Select Benefit Services Association. Membership Includes: Select Benefit Services Association

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1 Select Beneft Servces Assocaton Membershp Includes: 24 HOUR ACCIDENT COVERAGE ACCIDENTAL DEATH AND DISMEMBERMENT BENEFITS LIFESTYLE DISCOUNTS AND SERVICES MEDICAL DISCOUNTS Select Beneft Servces Assocaton ADHV28-10 (Rev. 1/2014) 15B942

2 The Benefts of Havng Accdent Coverage An accdent can happen when you or one of your famly members least expect t! GTL s 24 Hour Accdent plan provdes you wth the comfort and the coverage you need for those unexpected expenses. Guarantee Trust Lfe Insurance Company has desgned the 24 Hour Accdent plan to provde you wth the protecton you need wth several optons to choose from. Accdent Coverage Optons: Issue Ages OPTION ONE 1 $40.00 $22.00 $2,500 Accdent Medcal Coverage - $250 Deductble $2,500 Accdental Death and Dsmemberment OPTION TWO 2 $54.00 $28.00 $5,000 Accdent Medcal Coverage - $250 Deductble $5,000 Accdental Death and Dsmemberment OPTION THREE $7,500 Accdent Medcal Coverage - $250 Deductble $7,500 Accdental Death and Dsmemberment OPTION FIVE 3 $68.00 $ OPTION FOUR 5 $87.00 $ OPTION SIX $12,500 Accdent Medcal Coverage - $250 Deductble $12,500 Accdental Death and Dsmemberment $82.00 $10,000 Accdent Medcal Coverage - $250 Deductble $10,000 Accdental Death and Dsmemberment $90.00 $40.00 $42.00 $15,000 Accdent Medcal Coverage - $250 Deductble $15,000 Accdental Death and Dsmemberment OPTION SEVEN 7 $97.00 $45.00 $20,000 Accdent Medcal Coverage - $250 Deductble $20,000 Accdental Death and Dsmemberment OPTION EIGHT 8 $ $48.00 $25,000 Accdent Medcal Coverage - $250 Deductble $25,000 Accdental Death and Dsmemberment Your Monthly Rate Includes $10.95 Membershp Dues & Dscount Medcal Plan Opton Costs

3 Beneft Descrptons by Guarantee Trust Lfe Insurance Company Accdent Medcal Coverage ANY DOCTOR, EMERGENCY ROOM, CLINIC OR HOSPITAL Medcal Servces means the cost for: medcally necessary treatment by a physcan, nurse, dentst, hosptal room and board, outpatent surgery, use of an ambulance, dental work for njury to sound and natural teeth, drugs, medcnes, dagnostc tests and x-rays, oxygen, casts, splnts, crutches, blood plasma, treatment performed by a lcensed medcal professonal and the rental of durable medcal equpment. Benefts are excess of other coverage. Total medcal expense benefts for a sngle accdent shall not exceed the maxmum beneft amount per njury shown n your certfcate. $4,000 Emergency Ar Ambulance Most medcal plans only cover ground ambulance. In the event a member suffers from a covered njury that requres emergency ar ambulance servce we wll remburse the member up to the maxmum amount of $4,000. Accdental Death & Dsmemberment If a covered famly member s njury results n a loss, as defned n your certfcate of coverage, wthn one year after the accdent causng the loss, we wll pay benefts as descrbed n your certfcate of coverage for loss of lfe. Benefts for loss of lmb and sght are also shown n the schedule of benefts. AD&D benefts reduce by 50% on a covered person s 70th brthday.

4 Select Beneft Servces Assocaton The followng Dscount Medcal Plans are ncluded wth all eght optons: Teladoc: Speak wth a lve Board Certfed Physcan Wth Teladoc, you can speak wth a physcan anytme, anywhere, 24 hours a day, 7 days a week, 365 days a year. Call Teladoc and you can speak to a physcan n most cases n less than 30 mnutes, but wthn 3 hours guaranteed. Please note that there s a $40 per consultaton charge for ths servce. Pharmacy Dscount Plan: APS The Prescrpton Drug Program lnks most of the largest pharmacy chans nto a common and consstent dscount program. Through an exclusve agreement wth one of the naton s premer drug management organzatons, members can obtan dscounts on drug prces through a natonal network of more than 50,000 pharmaces. The network ncludes pharmacy chans such as CVS, Rte Ad, Medcne Shoppe, Walgreens, Wal-Mart, as well as thousands of ndependent pharmaces throughout the country. Mal order s also avalable! Dental Dscounts: UNI-CARE Network Members may take advantage of savngs through the UNI-CARE Dental Network, one of the largest and most recognzed dscount dental networks n the naton. Members save 10% to 50% on everythng from general dentstry to root canals, crowns and orthodonta at over 50,000 avalable dental practces natonwde. Examples of Dscounts: PRODUCT/SERVICE AVG. PRICE YOU PAY* SAVINGS* % SAVED Dental exam/cleanng (adult) $ $ $ % Dental exam/cleanng (chld) $ $87.67 $ % Complete X-rays $ $66.00 $ % Root Canal (One Canal) $ $ $ % Complete Upper Denture $1, $1, $ % *These are examples only. Savng wll vary by procedure, provder and geographcal area. The name, address and phone number for provders n your area can be obtaned by callng our toll-free number at , or by vstng our webste at Teladoc does not replace the prmary care physcan. Teladoc does not guarantee that a prescrpton wll be wrtten and operates subject to state regulatons. Teladoc does not prescrbe DEA controlled substances. Teladoc physcans reserve the rght to deny care for potental msuse of servces. Teladoc, Inc Dsclosures: (a) The dscount medcal card program s NOT health nsurance. (b) The plan provdes dscounts at certan health care provders for medcal servces. (c) The plan does not make payments drectly to the provders of medcal servces. (d) The range of dscounts for medcal or ancllary servces provded under the plan wll vary dependng on the type of provder and medcal or ancllary servces receved. (e) The plan member s oblgated to pay for all health care servces but wll receve a dscount from those health care provders who have contracted wth VantageAmerca Solutons, Inc., a dscount medcal plan organzaton. Managed and Admnstered by: VantageAmerca Solutons, Inc Mlwaukee Avenue Glenvew, IL Ths dscount plan s not A Medcare Prescrpton Drug Plan. (1) Membershp n the dscount drug plan enttles members to dscounts for certan pharmaceutcal supples, prescrpton drugs, or medcal equpment and supples offered by provders who have agreed to partcpate n the dscount drug plan; (2) The dscount drug plan organzaton does not pay provders of pharmaceutcal supples, prescrpton drugs, and medcal equpment and supples provded to plan members. (3) The dscount drug plan member s requred to pay for all pharmaceutcal supples.

5 Other Dscounts and Servces For a lst of provders please vst CAR PRICING: CAR RENTAL: LONG DISTANCE: SHOPPING SPREE: Car leasng, purchasng and referral servce Ths servce s avalable for new and late model used cars Includes USA, Canada and Europe Great Savngs 24 hours per day/7 days per week Over 120 gft tems to choose from Up to $1,000 n merchandse and servces GIFT BASKETS: Includes flowers, gourmet baskets, sweet treats and more TRAVEL: HOTEL/MOTEL: RENTAL & SALES: GROCERY COUPONS: MOVING SERVICES: FITNESS HEALTH: Includes car rentals, cruses and more Hotel, motel and resort chans natonwde Save on motor homes Members can also purchase new and used brand name motor homes Stretch your grocery dollars Enjoy savngs wth coupons for goods natonwde Traned planner wll help members wth ther resdental, busness or offce move Save on natonal brand exercse equpment Includes star clmbers, exercse bkes, rowng machnes and more

6 The polcy does not provde benefts for: Treatment, servces or supples whch: -Are not Medcally Necessary; -Are not prescrbed by a Doctor as necessary to treat an Injury; -Are determned to be Expermental/Investgatonal n nature; -Are receved wthout charge or legal oblgaton to pay; -Are receved from persons employed or retaned by any Famly Member, unless otherwse specfed; or -Are not specfcally lsted as Covered Charges n the Polcy. Injury by acts of war, whether declared or not. Injury receved whle travelng or flyng by ar, except as a fare-payng passenger and not as a plot or crew member, on a regularly scheduled commercal arlne. Injury covered by Worker s Compensaton, Employer Lablty Law or Occupatonal Dsease Act or Law. Dental treatment, except as specfcally stated. Injury sustaned whle commttng or attemptng to commt a felony. Prescrpton Drugs except as specfcally stated. Sucde or attempted sucde whle sane or nsane. Intentonally self-nflcted Injury. Loss resultng from beng legally ntoxcated or under the nfluence of alcohol as defned by the laws of the state or jursdcton n whch the Injury occurs. Loss resultng from beng under the nfluence of any drugs or narcotc unless admnstered on the advce of a Doctor. Injury sustaned whle partcpatng n or practcng for any professonal, ntercollegate or club sports actvty, except as specfcally provded. Injury whch occurs whle a Covered Person s on actve duty servce n any armed forces. Reserve or Natonal Guard actve duty for tranng s not excluded unless t extends beyond 31 days. Injury sustaned flyng n an ultra lght, hang gldng, parachutng or bungee-cord jumpng, by flght n a space craft or any craft desgned for navgaton above or beyond the earth s atmosphere. Injury sustaned whle drvng or rdng on vehcles for off-road use ncludng but not lmted to all-terran vehcles (ATV s). Injury sustaned where a Covered Person s the operator and does not possess a current and vald motor vehcle operator s lcense, except n a Drver s Educaton Program. Treatment n any Veteran s Admnstraton or federal Hosptal, except f there s a legal oblgaton to pay. Cosmetc surgery, except for reconstructve surgery on an njured part of the body. Covered Charges ncurred outsde of the Unted States or ts possessons. Competng n motor sports races or compettons. Competng n water sports races or compettons. Testng cars/trucks on any racetrack or speedway. Handlng, storng or transportng explosves. Scalng up clffs or mountan walls. Spelunkng (explorng caves). Handlng or workng wth dangerous anmals. Repettve moton njures, strans, herna, tendonts, bursts and heat exhauston not related to a specfc njury. The followng treatments, servces or supples are lmted to the followng charges: -Doctor s vsts (npatent and outpatent) per vst lmted to $100 -Ambulance expense lmted to $400 per Accdent -Dental treatment for Injury to Sound Natural Teeth per vst lmted to $250 -Chropractc per vst lmted to $20 CLAIM PROVISIONS: Notce of Clam: Wrtten notce of clam must be gven to the Company or ts authorzed representatve wthn 60 days after a covered loss starts, or as soon thereafter as s reasonably possble. Notce should nclude nformaton suffcent to dentfy the Covered Person. Insurance Underwrtten by Guarantee Trust Lfe Insurance Company: Polcy Form MP-1300 Ths brochure s an llustraton, not a contract. For complete detals of all provsons, please read your certfcate carefully. Not all benefts may be avalable n every state. Plan membershp may be cancelled wthn 30 days and any premum pad wll be fully refunded. 24 Hour Accdent Coverage Ths product s not avalable n AK, AR, CT, DE, FL, HI, KS, ME, MD, MA, MN, MT, NH, NY, NC, NV, OR, RI, UT, VT, WA Nether the Accdent Coverage provded by Guarantee Trust Lfe Insurance Company nor the Medcal dscounts offered through VantageAmerca Solutons, Inc. provde comprehensve health nsurance coverage ( major medcal coverage ) nor do they satsfy the requrement of mnmum essental coverage requred under the Affordable Care Act. GTL

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