20 B 15 E N E F I T S G U I D E

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1 2015 BENEFITS GUIDE

2 CONTENTS Welcome Benefit Highlights 2 Healthcare Reform 3 Eligibility 4 Medical Plan Descriptions 5 Medical Plans at a Glance E M P L O Y E E B E N E F I T S DEAR VALUED EMPLOYEES, As a Company, Discount Tire/America s Tire/Discount Tire Direct (DTC/ATC/DTD) has made investments in benefits, programs and services that will help you and your family stay healthy. This enrollment guide is designed to help you understand our benefit offerings for 2015 and how and when to complete your benefits enrollment. DTC/ATC/DTD cares for and cultivates our people by making adjustments and enhancements to our benefits programs and continues to absorb most costs. We strive to keep your costs affordable while providing the best possible value and coverage. Please review all of your options before making a selection for Take this time to make adjustments you may need to ensure you and your family have the coverage that will help encourage and reward you in taking personal accountability for your health. Changes made during Annual Enrollment will be effective January 1, Medical Plan Contributions 7 Choosing the Right Plan 8 Using the Health Reimbursement Account 9 Dental Plan 10 Vision Plan 11 Flexible Spending Accounts (FSAs) 12 Wellness Program (K) Plan 14 Employee Assistance Program (EAP) 14 Life and Disability 15 How to Enroll/Enrollment Checklist 16

3 2015 BENEFIT HIGHLIGHTS IMPORTANT TO NOTE! Annual Enrollment ends Friday, October 24, Weekly contribution adjustment to Medical Plan. No contribution increase to all other plans. Complete Tobacco Free Affidavit and return to HR by October 24, Save $240 per year on your Medical Plan contributions!! A new Affidavit needs to be completed each year. Have your Physician complete the Physician Affidavit, add your signature and return it to HR by December 31, You and your spouse are eligible. Receive $50 gift card each. Great - West Financial completes purchase of Retirement Plan Services from J.P. Morgan The only changes you will see are the updated disclosures on your plan s web site and updated branding on the materials you will be receiving. 2

4 HEALTHCARE REFORM We understand Healthcare Reform is confusing and creates a number of questions. We continue to ensure the Company s Plans comply with the new health care regulations. Healthcare Reform requires all individuals to be covered under a medical plan. If you choose not to participate in our medical plan and are not covered in any other qualified plan you may be subject to an IRS penalty. HEALTHCARE REFORM To get more details on the health insurance plans available in the Health Insurance Marketplace, please visit MORE CHOICES! ENROLL OR STAY ON THE DTC/ATC/DTD PLAN ENROLL OR STAY ON YOUR SPOUSE S PLAN IF UNDER 26, ENROLL OR STAY ON YOUR PARENTS PLAN ENROLL IN THE HEALTHCARE.GOV MARKETPLACE GO WITHOUT COVERAGE (NOT RECOMMENDED) 3

5 ELIGIBILITY WHO IS ELIGIBLE TO ENROLL FOR BENEFITS? Employees: All full time employees are eligible for the DTC/ATC/DTD benefit plans after 90-days of full time employment. Dependents: Dependents eligible for coverage under the DTC/ATC/DTD benefit plans include your legal spouse and your child(ren) up to age 26, if they do not have access to other employer coverage. The definition of child includes any of the following: Your child A child placed with you for adoption Your stepchild A child for whom you have legal guardianship Your legally adopted child Your child for whom health coverage is required through a Qualified Medical Child Support Order (QMCSO) Information About Making Mid-year Changes! Please enroll your covered dependents in Medical, Dental, and Vision if needed. This is the only time during the year you may do so, unless a qualifying life event occurs as described below. Documentation is required if adding dependent(s). The only other time that you may make a change in your coverage during the year is if you have a qualifying life event in your family or employment status. Enrollees may change from one coverage type to another upon the occurrence of one of the qualifying life events listed below, as long as the election is made for the change in coverage within 31 days of the qualifying life event (or 60 days in the event of Children s Health Insurance Program). Changes will be effective on the date of the qualifying event. Below is an outline of Qualifying Life Events and the documentation needed to make a change to your benefit plan(s). Qualifying Life Event A change in marital status: Marriage Divorce Death of Spouse A change in the number of your dependents: Birth or adoption Death of a dependent Dependent(s) obtain their own coverage Termination or commencement of employment by employee, spouse, or dependent Any significant change in your family s health care plan coverage through your spouse s health care plan Change in a dependent s eligibility status (i.e. a dependent child exceeding the maximum age for coverage) Documentation Required Marriage Certificate Divorce Decree Death Certificate Birth Certificate/Adoption Agreement Death Certificate Proof of other coverage and effective date Documentation from the employer confirming prior coverage and effective date. Documentation from spouse s employer confirming change in coverage and effective date of change. Proof of the event (i.e. proof of child s date of birth) Once a qualifying life event occurs, you have 31 days from the date of the event to contact Human Resources and make changes to your benefit elections. It is imperative that you contact Human Resources, otherwise you may not be eligible to change your benefits election until next annual enrollment. 4

6 You have two medical insurance options. Each plan covers the same types of services, however, they differ in how much you will pay in your payroll contributions, co-payments, co-insurance, deductibles or a combination of these items, depending on the plan chosen. Find preferred providers at: Choice Plus Plan (PPO) Coverage through the Choice Plus Plan will provide you with access to the extensive United Healthcare (UHC) network of providers you have come to expect. It is the more traditional health care option with a deductible, set co-pays and co-insurance amounts. You are encouraged to use a provider in the UHC network to receive the most cost-effective benefits. If you use an out-of-network provider, your out-of-pocket costs will be greater. By enrolling in the Choice Plus Plan you have the option to elect the Flexible Spending Account. See details on page 12. Preventive care visits are provided at no cost to you. Consumer Plan MEDICAL PLAN DESCRIPTIONS UNITED HEALTHCARE (UHC) MEDICAL PLANS The Consumer Plan features a lower weekly premium cost, with a higher annual deductible. By enrolling in the Consumer Plan you will also be enrolled in a Health Reimbursement Account (HRA), which will help pay your first out-of-pocket deductible expenses up to $500 individual/ $1,000 family. See details on page 9. You will then pay any additional up front costs for all physicians visits, medical services, and prescriptions until you meet your annual deductible. If you stay in-network, you will pay the negotiated rate on these expenses. Once you meet the deductible, coverage is shared with the Company in a co-insurance arrangement until annual out-of-pocket limit is met. By enrolling in the Consumer Plan you have the option to elect the Flexible Spending Account. See details on Page 12. Prescriptions are not subject to the annual deductible and are covered under a co-pay. Preventive care visits are provided at no cost to you. 5

7 MEDICAL PLANS AT A GLANCE UNITED HEALTHCARE MEDICAL PLANS Benefit Annual Deductible In-Network Plan Pays Choice Plus Plan Out-of-Network Plan Pays In-Network Plan Pays Consumer Plan Out-of-Network Plan Pays Individual/Family $500/$1,500 $1,000/$3,000 $1,500/$3,000 $2,500/$5,000 Maximums Out-of-Pocket: Individual/Family $2,500/$6,500 $7,000/$18,000 $3,500/$7,000 $7,000/$14,000 Lifetime Maximum Unlimited Unlimited Unlimited Unlimited Office Visits Physician $20/visit 70%** 90%* 70%** Specialist $40/visit 70%** 90%* 70%** Preventive Care Routine physicals, immunizations, pap smear, mammogram, prostate screening, etc. Frequency limitations apply. Maternity Care 100% 70%** 100% 70%** Prenatal Visit $40 70%** 90%* 70%** Postnatal Visits/Surgery 90%* 70%** 90%* 70%** Care Urgent Care $40/visit 90%* 90%* 90%** Emergency Room $200 $200 90%* 90%** Hospital Care 90%* 70%** 90%* 70%** Outpatient Surgery 90%* 70%** 90%* 70%** Prescription Drugs Retail Pharmacy/Mail Order *Co-Pays not subject to the annual deductible. Retail (30 day supply) Mail Order (90 day supply) Retail (30 day supply) Mail Order (90 day supply) Tier 1 $10 $20 $10 $20 Tier 2 $30 $60 $30 $60 Tier 3 $60 $120 $60 $120 Tier 4 $90 $180 $90 $180 *After deductible **When you receive out-of-network care, the plan covers its percentage up to the Reasonable and Customary (R&C) limit, after you satisfy the Annual Deductible. You pay the remaining percentage up to the R&C limit plus any amount above the R&C limit. 6

8 Wellness Rate: Save on 2015 Medical Benefits! We are pleased to provide a special Wellness Rate for 2015 medical plan contributions. Employees who complete a Tobacco Free Affidavit declaring they are tobacco free or enrolled in a tobacco cessation program are eligible. Complete the affidavit in your packet and return it to Human Resources by Friday, October 24, MEDICAL PLAN CONTRIBUTIONS Be sure to visit It contains valuable tools and resources to get the most out of your benefits so you and your family may lead a healthier lifestyle. 7

9 CHOOSING THE RIGHT PLAN The chart below helps you determine which plan may be the best solution for you if you were to utilize UHC s network of providers. Claim Amounts Add up the total cost of claims you anticipate in This will give you the annual claim amount listed in the tires below. When determining the annual claim amount, consider your plans in Do you anticipate an outpatient surgery? Are you and your spouse expecting? Annual Estimated Out-of-Pocket Expenses Coverage Level Who is covered for benefits in your family for 2015? Just You? Spouse? Children? Family? In the chart below, determine which category best reflects your coverage for 2015 and look at the two columns beneath the category. After determining your anticipated Annual Claim Amount and Coverage Level review the two corresponding columns in the chart below. The green highlighted boxes may be the most cost effective choice. Please note: this chart does not incorporate co-pays, (it only includes payroll contributions for medical coverage and deductible/coinsurance). Which Plan is Right for Me? Based on your anticipated claim amount, identify the annual claims total on the chart below. Then, look at the coverage level anticipated for The plan highlighted in green is the plan which may be ideal for you. Annual Claim Amount $50,000 $25,000 $15,000 $10,000 $7,500 $5,000 $2,500 $1,500 $1,000 $500 $100 $0 Coverage Level Employee Only Employee + Spouse Employee + Child(ren) Employee + Family PPO Consumer PPO Consumer PPO Consumer PPO Consumer $3,771 $4,509 $5,841 $9,901 $5,551 $9,854 $10,865 $8,635 $3,771 $4,509 $5,841 $8,101 $5,551 $8,054 $8,365 $8,635 $3,221 $3,859 $5,841 $7,101 $5,551 $7,054 $7,365 $7,835 $2,721 $3,359 $5,741 $6,601 $5,451 $6,554 $6,865 $7,335 $2,471 $3,109 $5,491 $6,351 $5,201 $6,304 $6,865 $7,085 $2,221 $2,859 $5,241 $6,101 $4,951 $6,054 $6,365 $6,835 $1,971 $2,609 $4,991 $5,401 $4,701 $5,354 $6,115 $6,135 $1,871 $2,509 $4,891 $4,401 $4,601 $4,354 $6,015 $5,135 $1,821 $2,009 $4,841 $3,901 $4,551 $3,854 $5,515 $4,635 $1,771 $1,509 $4,341 $3,401 $4,051 $3,354 $5,015 $4,135 $1,371 $1,109 $3,941 $3,001 $3,651 $2,954 $4,615 $3,735 $1,271 $1,009 $3,841 $2,901 $3,551 $2,854 $4,515 $3,635 8

10 WHAT IS AN HRA? Many people are concerned about being able to pay their out-of-pocket expenses. DTC/ATC/DTD contributes dollars ($500 individual / $1,000 employee + any dependent coverage level) to the HRA that helps offset the initial medical plan deductible expenses you would otherwise be responsible to pay. How the Plan Works 1. Your HRA pays the first $500 / $1,000 of your deductible expenses. Remember, preventive care services, in network, are covered at 100% throughout the plan year and do not come out of your HRA. 2. Once the money DTC/ATC/DTD contributes has been used, you will be responsible for paying the full cost until you have paid any annual remaining deductible. 3. After you reach the deductible, the plan begins to pay. The plan will pay a percentage of your covered medical expenses. Once your deductible and co-insurance payments add up to the plan s out-of-pocket maximum in-network ($3,500 individuals / $7,000 employee + spouse, employee + child(ren) or family), the plan pays 100% of all eligible expenses for the rest of the year. 4. Any money left in your HRA account at the end of the year rolls over to the following year (up to maximum $4,000). IT S POSSIBLE THE MONEY IN THE HRA MAY BE ENOUGH TO COVER ALL YOUR COSTS FOR THE YEAR. THIS MEANS YOU WOULD PAY NOTHING OUT OF POCKET. The Consumer Plan Coverage Annual Deductible DTC/ATC/DTD Annual Contribution Remaining Deductible to be Satisfied A B A minus B Total Out-of-Pocket Maximum In-Network Single/Family $1,500/$3,000 $500/$1,000 $1,000/$2,000 $3,500/$7,000 Out-of-Network Single/Family $2,500/$5,000 $500/$1,000 $2,000/$4,000 $7,000/$14,000 Using your Consumer Plan/HRA when visiting the Doctor 1SHOW YOUR MEDICAL ID CARD TO DOCTOR. AN IN-NETWORK DOCTOR WILL SEND YOUR CLAIM 2 TO UHC; OR AN OUT-OF-NETWORK DOCTOR WILL BILL YOU. UHC WILL TAKE THE MONEY OUT OF YOUR HRA ACCOUNT 3 AND PAY THE DOCTOR. ONCE YOUR DEDUCTIBLE IS MET, UHC WILL PAY THE APPLICABLE CO-INSURANCE. YOU ARE RESPONSIBLE FOR PAYING ANY REMAINING 4 BALANCE TO THE DOCTOR DIRECTLY OUT-OF-POCKET (CASH, CHECK OR CREDIT CARD). USING THE HEALTH REIMBURSEMENT ACCOUNT 9

11 DENTAL PLAN DELTA DENTAL OF ILLINOIS Your dental benefits are offered through Delta Dental. You have access to a national network of preferred providers. Although you are not required to use these providers, benefits are enhanced when selecting providers within the preferred network. Find preferred providers at: or download the smart phone Delta Dental app. Benefit Annual Deductible PPO Network Plan Pays Premier Network Plan Pays Out-of-Network Plan Pays Individual/Family $50/$150 $50/$150 $50/$150 Maximum Benefits Annual Max Per Individual $1,750 $1,750 $1,750 Lifetime Maximum Unlimited Unlimited Unlimited Preventive Services Include: Oral Evaluations, X-Rays and Cleanings (2 cleanings/year) Basic Services Include: 100%* of reduced fee 100%** of MPA 100%*** of MPA Fillings, Extractions, Endodontics 80%* of reduced fee 80%** of reduced fee 80%*** of reduced fee Major Services Include: Implants, Inlays, Onlays, Crowns, Bridges and Prosthodontics Orthodontia 50%* of reduced fee 50%** of reduced fee 50%*** of reduced fee Coverage Level 50% of reduced fee 50% of dentist s fee 50% of dentist s fee Lifetime Maximum $2,000 $2,000 $2,000 * You will not be balance billed for charges exceeding Delta Dental s allowed PPO fees. ** You will not be balance billed for charges exceeding Delta Dental s maximum plan allowances (MPAs) *** You are responsible for charges exceeding Delta Dental s maximum plan allowances (MPAs) FSA dollars can be used for dental services. 10

12 SUPERIOR VISION Vision benefits are offered through Superior Vision. You can choose any provider you like, however, you save money when using an innetwork provider. With Superior Vision, there is a large number of in-network providers for you to consider. Find an in-network provider, or confirm your current provider is in the network, at: The vision plan is a voluntary benefit: 100% employee paid. Benefit Exams (once every 12 months): In-Network Plan Pays Out-of-Network Reimbursement Exams/Screenings 100% $34 Lenses (once every 12 months): Single Vision 100% $29 Bifocal 100% $43 Trifocal 100% $53 Frames (once every 12 months): Retail Chain Provider $130 allowance $65 Contacts - in lieu of eyeglasses (once every 12 months): Elective $125 allowance $100 allowance FSA dollars can be used for vision services. VISION PLAN 11

13 FLEXIBLE SPENDING ACCOUNTS (FSA) HEALTH AND DEPENDENT CARE FLEXIBLE SPENDING ACCOUNTS DTC/ATC/DTDs Flexible Spending Accounts (FSA) can help you save money. By paying for eligible health care and dependent care expenses for you or your qualified dependent(s) with an FSA, you reduce your taxable income and pay no federal, state or social security taxes on the money used for those expenses. You must enroll each year to participate. Health Care Flexible Spending Account Save money by using the Health Care FSA for eligible medical, pharmacy, dental and vision expenses for you and your dependents. This includes but is not limited to, the cost of co-pays, co-insurance, eye glasses, orthodontia, chiropractic care, and eligible over-the-counter drugs. For plan year 2015, the maximum amount you can contribute to your Flexible Spending Account is $2,500. The plan contains a Use It Or Lose It provision so plan carefully! Benefits terminate when you leave the company. For a list of eligible expenses, visit: You must enroll each year for Health & Dependent Care Flexible Spending Accounts. Dependent Care Flexible Spending Account You can use the Dependent Care FSA to pay eligible child care (up to age 13) and elder care expenses that you incur because you and your spouse work. By law, the maximum amount that you may contribute to any Dependent Care Flexible Spending Account for your family is $5,000, or $2,500 if you are married and filing a separate return each calendar year. The plan contains a Use It Or Lose It provision plan carefully! Benefits terminate when you leave the company. In addition, your provider of care must furnish you with either his/her Social Security Number or Tax Identification Number. For a list of eligible expenses, visit: Estimate your expenses today by visiting employees/benefits/healthcare-flexible-spending-accounts-fsa.aspx for healthcare FSAs or dependent-care-flexible-spending-account-fsa.aspx for Dependent Care FSAs or using the example provided below. Employee Tax Savings Illustration Without FSA Accounts With FSA Accounts Weekly Earnings $ $ Account Deposit (Before Taxes) $0 $20 Medical + $100 Daycare Taxable Wages $ $ Taxes: Federal 15%, FICA 7.65%, State 5% $ $ Expense (After tax) $ $0 Net Take Home Pay $ $ Weekly Savings $33.18 Annual Savings $1, Managing your account is easy. With a variety of payment and reimbursement options, your WageWorks Healthcare FSA is easy to use. The convenient WageWorks Healthcare Card associated with your account will give you swipe-and-go convenience without the hassle of submitting receipts. You also have the option to submit your receipts using the WageWorks EZ Receipts mobile app. When you access your FSA account online, you can submit claims, check your balance and access forms. You can also: View claim status View claim history Add a dependent Sign up for electronic notifications 12

14 WELLNESS DTC/ATC/DTD proudly offers a Wellness Program at no cost to you as part of our comprehensive medical program. By taking better care of ourselves, we have the opportunity to live healthier lives, as well as reduce future unnecessary medical costs. The Wellness Program is integrated with your medical benefit plan, UnitedHealthcare (UHC). Your wellness benefits include: Health Assessment (HA) Online questionnaire can be completed in approximately 15 minutes Provides you with a detailed report of your personal health that can be discussed with your doctor or a UHC Health Coach You are encouraged to take the HA every year to track your progress Log onto and select the Health & Wellness tab to take your HA today Care Coordination WELLNESS PROGRAM HealtheNotes Messages Nurseline at Healthy Pregnancy at Health Coaching UHC s online coaching programs are designed to guide you down a path of personalized health and well-being. Customized for you, the interactive online coaching provides you with support every step of the way including: Weekly To-Do Lists Tools & Trackers Meal Plans Messaging to Keep You Motivated Care Management This program is designed for individuals who are living with a chronic condition or dealing with complex health care needs. Simply call the number on the back of your UHC medical ID card to speak directly to a nurse. If you re dealing with complex health care needs, living with a chronic condition, or if you are identified as at-risk based on your HA completion, you may be contacted by a registered nurse who can help you better manage your health care needs and improve your quality of life. You will: Receive support with understanding and following your doctor s treatment plan Learn more about a condition Receive health, well-being and preventive care information Preventive Services Our benefit plans offer preventive services paid at 100% when an In-Network provider is used. We offer this benefit enhancement to encourage you and your family to visit your doctor to get the preventive screenings needed to keep you healthy. Routine Physical Examinations Immunizations Well-Baby and Well-Child care Well-Woman Care and PAP tests PSA Screening Colonoscopy Mammograms Hearing Screenings 13

15 401(K) PLAN 401(K) PLAN Planning for your retirement is nothing to play around with. The Company makes contributing to your future a win/win situation. We take your retirement seriously and encourage you to save by matching your contributions 100% up to the first 3% of compensation and 50% up to 6% of compensation you contribute to the Company 401(k) plan. If your weekly deferral is: Your annual contribution would be*: The annual company match would be: Total annual account contribution would be: 4% $1,600 $1,400 $3,000 5% $2,000 $1,600 $3,600 6% $2,400 $1,800 $4,200 *based on an annual salary of $40,000 Any employee who is age 21 or older and has completed 1,000 hours of service is eligible to participate. The investment company for the Company 401(k) plan is Great-West Financial. To take full advantage of the company match, visit the Great-West Financial website at or call *Employer matching contributions are invested in your account quarterly. You are 100% vested in the employer matching contributions after 3 years of service. EMPLOYEE ASSISTANCE PROGRAM (EAP) EMPLOYEECONNECT PLUS EMPLOYEE ASSISTANCE PROGRAM (EAP) DTC/ATC/DTD is concerned about your total well-being and provides a free, confidential resource to you and your family. The EAP program is provided by EmployeeConnect Plus to help you manage problems before they affect your personal life, health and job performance. Call , or visit them online at (Web ID = Lincoln). What is an EAP? An EAP is a confidential counseling service that is available 24 hours a day, 365 days a year. The service is available via a toll-free number and is staffed by professionals and experienced clinicians to help address personal issues which might be affecting you and/or your family. Some of the reasons you might use an EAP include, but are not limited to: Personal/family issues Work concerns/work-related stress Financial concerns Substance abuse How Does the Program Work? Relationship issues (at work or at home) Legal Childcare referrals Eldercare referrals When you call the EAP, a counselor will spend time with you or your family member on the phone to identify the issue, gather information and provide personal assistance. When appropriate, the EAP counselor will help schedule an appointment with an EAP Plus affiliate for a face-toface meeting. All of the EAP Plus counselors and affiliates are licensed by state governing agencies. Up to 6 sessions are provided free of charge to each employee or family member per issue. 14

16 LINCOLN FINANCIAL GROUP Basic Life Insurance and AD&D Life insurance needs vary greatly from one individual to the next. The insurance benefits through DTC/ATC/DTD offer you a way to protect your family s financial security in case of injury or death. Additional Life Insurance DTC/ATC/DTD offers employees the flexibility to purchase additional coverage - and increase your peace of mind - with Additional Life coverage for you and your dependents. The cost of this coverage is deducted from your pay through payroll contributions. The benefit amount reduces at age 65. Benefits terminate when you leave the company. You may change your beneficiary in Workday during Annual Enrollment. Your coverage options are summarized in the following chart: Basic & Additional Life Options (Employee Paid) Who is Covered? Employee Basic Life and AD&D Additional Life Spouse Life* Child(ren) Life* (If you elect Child Life it will cover all of your children) Benefit 1.5x base salary to a maximum of $50,000 $10,000 increments up to the lesser of 7x base salary or $500,000 $5,000 increments to 50% of the Employee s additional benefit up to $100,000 $5,000 or $10,000 *Must have additional life insurance to elect spouse or child life insurance. Note: You must designate a beneficiary for your benefits under the Life Insurance program. You have the right to change the beneficiary at any time by completing a benefit change form and faxing the form to HR. LIFE AND DISABILITY Why Do I Need a Beneficiary? Your beneficiary is the person(s) or entity(ies) who will receive the cash benefit from your policy when you die. When you designate beneficiaries, you have the final say over who receives your death benefit. If you don t choose one, your state s laws determine who receives the proceeds. Disability Insurance Short Term Disability You may purchase Short Term Disability for yourself. This benefit is designed to replace 60% of your income, up to a maximum of $1,200 per week, if you are unable to work due to a non-work related short term illness or injury. This benefit pays for up to 24 weeks. The cost for this benefit is based on your annual earnings. Long Term Disability You may also purchase Long Term Disability for yourself. This plan provides 60%, up to a maximum of $6,000 per month, of your income beginning after 180 days of continuous disability. The cost for this benefit is based on your annual earnings and age. Please refer to the weekly rates table provided as a separate handout within your enrollment materials to see the weekly cost. Plan Benefits Begin Duration of Benefits What You Will Receive Up to a Maximum of Short Term Disability Plan 15 th day of absence from work due to an illness/injury Up to 24 weeks (after waiting period) 60% of basic weekly earnings* $1,200/week Long Term Disability Plan After 180 days of disability As determined by the Plan 60% of monthly earnings* $6,000/month *Earnings are defined based on your employment class. Pre-existing condition limitation may apply. Please refer to the Summary Plan Description for more information. 15

17 HOW TO ENROLL/ENROLLMENT CHECKLIST 1. Complete Your Enrollment Detailed instructions are in the Quick Reference Guide located in the front pocket of this packet. Please log into Workday to review your benefit coverage. Complete the online enrollment only if you are making any changes to your current benefit elections. If you want to: Enroll in the Medical, Dental and/or Vision plans for the first time Make a change to your current benefits: Medical, Dental and Vision Add or cancel benefits for your dependent(s) Participate in WageWorks Healthcare and/or Dependent Care Flexible Spending Accounts for 2015 Apply for Basic, Additional, Spouse and/or Child Life for the first time (evidence of insurability is required) Apply to increase the amount of your Additional, Spouse and/or Child Life for the first time (evidence of insurability is required) Apply for Short Term Disability and/or Long Term Disability for the first time (evidence of insurability is required) Waive coverage completely: medical, dental, vision, life or disability Change your life insurance beneficiary 2. Complete Your Tobacco Free Affidavit DUE BY FRIDAY, OCTOBER 24 TH, 2014 LOG INTO WORKDAY AT: Are you tobacco free? Don t miss out on DTC/ATC/DTD s $240 annual Wellness Rate on your 2015 medical plan contributions. See page 7 for more details! Affidavits are located in the front pocket. The deadline to submit the Tobacco Free Affidavit is Friday, October 24 th, Complete Your Physician Affidavit Have you had your 2014 physical? Make sure you get your physical and have the Physician Affidavit signed for the opportunity to receive a $50 gift certificate. If your spouse gets a physical, they will also receive a $50 gift certificate. The deadline to submit the Physician Affidavit is Wednesday, December 31 st, If you received the Wellness Rate in 2014, you will need to complete the Tobacco Free Affidavit again to continue receiving the discount in

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