child(ren) $31.13 $ Family $36.65 $ SHORT-TERM DISABILITY You must enroll in Plan B + Hospitalization OR Plan C to purchase this dental insurance. EMPLOYEE S STATEMENTS AND AGREEMENTS: PLAN PLAN B (includes B (INCLUDES PLAN PLAN A) A) Weekly Premiums Basic Coverage Employee Only $23.48 $ Employee + Spouse $42.12 $ Employee + Child(ren) $54.21 $ Family $70.19 $ GROUP TERM LIFE - see page 6 for rates DENTAL You must enroll in Plan B + Hospitalization OR Plan C to purchase this dental insurance. Weekly Premiums Basic Coverage Employee Only $4.75 $ Employee + Spouse $9.24 $ Employee + Child(ren) $10.03 $ Family $15.50 $ Age Tobacco Benefit Level Weekly Cost Weekly Premium, Employee Only $ 4.95 Yes No $25,000 $50,000 $ risk or the hazard assumed may result in loss of coverage under the policy/certificate to which this application is attached. I understand that any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a be a member of an eligible class of employees; b) I must have satisfied the employer waiting period; c) the employer group must have met the insurer s minimum participation requirement; d) I must satisfactorily answer Signed in (City/State) This Day of (Month/Year) Employee s signature Spouse s Signature (if applicable) Licensed Representative s Name Licensed Representative s Signature Agent # If you choose not to enroll in coverage, please sign below. I decline coverage at this time. Signed in (City/State) This Day of (Month/Year) Employee s signature I agree that typing my full legal name and last four digits of my social security number shall be the electronic representation of my signature for all purposes, with the exception of the cancellation of any coverage, when I {or my Agent} use them on documents, including legally binding contracts, to include all Employee Benefits applications and Section 125 forms, just the same as a pen and paper signature. Full Legal Name Last Four Digits of Social

8 Customer Service Center P.O. Box Knoxville, TN IMPORTANT EMPLOYEE BENEFIT INFORMATION. DO NOT DISCARD! Open Enrollment Ends March 27, It s Time to Choose Your 2015 Benefits PLAN A or B COMPLETE + FAX THE ENCLOSED ENROLLMENT FORM OR CALL US TOLL-FREE AT Open Enrollment ends March 27. choose optional purchase to add to coverage C A B Plan C Plan A Wellness + Preventive $7.83 / week Plan B Wellness + Preventive + Sickness, Dr. Office Visits + Rx + Accident, X-Ray + Optional Hospitalization Benefits $23.48 / week Limited Hospital Benefits + Life +Dental + Short-Term Disability* * Not Available in NY, NJ, CA or WA see page 5-6

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