Premium Chart for Aetna Term Life Insurance

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1 Premium Chart for Aetna Term Life Insurance Physician Premiums PLEASE NOTE 1) Your premium amount is the number located in the table cell where your age and desired coverage intersect. Up to $200,000 in guaranteed issue coverage available to physicians. 2) If you are adding a spouse to your policy, add their premium rate to your premium rate to calculate your total monthly premium. 3) If you select dependent child(ren) coverage, add a total of $1.10 to your monthly premium. 4) If you have any questions please call Age Range Employee Coverage Amount (Monthly Premium) Spouse Coverage Amount (Monthly Premium) $100,000 $150,000 $200,000 $25,000 $50,000 Under 30 $10.50 $15.75 $21.00 $1.75 $ $13.50 $20.25 $27.00 $2.50 $ $14.50 $21.75 $29.00 $2.75 $ $16.50 $24.75 $33.00 $3.25 $ $20.50 $30.75 $41.00 $4.25 $ $31.50 $47.25 $63.00 $7.00 $ $52.50 $78.75 $ $12.25 $ $74.50 $ $ $17.75 $ $ $ $ $32.00 $ $ $ $ $51.25 $ Over 74 $ $ $ $57.75 $ Dependent Child Coverage Amount (Monthly Premium) All child(ren) 14 days to age 19 (23 if full time student)are eligible for coverage. One monthly rate installment of $1.10 covers all eligible child(ren) Coverage Amount Rate $10,000 $1.10

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3 Aetna Vision SM Preferred Benefits Summary Aetna Vision Network In-Network Out of Network Please note: The availability of certain vision plan designs may Maximum Plan Benefit vary by state. Service Frequencies: Comprehensive Exam Lenses (including contacts lenses) 1 Frames Routine/Comprehensive Eye Exam Benefit $10 Copay 1 every rolling 12 months 1 every rolling 12 months 1 every rolling 24 months Up to $25 Reimbursement Exam Options: Standard Contact Lens Fit and Follow-Up Member pays discounted fee Not Covered Premium Contact Lens Fit and Follow-Up Member pays discounted fee Not Covered Frames Any available frame at provider location $150 Plan Allowance. Member pays 80% of balance over $150 Plan Allowance Up to $75 Reimbursement Standard Plastic Lenses Single Vision $25 Copay Up to $10 Reimbursement Bifocal $25 Copay Up to $25 Reimbursement Trifocal $25 Copay Up to $55 Reimbursement Lenticular $25 Copay Up to $55 Reimbursement Standard Progressive Lens Member Pays $90 Up to $25 Reimbursement Premium Progressive Lens Member Pays $90 Up to $25 Reimbursement $120 Plan Allowance. Member pays 80% of charges over $120 Plan Allowance Lens Options: UV Treatment Member Pays $15 Not Covered Tint (Solid and Gradient) Member Pays $15 Not Covered Standard Plastic Scratch Coating $0 Copay Up to $15 Reimbursement Standard Polycarbonate - Adults Member Pays $40 Not Covered Standard Polycarbonate - Kids under 19 $0 Copay Up to $35 Reimbursement Standard Anti-Reflective Coating Member Pays $45 Not Covered Polarized Member Pays 80% of Retail Not Covered Contact Lenses (Contact lens reimbursement includes materials only) Conventional $150 Plan Allowance. Member pays 85% of balance over $150 Allowance Up to $105 Reimbursement Disposable $150 Plan Allowance. Member pays Up to $105 Reimbursement 100% of balance over $150 Allowance Medically Necessary $0 Copay $200 Reimbursement Laser Vision Correction 15% off retail price or 5% off Not Covered Lasik or PRK from U.S. Laser Network 2 promotional price Second Pair Discount Members can receive up to 40% off Not Covered additional pairs of eyeglasses. Additional discounts are available on contact lens purchases. Use of this program is unlimited. Tiers Monthly Rates Retail Chains Employee Only $9.61 Lenscrafters Employee & Spouse $18.26 Pearle Vision Employee & Child(ren) $19.22 Sears Employee & Family $28.25 Target JC Penney

4 1 During each benefit period the plan allows for EITHER lenses or contacts. 2 Lasik or PRK from the US Laser Network, owned and operated by LCA Vision. This material is for Additional f Discounts: Members receive a 20% discount After initial purchase, Benefit allowances provide no Providers participating in the Partial list of exclusions and limitations - Coverage is not provided for the following: Special vision procedures, such as orthoptics, vision therapy, or vision training. Vision services that are For an eye exam which: Is For prescription sunglasses or Replacement of lost, stolen or broken prescription lenses or frames. Any exams given during your stay in a hospital or other facility for medical care. Other exclusions and limitations may apply. Please refer to your plan documents for additional informat Vision plans are underwritten by Aetna This quote is based on a contract situs

5 ATTENTION Retain a copy of this sheet and your application for your records. 1. This Offer is Only for MASA Physician Members and their Staff. If you are a physician and not a member of MASA you must join in order to be eligible for these member benefits. To join visit or call (800) This is an active at work benefit. If you leave your current employment, it is your responsibility to notify customer service at in order to retain coverage. 3. If you have questions about your benefit or need to obtain claims forms, please contact customer service at or online at

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7 Aetna Term Life Insurance/Vision SM Preferred Enrollment Form Aetna Life Insurance Company Form Code: Retain a copy of this form for your records as documentation of your elections under this group coverage.* The Aetna Life Insurance Certificate can be obtained at under the Form section. Employee Information Name Home Address City/State/Zip Social Security Number Birthdate Home Telephone Number Work Telephone Number Practice Name Occupation/Title Circle One: Active Employee Y/N On COBRA Y/N Date of Hire Product Selection Select desired coverage by placing an X in the appropriate box. Refer to the rate chart on the attached page to calculate Premium amount. If selecting dependent or spouse coverage add indicated amount to total premium. For larger coverage amounts call to complete additional paperwork. Spouse is only eligible for a maximum of half employee s selected coverage amount. Up to $200,000 in guaranteed issue coverage available to physicians. Vision *Pick one Premium Single $9.61 Employee & Spouse $18.26 Employee & Child(ren) $19.22 Employee & Family $28.25 None Life/AD&D *Pick one in each category Employee Spouse Dependent Life $100,000 $25,000 Yes No $150,000 $50,000 $10,000 for all $200,000 None dependents. None *$1.10 Rate Includes All Children $ + $ + $ = $ Employee Spouse Dependent Total Premium Covered Spouse/Dependents If adding dependents to coverage, provide their information below. *Child age limit for Life Insurance is 14 days to 19 years (23 if student). Child age limit for Vision Insurance is 14 days to 26 years. You must provide SS # for spouse and all dependents. If dependents address is different than the one listed above, please write on additional sheet of paper and send back with completed application. Name Social Security # Relationship Date of Birth F/T Student Vision Life 1. Yes No Yes No Yes No 2. Yes No Yes No Yes No 3. Yes No Yes No Yes No 4. Yes No Yes No Yes No 5. Yes No Yes No Yes No *Enrollment of myself and the listed dependents into the plan is only effective upon acceptance by Aenta Life Insurance Company. Coverage and benefits are contingent on timely payment of premiums and may be terminated as provided in the contract. Signature Required On Back

8 Beneficiary Information If applying for Term Life Insurance, indicate desired beneficiary information below. Name Social Security Number Relationship Conditions of Enrollment Applicant Acknowledgments and Agreements. On behalf of myself and the dependents listed on Page 1, I agree to or with the following: 1) I acknowledge by enrolling in an Aetna Life Insurance Company group policy, coverage is provided by Aetna Life Insurance Company in accordance with the group contract. 2) I agree that this enrollment application is authorization of my participation under the group policy. Enrollment of myself and the listed dependents into the plan is effective on acceptance by Aenta Life Insurance Company. 3) I know that I have a right to receive a copy of this enrollment form if I request one. 4) I agree that a photocopy of this enrollment form is as valid as the original. 5) Coverage and benefits are contingent on timely payment of premiums and may be terminated as provided in the contract. 6) I acknowledge that by enrolling in an Aetna Vision SM Preferred plan, coverage is underwritten by Aetna Life Insurance Company (referred to as Aetna) and that certain claims adjudication and other administrative services are provided by First American Administrators, Inc. (an affiliate of EyeMed Vision Care, LLC) and/or affiliates. 7) I understand and agree that this Enrollment Form may be transmitted to Aetna or its agent by my employer or its agent. I authorize any physician, optometrist, other healthcare professional, hospital or any other healthcare organization ( Providers ) to give Aetna or its agent information concerning the medical history, services or treatment provide to anyone listed on this Enrollment Form, including those involving payors, other insurers, third party administrators, vendors, consultants and governmental authorities with jurisdiction when necessary for my care or treatment, payment for services, the operation of my health plan, or to conduct related activities. I have discussed the terms of this authorization with my spouse and competent adult dependents and I have obtained their consent to those terms. I understand that this authorization is provided under state law and that it is not an authorization within the meaning of the federal Health Insurance Portability and Accountability Act. This authorization will remain valid for the term of the coverage and so long thereafter as allowed by law. I understand I am entitled to a copy of this authorization upon request and that a photocopy is as valid as the original. 8) I understand and agree that, with exception of Aetna Rx Home Delivery, all participating providers and vendors are independent contractors and are neither agents nor employees of Aetna. Aetna Rx Home Delivery, LLC, is a subsidiary of Aetna Inc. The availability of any particular provider cannot be guaranteed and provider network composition is subject to change. Notice of the change shall be provided in accordance with applicable state law. 9) I certify that all information on this form is true and complete to the best of my knowledge and belief. I understand that the effective date of insurance for myself or for any of my dependents is subject to my being actively at work as a full-time employee on that date and that the effective date of insurance for any of my dependents is also subject to the dependent health condition requirements of the Plan. Further, I understand that any insurance subject to evidence of good health or medical information will not become effective until Aetna gives its written consent. I understand that, in the event I fail to sign this form within 31 days of the effective date of eligibility or that for any reason Aetna does not receive notice of the Enrollment Request within a reasonable time following the event, my and my dependents eligibility may be affected. 10) Collateral Benefits Group (CBG) is the marketing partner for MPRG. CBG makes no claims or warranty about the validity, the continuity, or the continuation of coverage. For questions about this coverage, review a copy of the certificate on Misrepresentations: Any person who includes any false or misleading information on a Application/Change Request Form for a benefits plan is subject to criminal and civil penalties. Signature - Required I certify that all information supplied in this form is true and complete to the best of my knowledge and belief. I have read and agree to the Conditions of Enrollment and Misrepresentation on the Employee Enrollment form. I understand that if I leave my current employment, it is my responsibility to contact customer service in order to complete the appropriate paperwork for portability of coverage. Applicant Signature Date Must Have Bank Draft Authorization Attached or Enrollment Application Will Not Be Processed

9 Bank Draft Authorization Form Group Name: MASA Form Code: Insuree s Personal Information. Name: Telephone Number ( ) Address: (Street) (Apt/Suite) (City) (State) (Zip) Write-in product name and premium amount (monthly) for selected coverage in space provided. Provide premium total plus processing fee amount in the Authorization Total section. Product Premium Product Premium Product Premium Processing Fee $2.00 (monthly) Authorization Total $ Payor s Information. Copy Routing Number and Account Number from account you wish to use for bank draft deductions into spaces below. Check appropriate box to indicate whether account is Checking or Savings. *Attach copy of voided check or savings deposit to back. Checking Savings Name on Account: Routing Number: Account Number: I authorize carrier and/or its designee Southland Benefit Solutions ( Southland ) to collect premiums via electronic funds transfer, or to affect a charge by any other commercially accepted practice in connection with the premium contribution. The attached voided check/withdrawal slip shows the account number from which deductions should be made. This authorization will apply to any renewal or change later made in the policy/certificate and in no way affects the terms of the policy(ies)/certificates(s) described above. I authorize the Southland to vary the transfer amount without notice in order to maintain the policy in force in accordance with its terms. If I change my financial institution or my account number, or wish to discontinue this agreement, I agree to give 30 days written notice to Southland. Notice to the financial institution without notice to Southland is not sufficient. Southland may terminate this agreement if any debit is not paid upon presentation, or upon 30 days written notice. Southland assumes no responsibility for bank charges. If any payment is returned unpaid, I authorize Southland to make a one-time electronic fund transfer from my account to collect a return fee of $ This fee will be assessed on each regularly scheduled monthly draft returned unpaid. This authorization will remain in effect until termination by either party. If the individual policy premium changes due to a rate increase, alternate plan selection, or age migration of the policy holder, this authorization will automatically be amended to authorize withdrawal of an amount equal to the new premium. I agree that if such electronic debit be dishonored, whether with or without cause, Southland shall be under no liability whatsoever even though such dishonor may result in the loss of insurance or other benefit program. Sign Authorization and Attach voided check to form. Authorization Signature: Date: Southland Benefit Solutions, LLC P. O. Box 1250 Tuscaloosa, AL