WAGES. January 1, December 31, 2014

Transcription

1 January 1, December 31, 2014 Plan Benefit Descriptions WAGES Section 125 Services Provided By: Wellington Benefits a Member of the First Financial Group of America 3904 Oleander Drive, Suite 200 Wilmington, NC (800) Section 125 Third Party Administrator: First Financial Administrators, Inc. P.O. Box Houston, TX (800) Medical Reimbursement Dependent/Child Care Reimbursement Disability Insurance Life Insurance Cancer and Specified Disease Insurance Accident Insurance Dental Insurance Vision Insurance

2 PROVIDER SEARCH To locate a provider in your area, go to communityeyecare.net and search by: county doctor s last name practice name zip code CLAIMS There are no claims to file when you see an in-network provider. Network providers file claims on your behalf. Additionally, most CEC network providers offer discounts on the overage if you exceed your allowance 20% on glasses and 10% on contact lenses. If you see a non-network provider, simply submit a claim form and a receipt to Community Eye Care. CUSTOMER SUPPORT Contact CEC s helpful Customer Support Team at with any questions about benefits or providers. WAGES Vision Plan WAGES is pleased to announce the addition of a voluntary vision plan to the list of benefits available to our employees. The plan enables employees and their families to significantly reduce their expenditures for routine eye care. Offered through Community Eye Care, the benefit includes the following: An eye exam once a year ($15 co-pay) HOW TO USE THE BENEFIT 1. Select a provider from the Community Eye Care provider network. 2. Call the provider to make an appointment, and let them know that you have Community Eye Care coverage. 3. See the doctor and select your eyewear. EYE EXAMINATION A standard contact lens fitting for new fits or re-fits, as needed ($15 co-pay) (Periodic contact lens evaluations are not covered) EYEWEAR ALLOWANCE A $150 allowance for eyewear annually ($15 co-pay) The allowance can be applied to frames, spectacle lenses, contact lenses, special lens options, or any combination. As long as you select eyewear having a retail price that s less than or equal to your allowance, the only out-of-pocket expense you incur for the eyewear is the $15 co-pay. 4. Your only payments to the provider are your co-pays, plus any discounted amount that exceeds the $150 eyewear allowance. WEEKLY RATES (36 pay periods) Employee Only $3.20 Employee + One $6.29 Employee + Family $9.68 TABLE OF CONTENTS What is Section 125? Page 1 What Benefits are Available? Page 2 How Do I Enroll? Page 3 Medical Reimbursement Expense Page 5 Accounts Dependent Care Expense Accounts Page 12 Debit Card Page 14 Medical-Dependent Care Expense Page 15 Voucher Benefit Brochures Short Term Disability Page 18 Permanent Life Page 23 Cancer Page 28 Accident Page 29 Dental Page 37 Vision Page 39 WAGES has adopted a Section 125 Flexible Benefit Plan for all eligible employees. The purpose of this booklet is to provide you with a brief description of the Plan and the benefits available to you under the Plan. In the event that a conflict develops between this booklet and the terms of the Plan, the latter instrument must control since it is the legal instrument which actually constitutes the Plan. Although the employer currently intends to continue all of the benefits described in this booklet, the employer reserves the right to amend, reduce or terminate any of these benefits at any time. 39

3 WHAT IS A SECTION 125 FLEXIBLE BENEFIT PLAN? A Section 125 Flexible Benefit Plan allows you, the employee, to spend benefit dollars for benefits that you choose to meet your needs. The benefits from which you may choose are listed later in this booklet. The benefits that you elect under the Plan are paid for with benefit dollars made available to you by your employer or through a salary reduction agreement with your employer. Salary reduction means that you are able to use "pre-tax" dollars to pay for certain benefits that you may have previously paid for with "after-tax" dollars. HOW CAN THIS PLAN HELP YOU? By implementing this Plan, your employer is helping you reduce your taxes and increase your spendable income. The cost saving advantage of the Plan is simple. Any benefit costs or insurance premiums you pay under the plan are paid on a pre-tax basis. The example below illustrates the advantage of the Section 125 Plan in comparison with a situation without the benefits of a Plan. The bottom line is that you may have more dollars available to you for the purchase of other benefits you may need or available to you as increased take-home pay. WITHOUT SECTION 125 WITH SECTION 125 Average Monthly Salary $2,000 Less Estimated Federal Withholding (20%) -400 $1,600 Less Insurance Premium(s) -200 Net Take-Home Pay $1,400 Less Out-of-Pocket "Flex" Expenses -50 Spendable Income $1,350 Average Monthly Salary $2,000 Less Qualified Insurance Premium(s) -200 Less Out-of-Pocket "Flex" Expenses -50 Taxable Income $1,750 Less Estimated Federal Withholding (20%) -350 Net Take-Home Pay/Spendable $1,400 Income 1 38

4 WHAT BENEFITS ARE AVAILABLE? The following benefits are available to you under the Plan: Insurance Benefits: Cancer, Accident, Vision, Dental, Disability*, and Life* * coverages available outside Section 125 only Expense Reimbursement Accounts: Medical Expense Reimbursement Dependent Care Expense Reimbursement * If maternity benefits are provided: Group health plans and health insurance issuers offering group insurance coverage generally, under federal law, may not restrict benefits for any hospital length of stay in connection with childbirth for the mother or newborn child to less than 48 hours following a normal vaginal delivery, or less than 96 hours following a caesarian section, or require that a provider obtain authorization from the plan or the insurance issuer for prescribing a length of stay not in excess of the above periods. WHO CAN PARTICIPATE IN THE PLAN? All employees of WAGES who normally work at least 30 hours per week. If you are an existing employee, you must sign an election form for the next plan year during the annual enrollment period. New employees are eligible immediately. HOW MUCH DOES IT COST TO PARTICIPATE? There is a no charge to participate in the Cafeteria Plan! 37 2

5 HOW DO I ENROLL IN THE PLAN? During the enrollment period, there will be group meetings scheduled for all employees to attend. These meetings will allow you the opportunity to hear a presentation concerning how the Plan works and information on the benefits available. Following the meeting, you will have the opportunity to visit with a representative from Wellington Benefits on a one-on-one basis concerning your individual needs. At this meeting, you will again have the opportunity to ask questions and you will complete an election form. This election form must be completed and signed by each employee, whether or not you wish to elect to participate in the benefit portion of the Plan. MAY I CHANGE MY BENEFIT ELECTION? The benefit election made during the enrollment period will remain in effect for the plan year. The plan year will be from January 1, 2014 to December 31, If you wish to change your benefit election, you must effect the change prior to the beginning of the next plan year. You may, however, change your benefit election during the plan year if you experience a change in status which affects your need for a benefit. Any election change must be consistent with the change in status that has occurred. The following circumstances are examples of events that qualify as a change in status: Marriage, divorce, or legal separation; Birth or adoption of a child; Death of a dependent child or spouse; A change in the employment status of the employee or spouse, such as the termination or commencement of employment, or going from part-time to full-time or full-time to part-time employment, which affects the eligibility for that benefit. You may also revoke any election you made for the period during which you are absent from work for a family medical leave covered by the federal Family and Medical Leave Act (FMLA). You may reinstate your election of group medical benefits when you return from the FMLA leave. However, you may not reinstate a revoked election as to the non-health insurance benefits until the next regular enrollment period. 3 36

6 CAN I STAY IN THE PLAN IF I AM ABSENT ON A FAMILY MEDICAL LEAVE? If you are absent from work on a leave of absence covered by the Family Medical Leave Act (FMLA) for periods totaling 12 weeks during the plan year, you are entitled to maintain the coverage you have under the Plan during your absence. Of course, you must pay the premiums for the coverage during your absence using one of the following methods: Prepayment: Under the prepayment option, you may (at your option) increase your salary reduction in an amount sufficient to cover the premiums that will come due during the FMLA leave. Pay-as-you-go: With the pay-as-you-go option, you continue to pay premiums on a regular basis through the FMLA leave. If you continue to receive your salary while you are gone, the premiums will be paid with pre-tax money as if you had not taken the leave. On the other hand, if your FMLA leave is unpaid and you choose this option, you will have to reimburse the Plan at regular intervals from your after-tax funds for the premiums that come due during the leave. The language above regarding the two payment methods assumes that both the prepayment and the pay-as-you-go methods are offered under the Plan. PREMIUM CONVERSION The following insurance products may be purchased under the Section 125 Flexible Benefit Plan with the premiums paid on a pre-tax basis: Cancer, Accident, Vision, and Dental Enrolling in any of these benefits on the election form does not enroll you in the insurance product itself. In most cases, an insurance application to the company issuing the insurance product must also be completed. EXPENSE REIMBURSEMENT ACCOUNTS The following expense reimbursement accounts are available under the Section 125 Flexible Benefit Plan with your contributions to the account paid on a pre-tax basis: Dependent Care Expense Reimbursement Medical Expense Reimbursement 35 4

7 EXPENSE REIMBURSEMENT ACCOUNTS If available as a plan benefit option, expense reimbursement accounts allow you to establish an account to reimburse certain types of expenses on a tax exempt basis. There are two types of reimbursement accounts which may be elected. The first is the Medical Expense Reimbursement Account to reimburse uninsured out-of-pocket medical expenses, and the second is the Dependent Care Expense Reimbursement Account to reimburse dependent day care expenses. HOW DO THE REIMBURSEMENT ACCOUNTS WORK? Each month, pre-tax payments are made to an account set up in your name. As one of your Section 125 Flexible Benefit Plan elections, you can specify the payment amount to be set aside on a tax-free basis for one or both of the reimbursement accounts. As you incur qualified medical expenses or dependent day care expenses, you can submit a voucher form for reimbursement from the proper account. HOW DO I GET REIMBURSED FOR MY QUALIFIED EXPENSES? Each month in which you incur an expense, you may submit a voucher form for reimbursement. This voucher form must be accompanied by your original receipts or, in the case of a dependent day care expense, a dependent care provider acknowledgment form. These forms will be provided to you. The voucher will be processed and you will be sent a reimbursement check for your expense(s). The medical expense reimbursement check will be for the expenses claimed up to the maximum benefit amount you elected for the year less expenses previously reimbursed. The dependent care expense check will be for the expense you claimed up to the amount you have in your account. WHAT HAPPENS IF MY EXPENSES ARE LESS THAN THE AMOUNT SET ASIDE? Any expense dollars not used for expenses are forfeited. This is known as the "use it or lose it" provision of Section 125. It is very important that you be conservative and accurate when estimating your expenses for the plan year. 5 34

8 IMPORTANT GUIDELINES FOR ENROLLMENT IN REIMBURSEMENT ACCOUNTS 1. Be sure that the amount set aside is conservative amounts not used for qualified expenses cannot be carried over or returned to you. 2. You cannot be reimbursed for these expenses from any other source. 3. All expenses to be reimbursed must be incurred in the plan year in which your contributions are made. 4. Expenses reimbursed under the Plan may not be used when calculating your medical expense deduction or the dependent care tax credit. 5. You have a 90-day grace period at the end of the plan year to request reimbursement of expenses you incurred during the plan year. 6. You should consult with your tax advisor concerning participation in the reimbursement accounts. MEDICAL EXPENSE REIMBURSEMENT ACCOUNTS The Medical Expense Reimbursement Account can benefit you if you have any predictable out-ofpocket medical, dental or vision care expenses. Only expenses incurred for you or your dependents during the plan year may be reimbursed. For the Medical Expense Reimbursement Account, you will only be allowed to change your benefit election due to termination of your employment. HOW MUCH IS AVAILABLE FOR REIMBURSEMENT? The total amount of a qualified expense is available for reimbursement upon receipt of a voucher and original bill or receipt. The amount of the reimbursement, however, will not exceed the total contribution for the plan year less any reimbursements paid to date. Total reimbursements for the plan year will not exceed the contribution amount for the plan year. IS THERE A CONTRIBUTION LIMIT? Maximum amount available under the Medical Expense Reimbursement Account is $2500 per plan year. 33 6

9 SECTION 125 FLEXIBLE BENEFITS PLAN PARTICIPANT GUIDELINES FOR SPENDING ACCOUNTS - Medical Expense Reimbursement - Dependent Care Reimbursement PREPARED BY: First Financial Administrators, Inc. For your Employer s Plan 7 32

10 Section 125 Flexible Spending Account First Financial Administrators, Inc. WE ARE COMMITTED First Financial Administrators, Inc. is dedicated to providing excellent service to our customers and are delighted to serve as your cafeteria plan service provider. Our role is to process your requests for reimbursement according to the plan designed by your employer.» There are two types of Flexible Spending Accounts (FSAs): The first is unreimbursed medical (URM) and the second is dependent day care (DDC).» Your participation in an FSA program allows a portion of your salary to be redirected to provide reimbursement for these types of expenses on a tax-exempt basis.» At the beginning of each plan year, you elect a specific dollar amount for each FSA you wish to participate.» Participation in one or both FSAs can save you money by reducing your taxable income. This is because taxes will be calculated after the elected amount is deducted from your salary.» If applicable, your taxable income will be reduced for Social Security purposes; therefore, there may be a corresponding reduction In Social Security benefits.» Once you have elected your annual amount, you cannot change your election unless you experience a change in family status. See Election Irrevocability» To ensure that you are aware of your account balance at all times, we send a new explanation of benefits with each claim that is paid. The explanation of benefits will provide you with information regarding your account balance, claims paid to date, and claims pending.» We send notifications 45 days prior to the end of the plan year. The notification reflects your current available balance. You can view account information by logging into our secure website. FILING A CLAIM Before submitting your claim, make sure you have had the service(s). TO FILE YOUR CLAIM 1. Complete a claim form, and be sure to sign and date it. 2. Attach a legible receipt(s) from the service provided or an EOB (Explanation Of Benefits) showing:» A description of the service or a list of supplies furnished.» The charge(s) for each service.» The date(s) of service.» The name of the person(s) receiving the service.» The amount you are responsible for. 3. For convenient direct deposit, complete the Automatic Deposit Agreement form. Or use your FFA Benefits Card REQUESTING SERVICES (Toll-free) For Inquires: For Claim Forms: To Submit Claims by Fax:

11 General IRS Rules & Information The following rules apply to both URM and DDC FSAs ELECTION IRREVOCABILITY You may not make changes before the beginning of the next plan year unless there is a qualified change in status (as permitted by your plan) that affects Eligibility. Qualified changes in status may include:» Change in employee s legal marital status» Change in number of tax dependents» Change in employment status that affects eligibility» Dependent satisfies or ceases to satisfy eligibility requirements» Change in residence that affects eligibility» Judgment, decree, or court order dictating provision of coverage» Entitlement of Medicare or Medicaid (URM only)» Change in cost of the benefit (DDC only) Addition or elimination of benefit option Change in coverage of spouse or dependent under his/her employer s plan Significant curtailment of coverage If a change in status occurs, you may make changes consistent with the qualifying event or as otherwise defined by your plan document. See your plan Sponsor for further details about making changes. Dollar Limits Unreimbursed Medical Account: Your plan sponsor determines the maximum benefit that may be elected. Please see your employer for the maximum benefit amount allowed under your plan. Note: Due to Healthcare Reform, all URM Accounts will have an annual maximum of $2,500 starting January 1, Dependent Daycare Account: This reimbursement (when aggregated with all other dependent care reimbursements during the same calendar year) may not exceed the least of the following:» $5,000, or» $2,500, if married but filing separate tax returns Use-it-or-lose-it-Rule Money remaining in your FSA account(s) will not be returned to you at the end of the plan year. Any amount remaining after the end of the runoff or grace period, if your employer offers one, will be forfeited. Because of the use-it-or-lose-it rule, it is important for you to carefully estimate your out-of-pocket URM and DDC expenses for the upcoming plan year. TERMINATION OF EMPLOYMENT URM Account: Your salary redirections will end; however, you may still file claims for dates of service that were incurred within your employment period. You have 90 days after termination to submit a claim. DDC Account: If you have not received reimbursement for all contributions made to your DDC account upon termination, you have 90 days after the end of the plan year to submit a claim. COBRA COBRA does not apply to DDC. However, it may apply to your URM account and allow you to continue participation in your URM, thus allowing you to receive reimbursement for medical expenses incurred after your employment termination if:» The plan sponsor is subject to COBRA, and» When you terminate employment and you have contributed more for URM than you have received in URM benefits. Note: Under COBRA you must elect coverage within 60 days and continue to submit contributions to your employer to continue coverage under your URM account for the current year. 9 30

12 General IRS Rules & Information UNREIMBURSED MEDICAL FSA Almost every person has a number of necessary and predictable expenses that are not paid by their insurance plans. You can save money by putting that amount directly into your Unreimbursed Medical FSA. The FSA will help you pay for these predictable expenses with your pre-tax dollars. Please be aware of change in tax law Beginning Jan. 1, 2011, money from flexible spending accounts will no longer be available to pay for most over-the-counter drugs and medicines without a doctor s prescription. ELIGIBLE EXPENSES With the FSA, you can pay out-of-pocket health care expenses for yourself, your spouse and all of your eligibile dependents for health, dental, and vision care expenses. The services must be incurred while you are actively participating in the FSA plan. The eligible expenses may be reimbursed regardless of whether you, your spouse or dependents are covered by your employer s medical, dental, or health plan. Expenses for medical care will be limited to expenses incurred primarily for the prevention or improvement of a physical or mental defect or illness. An expense that is merely beneficial to your general health is not an eligible expense. It must be an expense to treat an existing medical condition. INELIGIBLE EXPENSES Some expenses that you incur during your plan year may not be eligible for reimbursement under current IRS regulations.» EXPENSES NOT YET INCURRED - Expenses that have been paid, but not yet incurred (i.e. Prepayment of service), cannot be reimbursed until the service is rendered. Expenses don t necessarily have to be PAID, but merely incurred.» PREMIUMS FOR INSURANCE - Premiums and payments to insurance policies are not eligible for reimbursement.» EXPENSES PAID BY ANOTHER PLAN OR THIRD PARTY - Expenses that have already been paid by an insurance company or other reimbursement through your FSA plan.» EXPENSES INCURRED AFTER TERMINATION/SEPARATION FROM YOUR EMPLOYER - If you are no longer participating in the FSA plan through your employer (termination, resignation, etc) any claims incurred after your participation ends are not eligible for reimbursement. COMMON ELIGIBLE EXPENSES» Co-Payments» Co-Insurance» Deductibles» Over-the Counter Drugs (with physician s prescription)» Dental Treatment» Orthodontia» Lab Fees» X-Rays» Vision Expenses» Lasik Surgery» Physical Therapy» Chiropractor Services» Acupuncture» Eye Contact Solution» Eye Drops COMMON INELIGIBLE EXPENSES» Cosmetic Surgery» Teeth Whitening» Veneers» Botox» Non Prescribed Vitamins and Supplements» Toiletries» Medical Insurance Premiums» Health Club Membership Fees 29 10

13 General IRS Rules & Information Humana Cancer Expense (Cancer Plus) North Carolina EXAMPLES OF ELIGIBLE MEDICAL CARE EXPENSES The following lists are examples of the types of expenses that may or may not be reimbursed. These lists are not intended to be complete, as other expenses may also be eligible or ineligible under federal tax law or under employer s plan. To be eligible under an FSA URM account, the medical expense(s) must be incurred for medical care that is not reimbursed from any other source. Medical care means the drug or service is needed to treat a medical condition. First Financial Administrators, Inc. may request additional information from you to substantiate that an expense is for health care. A key aspect of coping with cancer is knowing that funds are available to cover treatment and related costs. That way, you and your family can concentrate on what s most important: successful treatment and a positive outcome. Cancer expense coverage provides unlimited lifetime benefits and is renewable for life, paid directly to you. You can take the policy with you if you leave your current job, and premiums don t increase if you change employers. Coverage type Benefit amount Coverage for cancer Additional included benefits A cancer expense insurance policy provides funds to help offset the expenses incurred for treatment of a covered cancer. This is an annually restorable benefit policy. Benefit amounts are available at various levels. You can choose: $10,000, $15,000, $20,000, $25,000, $30,000, $35,000, $40,000, $45,000 or $50, % of usual and customary charges for the following covered expenses for each family member insured: Chemotherapy and radiation Medical or surgical services and anesthesia Services of a Professional Nurse other than yourself or a member of your immediate family Braces, crutches, and wheel chairs Prosthetic devices X-rays and cobalt treatment Hospital room and miscellaneous services Laboratory services, blood transfusions and actual charges for blood and plasma Ambulance service (ground or air) Cancer travel benefit: Pays $200 per day maximum for travel to and from a cancer treatment center in connection with surgery, chemotherapy, radiation therapy, or medical evaluation by a physician. Travel must be at least 60 miles each way outside the residence area. ELIGIBLE MEDICAL EXPENSES» Acupuncture» Alcohol and drug rehabilitation expenses» Ambulance» Anesthetist» Artificial limbs and teeth» Birth control pills» Blood donor (expense)» Chiropodist» Chiropractor» Christian Science Practitioners» Certain corrective surgery» Contact lens solution and cleaner» Co-payment for health insurance» Dental care and dentures» Drugs and medical supplies» Examinations» Eye exam, eyeglasses, and contacts» Gynecologist» Hearing aids and batteries» Home health care» Hospital and skilled nursing facility expenses» Laboratory fees» Lip-reading lessons» Midwife» Nursing care» Obstetrical expense» Oculist» Operations and related treatments» Optometrist» Orthodontist**» Osteopath» Outpatient clinic» Over-the-Counter Medications (with physician s prescription)» Pediatrician» Physician» Podiatrist» Practical nurse» Prescription drugs» Psychiatrist» Psychologist» Rental or purchase of medical equipment, including special equipment for use by handicapped persons» Sanitarium» Stop Smoking Programs and Drugs» Support or corrective devices» Surgery» Therapy» Transportation expenses» Weight Loss for Obesity*» X-ray INELIGIBLE EXPENSES» Dancing or swimming lessons» Medications purchased outside US» Expenses reimbursed under any health plan or other source» Health Club Dues» Face creams, moisturizers, etc.» Hair removal treatments/waxes» Vacation» Cosmetic Surgery» Teeth Whitening» Vitamins taken for overall health» OTC Medications not for Medical Care» Toothpaste/Toothbrushes» Mouth washes, oral anesthetics, etc. Presented by Cancer wellness benefit: We ll pay for usual and customary expenses up to $150 per insured per calendar year for mammography, cystologic screening, and prostate cancer screening. There is 12-month waiting period for this benefit. Benefits do not accumulate toward the policy s calendar year maximum. Mammography - One screening for breast cancer by low-dose mammography for an insured female per calendar year. Cystologic Screening - One cystologic screening (PAP smear) for an insured female per calendar year. Prostate Cancer Screening - One prostate specific antigen blood test (PSA) and one digital rectal exam for an insured male per calendar year. Cancer lump sum first diagnosis: Pays a one-time lump sum payment of 50% of the face amount at first diagnosis of a covered cancer. This benefit is not included in the calendar year maximum. This rider does not include coverage for skin cancer other than malignant melanoma. Bill Mode Frequency Action Monthly Semi-Monthly Divide modal premium by 2 Monthly Bi-Weekly Multiply modal premium by 12, then divide by 26 Monthly Weekly Multiply modal premium by 12, then divide by 52 Thirteenthly (Billed every 28 days) Bi-Weekly Divide modal premium by 2 Thirteenthly (Billed every 28 days) Weekly Divide modal premium by 4 Tenthly Monthly for 10 Months Multiply modal premium by 12, then divide by Pay Semi-monthly for 10 Months Multiply modal premium by 12, then divide by 20 9thly Monthly for 9 Months Multiply modal premium by 12, then divide by 9 * This service requires a letter of medical necessity with a diagnosis from the referring physician. ** Requires an active orthodontia contract be on file. 11 This is not a complete disclosure of plan qualifications and limitations. Please access our website to obtain a completed list for the Workplace Voluntary Benefit products at Disclosure.Humana.com. Please review this information before applying for coverage. The amount of benefits provided depends on the plan selected. Premiums will vary according to the selection made. Policy: /98 Underwritten by Kanawha Insurance Company NCHHGQ3HH 1/13 Insured by Kanawha Insurance Company, a Humana company HumanaVoluntaryBenefits.com

14 weekly premiums PureLife-plus Standard Risk Table Premiums Tobacco Express & Simplified Issue Life Insurance Face Amounts for Weekly Premiums Shown Tobacco GUARANTEED PERIOD Prem Includes Added Cost for to Which Issue For Accidental Death Benefit (s 17-59) Coverage is $10,000 Guaranteed at (ALB) Face $5.00 $6.00 $7.00 $8.00 $9.00 $10.00 $12.00 $13.00 Table Premium 15D ,013 47,400 55,787 64,174 72,561 80,948 97, , ,559 45,634 53,708 61,783 69,857 77,932 94, , ,559 45,634 53,708 61,783 69,857 77,932 94, , ,571 43,218 50,865 58,512 66,159 73,806 89,100 96, ,954 42,468 49,983 57,497 65,012 72,526 87,555 95, ,358 41,744 49,131 56,517 63,903 71,290 86,062 93, ,782 41,045 48,307 55,570 62,832 70,095 84,620 91, ,225 40,368 47,511 54,654 61,797 68,940 83,225 90, ,354 35,665 41,976 48,286 54,597 60,908 73,529 79, ,524 34,656 40,788 46,920 53,052 59,184 71,448 77, ,126 34,172 40,219 46,265 52,312 58,358 70,451 76, ,739 33,702 39,665 45,628 51,592 57,555 69,482 75, ,953 31,532 37,112 42,691 48,270 53,850 65,009 70, ,988 30,360 35,731 41,103 46,475 51,847 62,591 67, ,529 28,588 33,646 38,704 43,763 48,821 58,938 63, ,733 27,620 32,508 37,395 42,282 47,169 56,944 61, ,292 25,870 30,447 35,025 39,602 44,180 53,335 57, ,444 23,624 27,804 31,984 36,164 40,344 48,704 52, ,214 22,130 26,045 29,961 33,877 37,792 45,623 49, ,844 20,465 24,086 27,708 31,329 34,950 42,192 45, ,080 18,322 21,564 24,805 28,047 31,289 37,773 41, ,228 17,287 20,346 23,405 26,464 29,522 35,640 38, ,203 16,041 18,880 21,718 24,557 27,395 33,072 35, ,391 15,055 17,719 20,383 23,047 25,711 31,039 33, ,674 14,183 16,693 19,203 21,712 24,222 29,241 31, ,035 13,407 15,779 18,151 20,524 22,896 27,641 30, ,146 12,327 14,508 16,690 18,871 21,052 25,414 27, ,680 13,747 15,814 17,881 19,948 24,081 26, ,804 12,716 14,628 16,540 18,451 22,275 24, ,638 13,388 15,137 16,887 20,386 22, ,890 12,528 14,165 15,802 19,077 20, ,090 11,607 13,124 14,641 17,674 19, ,028 12,469 13,910 16,793 18, ,571 11,952 13,334 16,097 17, ,244 11,583 12,922 15,599 16, ,973 12,241 14,778 16, ,511 11,726 14,156 15, ,243 11,427 13,795 14, ,669 12,880 13, ,880 12, ,000 11, ,179 11, , PureLife-plus is permanent life insurance to Attained 121 that can never be cancelled as long as you pay the necessary premiums. After the Guaranteed Period, the premiums can be lower, the same, or higher than the Table Premium. See the brochure under Permanent Coverage. General IRS Rules & Information The following rules apply to both URM and DDC FSAs DEPENDENT CARE FSA The Dependent Care FSA allows you to pay for day care expenses for your qualified dependent/child with pre-tax dollars while you (and your spouse) are working, seeking employment, or attending school as a full-time student for at least 5 months during the year. ELIGIBILITY REQUIREMENTS Eligible dependents must be claimed as an exemption on your tax return. These dependents can include step-children, grandchildren, adopted children, or foster children. In a divorce situation, you must have custody of the child in order for the child to be considered an eligible dependent. Under IRS regulations, eligible dependents are further defined as: under the age of 13, and/or physically or mentally unable to care for themselves, such as a disabled spouse, disabled child, or elderly parents that live with you. ELIGIBLE EXPENSES Eligible dependent care expenses are those expenses you must pay for the care of a dependent so that you and your spouse can work. The care may be provided in your home or at a licensed center outside of your home. If the care is in your home, the service cannot be provided by another child of yours under the age of 19, by your spouse, or by your dependents. INELIGIBLE EXPENSES Only those dependents care expenses that enable you and your spouse to work are eligible. Some expenses that you incur during your plan year may not be eligible for reimbursement under current IRS regulations» Educational Costs» Weekends/Evening-out babysitting» Transportation, books, clothing, food, activities, entertainment, and registration fees are ineligible if these expenses are shown separately on your bill COMMON ELIGIBLE EXPENSES» Day Camps» Before/After School Care» Babysitters/Day Care Centers» Au Pair» Nanny» Nursery School COMMON INELIGIBLE EXPENSES» Registration Fees» Care for child while not working» Kindergarten» Food/Activity expenses if separate from cost of care» Care provided by anyone under age 19» Pre-School» Books and Supplies» Field Trips PureLife2010-B4AKB5ACD9CW 27 12

15 Claims Information THE REIMBURSEMENT PROCESS REIMBURSEMENTS- The healthcare/medical FSAs are pre-funded; therefore, you are eligible to receive reimbursement up to your elected annual contribution from the beginning of your FSA plan year. The healthcare/medical FSA funds that are reimbursed to you will be recovered as your deductions are taken from your paycheck throughout the plan year. Dependent Care FSAs are NOT pre-funded; therefore, you will only receive reimbursement up to your year-to-date contributions from payroll deductions. The remainder of the reimbursement request is paid when additional funds are received from payroll deductions. PAYMENT METHOD CHOICE- For Unreimbursed Medical expenses you may pay with your FFA Benefits Flex Card at the time you incur the expense, or pay the provider out-of-pocket and file a manual (paper) claim to receive a reimbursement. The FFA Benefits Flex Card is only available for Healthcare/Medical FSAs. MANUAL CLAIMS-To obtain reimbursement from your FSA, you must complete a manual claim form and attach all itemized receipts from the service provider. Cancelled checks, bankcard/credit card receipts, and credit card statements are NOT acceptable forms of documentation. The receipt must come from the service provider or the Explanation of Benefits from your medical health carrier and must include the following information:» Patient name» Date of service incurred» Provider / Merchant name» Amount of your out-of-pocket charge incurred» Type of service incurred» Must include prescription number REMEMBER-You must sign and date all claim forms. FFGA recommends submitting an Explanation of Benefits (EOB) from your insurance company, if available. CLAIMS PROCESSING AND PAYMENTS All claim reimbursements are handled with strict adherence to IRS adjudication and reporting regulations. Claims are processed daily, and our turn around time upon receipt is 3-5 business days and during peak periods (December-March) 5-10 business days. Your reimbursement check will be mailed to your home address on file. You may also elect to receive payment via direct deposit. You have a 2 ½ month grace period (employer permitting) to incur claims with an additional 2 weeks to file claims. Online Service to View Account Information, visit weekly premiums PureLife-plus Standard Risk Table Premiums Non-Tobacco Express/Simplified Issue Life Insurance Face Amounts for Weekly Premiums Shown Non-Tobacco GUARANTEED PERIOD Prem Includes Added Cost for to Which Issue For Accidental Death Benefit (s 17-59) Coverage is $10,000 Guaranteed at (ALB) Face $3.00 $4.00 $5.00 $6.00 $7.00 $8.00 $9.00 $10.00 Table Premium 15D ,144 45,644 58,144 70,644 83,144 95, , , ,215 44,364 56,514 68,664 80,813 92, , , ,215 44,364 56,514 68,664 80,813 92, , , ,336 43,155 54,973 66,791 78,609 90, , , ,504 42,009 53,513 65,018 76,522 88,027 99, , ,716 40,922 52,129 63,336 74,543 85,750 96, , ,716 40,922 52,129 63,336 74,543 85,750 96, , ,966 39,891 50,815 61,739 72,664 83,588 94, , ,254 38,910 49,566 60,221 70,877 81,533 92, , ,930 37,086 47,242 57,398 67,555 77,711 87,867 98, ,724 35,425 45,127 54,828 64,530 74,231 83,933 93, ,907 43,193 52,479 61,764 71,050 80,336 89, ,859 40,584 49,309 58,034 66,758 75,483 84, ,626 39,013 47,400 55,787 64,174 72,561 80, ,484 37,559 45,634 53,708 61,783 69,857 77, ,924 35,571 43,218 50,865 58,512 66,159 73, ,082 33,225 40,368 47,511 54,654 61,797 68, ,170 37,871 44,572 51,273 57,974 64, ,933 35,153 41,373 47,593 53,813 60, ,291 31,943 37,596 43,248 48,900 54, ,271 34,450 39,629 44,809 49, ,011 31,790 36,570 41,349 46, ,213 33,605 37,997 42, ,022 31,084 35,147 39, ,358 29,170 32,982 36, ,252 30,814 34, ,375 28,691 32, ,169 14,228 17,287 20,346 23,405 26,464 29, ,231 13,032 15,834 18,636 21,438 24,239 27, ,811 14,350 16,889 19,428 21,967 24, ,798 13,120 15,441 17,762 20,084 22, ,084 14,222 16,360 18,498 20, ,303 13,303 15,303 17,303 19, ,804 12,716 14,628 16,540 18, ,481 12,335 14,190 16,044 17, ,134 11,927 13,720 15,513 17, ,453 13,175 14,897 16, ,172 12,851 14,531 16, ,257 11,800 13,342 14, ,730 12,133 13, ,026 12, , , PureLife-plus is permanent life insurance to Attained 121 that can never be cancelled as long as you pay the necessary premiums. After the Guaranteed Period, the premiums can be lower, the same, or higher than the Table Premium. See the brochure under Permanent Coverage. 13 PureLife2010-B4AKB5ACD9CW 26

16 weekly premiums PureLife-plus Standard Risk Table Premiums Tobacco Express & Simplified Issue Weekly Premiums for Life Insurance Face Amounts Shown Includes Added Cost for Tobacco GUARANTEED PERIOD to Which Issue Accidental Death Benefit (s 17-59) Coverage is Guaranteed at (ALB) $10,000 $15,000 $20,000 $25,000 $50,000 $100,000 $150,000 $200,000 $250,000 Table Premium 15D PureLife-plus is permanent life insurance to Attained 121 that can never be cancelled as long as you pay the necessary premiums. After the Guaranteed Period, the premiums can be lower, the same, or higher than the Table Premium. See the brochure under Permanent Coverage. FFA Benefits Flex Card Medical reimbursement accounts only BENEFITS FLEX CARD The First Financial Administrators, Inc. Benefits Flex Card is available for Medical Reimbursement Flexible Spending Accounts. Cards can be issued to spouses and dependent children (ages 18 to 26) for no additional fee. The initial cards are free, but if a replacement card is issued, the cost is $10.00 per card and will be deducted from your account balance. Cards are good for three years from the issue date as long as you participate each consecutive plan year. Claims can also be submitted directly for reimbursement. If funds remain in your account after the end of the plan year, you may use the debit card during the 2½ month grace period (if your employer has elected to participate in the grace period option). The system will deduct all remaining funds from your old plan year and then deduct any balance from the new plan year, if you continue to participate. New cards (not replacement cards) are only activated with the upcoming plan year -- they are not activated to use money from the prior plan year. The IRS requires validation of most transactions you must submit receipts for verification of expenses when requested. If you fail to substantiate by providing a receipt to us within 60 days of purchase, your card will be suspended until the necessary receipt or explanation of benefits from your insurance provider is received. Claim forms can be found on our website, Copies can either be mailed to: First Financial Administrators, Inc. P.O. Box Houston, TX or faxed to: (800) WHERE TO USE YOUR DEBIT CARD FOR ELIGIBLE UNREIMBURSED MEDICAL EXPENSES:» Pharmacies always use your debit card at the pharmacy counter only.» In-Store Pharmacies If merchant code is programmed pharmacy, the expense will be authorized. However, if the MasterCard transaction code is programmed grocery/retail, the transaction may be denied. The debit card may not work, and the expense may be declined in some grocery/discount stores. (Your FFA Benefits Flex Card cannot be used past your termination date. If you have available funds in your account, a manual claim will be required.) First Financial Administrators, Inc. can provide you with a list of eligible expenses associated with your Medical Reimbursement Flexible Spending Account. This card is a signature debit card and does not require a PIN for use. Transactions must always be submitted as credit. Participants may review Flexible Spending Account balances online at CALL (866) 853-FLEX FOR MORE INFORMATION.» Physician Offices» Specialist Physician Offices» Dental Offices» Over-the-counter drugs (must be accompanied by a Physician s Rx)» Vision Care Providers» Medical Facilities» Medical Clinics» Hospitals, including Emergency Rooms PureLife2010-B4AKB5ACD9CW 25 14

17 Flexible Benefits Reimbursement Voucher PO Box , Houston, TX Telephone: (866) Fax: (800) PARTICIPANT INFORMATION ADDRESS CHANGE? Yes No NAME MAILING ADDRESS CITY STATE ZIP COMPLETE ONLY FOR DEPENDENT CARE PROVIDER NAME ADDRESS CITY STATE ZIP SS # TAX ID # SIGNATURE OF PROVIDER BENEFIT TYPE (please check as appropriate) ADDITIONAL FORMS AVAILABLE AT: and click on Participant Forms EMPLOYER SOCIAL SECURITY # ADDRESS TELEPHONE ( ) COMPLETE ONLY FOR ORTHODONTIA REIMBURSEMENT NAME AMOUNT DUE $ DATE SERVICE PERFORMED I certify that the dental procedure for the above patient HAS BEEN COMPLETED IS IN PROGRESS SIGNATURE OF DENTIST / ORTHODONTIST MEDICAL REIMBURSEMENT DEPENDENT CARE REIMBURSEMENT PREMIUM REIMBURSEMENT DATE OF SERVICE FAMILY MEMBER DESCRIPTION OF EXPENSE AMOUNT IMPORTANT NOTICE GRAND TOTAL ALL PAGES Effective January 1, 2011, all over-the-counter drugs eligible for reimbursement must be accompanied by a doctor s prescription and a reimbursement voucher. I hereby affirm that, to the best of my knowledge, all expenses listed above are eligible for reimbursement under Section 105(h) or 129 of the IRS Code and in accordance with my contract with First Financial Administrators, Inc. I further certify that these expenses have not been, nor will not be, reimbursed under any other health plan coverage. If you need verification of the eligibility of an expense, please contact First Financial Administrators, Inc. at Please send me additional envelopes (additional voucher given with every reimbursement) SIGNATURE NOTE: If you have direct deposit, First Financial Administrators, Inc. will not pay bank charges for Insufficient funds. Please call your financial Institution to verify deposit DATE before writing any checks on the amount $0.00 Mail or Fax Completed Form To: First Financial Administrators, Inc. P.O. Box , Houston, TX Fax Number: weekly premiums PureLife-plus Standard Risk Table Premiums Non-Tobacco Express/Simplified Issue Weekly Premiums for Life Insurance Face Amounts Shown Includes Added Cost for Non-Tobacco GUARANTEED PERIOD to Which Issue Accidental Death Benefit (s 17-59) Coverage is Guaranteed at (ALB) $10,000 $15,000 $20,000 $25,000 $50,000 $100,000 $150,000 $200,000 $250,000 Table Premium 15D PureLife-plus is permanent life insurance to Attained 121 that can never be cancelled as long as you pay the necessary premiums. After the Guaranteed Period, the premiums can be lower, the same, or higher than the Table Premium. See the brochure under Permanent Coverage. 15 PureLife2010-B4AKB5ACD9CW 24

18 Life Insurance Highlights For the employee purelife-plus Reimbursement Itemization Continued Flexible Premium Life Insurance to 121 Policy Form PRFNG-NI-10 DATE OF SERVICE FAMILY MEMBER DESCRIPTION OF EXPENSE AMOUNT Voluntary permanent life insurance can be an ideal complement to the group term and optional term your employer might provide. Designed to be in force when you die, this voluntary universal life product is yours to keep, even when you change jobs or retire, as long as you pay the necessary premium. Group and voluntary term, on the other hand, typically are not portable if you change jobs and, even if you can keep them after you retire, usually costs more and declines in death benefit. The policy, purelife-plus, is underwritten by Texas Life Insurance Company, and it has these outstanding features: High Death Benefit. With one of the highest death benefits available at the worksite, 1 purelife-plus gives your loved ones peace of mind, knowing there will be significant life insurance in force should you die prematurely. Minimal Cash Value. Designed to provide high death benefit, purelife-plus does not compete with the cash accumulation in your employer-sponsored retirement plans. Long Guarantees. Enjoy the assurance of a policy that has a guaranteed death benefit to age 121 and level premium that guarantees coverage for a significant period of time (after the guaranteed period, premiums may go down, stay the same, or go up). Refund of Premium. Unique in the marketplace, purelife-plus offers you a refund of 10 years premium, should you surrender the policy if the premium you pay when you buy the policy ever increases. (Conditions apply.) Accelerated Death Benefit Rider. Should you be diagnosed as terminally ill with the expectation of death within 12 months (24 months in Illinois), you will have the option to receive 92% (84% in Illinois) of the death benefit, minus a $150 ($100 in Florida) administrative fee. This valuable living benefit gives you peace of mind knowing that, should you need it, you can take the large majority of your death benefit while still alive. (Conditions apply.) You may apply for this permanent, portable coverage, not only for yourself, but also for your spouse, minor children and grandchildren. Like most life insurance policies, Texas Life policies contain certain exclusions, limitations, exceptions, reductions of benefits, waiting periods and terms for keeping them in force. Please contact a Texas Life representative for costs and complete details. 1 Voluntary and Universal Whole Life Products, Eastbridge Consulting Group, October 2008 See the purelife-plus brochure for details. MEDICAL REIMBURSEMENT SUBMISSION GUIDELINES: ACCEPTABLE DOCUMENTATION to accompany the reimbursement voucher: 1. Professional bill or receipt that includes:» Provider of service» Type of service rendered» Original date of service» Charges for the service 2. Insurance company Explanation of Benefits 3. Pharmacy statement that includes Rx number and name of the prescription DAYCARE SUBMISSION GUIDELINES: ACCEPTABLE DOCUMENTATION to accompany the reimbursement voucher: 1. Vouchers for Dependent Care signed by the Provider. Voucher must also be completed with the Provider s tax identification number or Social Security number and dates of service, Or Voucher with receipt from Provider, including Provider name, Provider signature, dates of service, amount for service, and tax identification/social security number. I.R.S Regulations prevent us from reimbursing dependent care yearly contracts. Monthly submissions are required. UNACCEPTABLE DOCUMENTATION 1. Cancelled checks / Credit card receipts 2. Bill or receipt that only shows a balance forward or previous balance 3. Cash register receipt Note: It is important to note that the date of service, not the date of payment, must fall within the dates of the plan year for which you are enrolled. SUB-TOTAL THIS PAGE $ M055-C 1040 (Expires 0612) 23 Not for use in WA. 16

19 Debit Card Agreement Medical reimbursement accounts only I ACCEPT RESPONSIBILITY FOR THE FOLLOWING: All card transactions will be solely for qualified expenditures incurred (not billed or paid) during the plan year; To the extent that if I misrepresent any card transaction as a qualified expenditure when it is a non-qualified expenditure, I hold you harmless for whatever penalties and consequences that may occur as a result of my actions; If I misrepresent any card transaction on a non-qualified expenditure, I must immediately repay all expenses to the account upon notification; if not repaid, I understand the amount will be considered taxable income. I agree to submit expense receipts to the third party administrator for all purchases when requested; If failure to substantiate, card will be suspended. Each time I present the card for payment, I will sign a receipt evidencing that the expense has been incurred and reaffirming my representation that it is a qualified expenditure that has not been and will not be reimbursed from any other source. DEBIT CARD VALID FOR 3 YEARS OF CONTINUAL PARTICIPATION PLEASE PRINT EMPLOYER NAME SOCIAL SECURITY NUMBER MAILING ADDRESS CITY / STATE / ZIP DAYTIME TELEPHONE NUMBER ADDRESS WAGES Community Action: 9 Pay Rates for Voluntary STD 0/7 Elimination Period / 3 Month Maximum Benefit Tobacco Premium $300 $400 $500 $600 $700 $800 $900 $1,000 $1,100 $1, $19.88 $25.51 $31.13 $36.76 $42.39 $48.01 $53.64 $59.27 $64.89 $ $21.68 $27.91 $34.13 $40.36 $46.59 $52.81 $59.04 $65.27 $71.49 $ $22.88 $29.51 $36.13 $42.76 $49.39 $56.01 $62.64 $69.27 $75.89 $ $24.28 $31.37 $38.47 $45.56 $52.65 $59.75 $66.84 $73.93 $81.03 $ $30.68 $39.91 $49.13 $58.36 $67.59 $76.81 $86.04 $95.27 $ $ $1,300 $1,400 $1,500 $1,600 $1,700 $1,800 $1,900 $2,000 $2,100 $2, $76.15 $81.77 $87.40 $93.03 $98.65 $ $ $ $ $ $83.95 $90.17 $96.40 $ $ $ $ $ $ $ $89.15 $95.77 $ $ $ $ $ $ $ $ $95.21 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $2,300 $2,400 $2,500 $2,600 $2,700 $2,800 $2,900 $3,000 $3,100 $3, $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $3,300 $3,400 $3,500 $3,600 $3,700 $3,800 $3,900 $4,000 $4,100 $4, $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $4,300 $4,400 $4,500 $4,600 $4,700 $4,800 $4,900 $5, $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ SIGNATURE DATE ADDITIONAL CARDS DEPENDENT CARDS ISSUED TO SPOUSES AND/OR DEPENDENT CHILDREN (AGES 18-26) NAME RELATIONSHIP DATE OF BIRTH PLEASE MAIL COMPLETED FORM TO: FIRST FINANCIAL ADMINISTRATORS, INC. PO BOX , HOUSTON TX PHONE: OR FAX:

20 WAGES Community Action: 36 Pay Rates for Voluntary STD 0/7 Elimination Period / 3 Month Maximum Benefit Tobacco Premium $300 $400 $500 $600 $700 $800 $900 $1,000 $1,100 $1, $4.97 $6.38 $7.78 $9.19 $10.60 $12.00 $13.41 $14.82 $16.22 $ $5.42 $6.98 $8.53 $10.09 $11.65 $13.20 $14.76 $16.32 $17.87 $ $5.72 $7.38 $9.03 $10.69 $12.35 $14.00 $15.66 $17.32 $18.97 $ $6.07 $7.84 $9.62 $11.39 $13.16 $14.94 $16.71 $18.48 $20.26 $ $7.67 $9.98 $12.28 $14.59 $16.90 $19.20 $21.51 $23.82 $26.12 $28.43 $1,300 $1,400 $1,500 $1,600 $1,700 $1,800 $1,900 $2,000 $2,100 $2, $19.04 $20.44 $21.85 $23.26 $24.66 $26.07 $27.48 $28.88 $30.29 $ $20.99 $22.54 $24.10 $25.66 $27.21 $28.77 $30.33 $31.88 $33.44 $ $22.29 $23.94 $25.60 $27.26 $28.91 $30.57 $32.23 $33.88 $35.54 $ $23.80 $25.58 $27.35 $29.12 $30.90 $32.67 $34.44 $36.22 $37.99 $ $30.74 $33.04 $35.35 $37.66 $39.96 $42.27 $44.58 $46.88 $49.19 $51.50 $2,300 $2,400 $2,500 $2,600 $2,700 $2,800 $2,900 $3,000 $3,100 $3, $33.10 $34.51 $35.92 $37.32 $38.73 $40.14 $41.54 $42.95 $44.36 $ $36.55 $38.11 $39.67 $41.22 $42.78 $44.34 $45.89 $47.45 $49.01 $ $38.85 $40.51 $42.17 $43.82 $45.48 $47.14 $48.79 $50.45 $52.11 $ $41.54 $43.31 $45.08 $46.86 $48.63 $50.40 $52.18 $53.95 $55.72 $ $53.80 $56.11 $58.42 $60.72 $63.03 $65.34 $67.64 $69.95 $72.26 $74.56 $3,300 $3,400 $3,500 $3,600 $3,700 $3,800 $3,900 $4,000 $4,100 $4, $47.17 $48.58 $49.98 $51.39 $52.80 $54.20 $55.61 $57.02 $58.42 $ $52.12 $53.68 $55.23 $56.79 $58.35 $59.90 $61.46 $63.02 $64.57 $ $55.42 $57.08 $58.73 $60.39 $62.05 $63.70 $65.36 $67.02 $68.67 $ $59.27 $61.04 $62.82 $64.59 $66.36 $68.14 $69.91 $71.68 $73.46 $ $76.87 $79.18 $81.48 $83.79 $86.10 $88.40 $90.71 $93.02 $95.32 $97.63 $4,300 $4,400 $4,500 $4,600 $4,700 $4,800 $4,900 $5, $61.24 $62.64 $64.05 $65.46 $66.86 $68.27 $69.68 $ $67.69 $69.24 $70.80 $72.36 $73.91 $75.47 $77.03 $ $71.99 $73.64 $75.30 $76.96 $78.61 $80.27 $81.93 $ $77.00 $78.78 $80.55 $82.32 $84.10 $85.87 $87.64 $ $99.94 $ $ $ $ $ $ $ Disability Income Plus Coverage type Benefit amount Plan design Benefit period Elimination period Definition of disability North Carolina School Districts Disability Income Plus provides a monthly disability income benefit as a result of a non-occupational off-the-job accident or sickness. If you re totally disabled by an accident or illness, Disability Income Plus can be there to help, helping pay the bills that won t go away just because you can t work: housing costs, food, car payments, and additional medical costs. You can focus on a full recovery and successful return to the workplace. Disability Income Plus is a group disability income insurance policy that provides a monthly disability income benefit due to a non-occupational off-the-job accident or injury. Minimum benefit of $300 and maximum benefit of $5,000 per month, not to exceed 65% of base monthly income. Accident & Sickness: Provides coverage for disabilities caused by either an accidental injury or sickness. Twelve months Provides non-occupational coverage for injuries after 0, 14 or 30 days and off-the job sicknesses after 7, 14 or 30 days of total disability (depending on your selection). Total disability: for the first 24 months of a disability that the employee/member is unable to perform the substantial and material duties of his or her regular occupation, not working in any other occupation, and under the care of a physician for the disability. After 24 months of total disability, totally disabled means that the employee/member is unable to perform the duties of any occupation, and under the care of a physician for the disability. Partial disability: because of a covered sickness or injury, the employee/member is working more than 20% but not more than 80% of the normal pre-disability schedule, and under the regular care of a physician. The normal pre-disability schedule is as defined by the employee/member s employer but does not include overtime. Recurrent disability: total and/or partial disability that is due to the same or related causes as a prior period of disability, follows a prior period for which a monthly benefit was paid, and occurs within 180 days after the end of a prior period for which a monthly benefit was paid. Optional benefit COBRA rider: Provides eligible candidates with reimbursement, minimum of $200 up to $2,000 per month, of COBRA premium when an employee is totally disabled, terminated, and receiving disability income benefits from inforce coverage. Benefit pays for the duration of the disability or until COBRA benefits terminate, whichever occurs first. This benefit pays in addition to the total disability benefit of the policy. Presented by Benefit amount selected Premium amount per paycheck 21 Insured by Kanawha Insurance Company, a Humana company. This is not a complete disclosure of plan qualifications and limitations. Your broker will provide you with specific limitations and exclusions as contained in the Regulatory and Technical Information Guide. Please review this information before applying for coverage. The amount of benefits provided depends on the plan selected. Premiums will vary according to the selection made. Policy: 8014 Underwritten by Kanawha Insurance Company HumanaVoluntaryBenefits.com