Additional Life Insurance with AD&D Coverage Highlights The Salvation Army

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1 Accidental Death and Dismemberment (AD&D) Standard Insurance Company has developed this document to provide you with information about the optional coverage you may select through. Written in non-technical language, this is not intended as a complete description of the coverage. If you have additional questions, please refer to the Additional Life Insurance Employee Brochure included in your packet or check with your human resources representative. Employer Plan Effective Date will provide Basic Life coverage from The Standard. If you qualify for Basic Life, you may also apply for Additional Life coverage to supplement your Basic Life amount. Eligibility To be eligible for this plan: You must be insured for Basic Life You must be an active employee of (including those employed at locations in Guam, the Marshall Islands, and Micronesia), excluding officers (ordained ministers of ), temporary and seasonal employees, full-time members of the armed forces, leased employees and independent contractors. You must be regularly working at least 30 hours each week. For Dependents Life insurance Your spouse or children must not be full-time member[s] of the armed forces. Employee Amount You may elect Additional Life coverage in units of $10,000 to a maximum of the lesser of (a) $750,000, or (b) 5 times your annual earnings. The minimum amount you can elect is $10,000. If you wish to become insured for an amount of Additional Life insurance in excess of the lesser of (a) $200,000, or (b) 3 times your annual earnings, the excess will be subject to medical underwriting approval. All late applications and requests for coverage increases are also subject to medical underwriting approval. Additional Accidental Death and Dismemberment insurance from Standard Insurance Company is also included in this plan. The amount of your Additional AD&D coverage is equal to the amount of your elected Additional Life coverage. Dependents Life insurance from Standard Insurance Company is also available with this plan. However, you must elect Additional Life insurance for yourself in order to elect Dependents Life insurance. Spouse Amount This coverage is available in units of $5,000 to a maximum of $150,000, but not to exceed 100 percent of your Additional Life coverage. If you elect an amount for your spouse greater than $50,000, the excess will be subject to medical underwriting approval. All late applications and requests for coverage increases will also require medical underwriting approval. Dependents AD&D insurance for your spouse is also included in this plan, if you elect Dependents Life insurance for your spouse. The amount of the Dependents AD&D coverage for your spouse is equal to the elected amount of Dependents Life insurance for your spouse. SI of 11 (8/14)

2 Standard Insurance Company Amount for Children You may elect Dependents Life insurance for your eligible children in units of $2,000 to a maximum of $10,000. This amount may not exceed 100 percent of your Additional Life coverage. Requests for coverage increases will be subject to medical underwriting approval. Dependents AD&D insurance for your eligible children is also included in this plan, if you elect Dependents Life insurance for your child(ren). The amount of the Dependents AD&D coverage for your children is equal to the elected amount of Dependents Life insurance for your children. Employee Rates for AD&D If you elect Additional Life insurance, your bi-weekly premium rate for this plan is indicated in the table below. Premiums for this coverage will be deducted directly from your paycheck. Employee s Age* < Bi-Weekly Rate (Per $1,000 of Total ) $0.035 $0.042 $0.060 $0.086 $0.127 $0.215 $0.236 $0.394 $0.690 $1.075 To calculate your premium: 1. Amount Elected: Write this amount on the Additional/Optional Life Requested Amount line on your Enrollment and Change Form. Line 1: 2. Line 1 divided by $1,000 = Line 2. Line 2: 3. Select your rate from the rate table and enter on Line 3. Line 3: 4. Line 2 multiplied by Line 3 = Your bi-weekly cost. See pages 6-11 for more information pertaining to premium calculation. Line 4: *As of the pay period coinciding with or next following the employee s last birthday. Spouse Rates for Dependents Life Insurance with AD&D If you elect Dependents Life insurance for your spouse, your bi-weekly premium rate for this coverage is indicated in the table below. Premiums for this coverage will be deducted directly from your paycheck. Employee s Age* < Bi-Weekly Rate (Per $1,000 of Total ) $0.035 $0.042 $0.060 $0.086 $0.127 $0.215 $0.236 $0.394 $0.690 $1.075 To calculate the premium for your spouse: 1. Amount Elected: Write this amount on the Dependent Life Spouse Requested Amount line on your Enrollment and Change Form. Line 1: 2. Line 1 divided by $1,000 = Line 2. Line 2: 3. Select your rate from the rate table and enter on Line 3. Line 3: 4. Line 2 multiplied by Line 3 = Your bi-weekly cost. See pages 6-11 for more information pertaining to premium calculation.. Line 4: *As of the pay period coinciding with or next following the employee s last birthday. Child(ren) Rate for Dependents Life Insurance with AD&D If you elect Dependents Life insurance for your eligible child(ren), your bi-weekly premium rate for this coverage is $0.044 per $1,000 of Dependents Life insurance; regardless of the number of eligible children covered. Premiums for this coverage will be deducted directly from your paycheck. See page 8 for more information pertaining to premium calculation for your child(ren). SI of 11 (8/14)

3 Employee Effective Date Please contact your human resources representative for more information regarding the following requirements that must be satisfied for your insurance to become effective. You must satisfy: Eligibility requirements An eligibility waiting period Any evidence of insurability requirements An active work requirement. This means that if you are not actively at work on the day before the scheduled effective date of insurance, including Dependents Life insurance, your insurance will not become effective until the day after you complete 1 full day of active work as an eligible employee. Age Reductions Under this plan, coverage for you and your spouse reduces to 65 percent at age 65, 50 percent at age 70, and 35 percent at age 75. If you are age 65 or over, ask your human resources representative for the amount of coverage available. See pages 9-11 for age reduction benefit amounts and bi-weekly premiums. Suicide Exclusion This plan includes an exclusion for death resulting from suicide or other intentionally self-inflicted injury. This exclusion applies to you and your spouse. The amount payable will exclude amounts that have not been continuously in effect for at least two years on the date of death. Waiver of Premium Provision The Standard may continue your Life insurance without premium payments if you: Become totally disabled while insured under the group policy Are under the age of 60 Complete the waiting period of 180 days Give us satisfactory proof of loss Waiver of Premium does not apply to AD&D insurance or to Dependents Life insurance. Portability If your insurance ends because your employment terminates, you may be eligible to buy portable group insurance coverage. Please see your human resources representative for additional information. When Spouse and Child Ends Your brochure includes information about when your insurance ends. Any spouse and child coverage will automatically end on the earliest of the following: Five months after the date you die (no premiums will be charged for your Dependents Life insurance during this time) The date your Life insurance ends The date Dependents Life insurance terminates under the group policy The date your employer s coverage under the group policy for Dependents Life insurance terminates The date the last period ends for which a premium was paid for your Dependents Life insurance When the dependent ceases to be an eligible dependent For your spouse, the date of your divorce or termination of your Domestic Partner relationship For a child who is disabled, 90 days after we mail you a proof of disability request, if proof is not given SI of 11 (8/14)

4 Accidental Death and Dismemberment Insurance With Additional AD&D insurance from Standard Insurance Company, you or your beneficiaries may be eligible to receive an additional amount in the event of death or dismemberment as a result of an accident. AD&D Insurance Amount The amount of this AD&D Insurance Benefit for loss of life is equal to the amount payable for Additional Life insurance coverage on the date of the accident. The amount of this AD&D Insurance Benefit for other covered losses is a percentage of the amount payable for Additional AD&D insurance coverage on the date of the accident, as shown in the following table: 1 Loss: Percentage Payable: One hand or one foot 50% Sight in one eye, speech, or hearing in both ears 50% Two or more of the losses listed above 100% Thumb and index finger of the same hand 1 25% Quadriplegia 100% Hemiplegia 50% Paraplegia 50% This benefit is not payable if an AD&D Insurance Benefit is payable for the loss of the entire hand. Additional Features Following are brief descriptions of features included in this plan. These features offer additional benefits when an AD&D Insurance Benefit is payable. Seat Belt Benefit Air Bag Benefit Family Benefits Package Occupational Assault Public Transportation This provision provides an additional benefit in the event of a covered automobile accident. This provision provides an additional benefit in the event of a covered automobile accident for which a Seat Belt Benefit is payable. Through this provision, your eligible family members may be entitled to receive additional financial help for child care, college or career training. Included are the Child Care Benefit, Higher Education Benefit and Career Adjustment Benefit. This provision provides an additional benefit if you suffer death or dismemberment as a result of an act of workplace physical violence that is punishable by law. This provision provides an additional benefit in the event of death as a result of an accident that occurs while you are riding as a fare-paying passenger on public transportation. Limitations The loss must occur solely by an accident and independently of all other causes, within 365 days after the accident. Loss of life must be evidenced by a certified copy of the death certificate. All other losses must be certified by a physician in the appropriate specialty as determined by us. SI of 11 (8/14)

5 Exclusions AD&D Insurance Benefits are not payable for death or dismemberment caused or contributed to by: War or act of war, declared or undeclared, whether civil or international, and any substantial armed conflict between organized forces of a military nature Suicide or other intentionally self-inflicted injury Committing or attempting to commit an assault or felony, or actively participating in a violent disorder or riot Voluntary use or consumption of any poison, chemical compound, alcohol or drug, unless used or consumed according to the directions of a physician Sickness or pregnancy existing at the time of the accident Heart attack or stroke Medical or surgical treatment for any of the above When Ends AD&D insurance for you and your dependents will automatically end on the earliest of the following: The date your Life insurance ends The date your Waiver of Premium begins The date AD&D insurance terminates under the group policy The date the last period ends for which a premium was paid for your AD&D insurance The date your employer s coverage under the group policy for AD&D insurance terminates For your dependents, the date your Dependents Life insurance ends The date your employment terminates Group Insurance Certificate If you become insured, you will receive a group insurance certificate containing a detailed description of the insurance coverage. The information presented above is controlled by the group policy and does not modify it in any way. The controlling provisions are in the group policy issued by Standard Insurance Company. SI of 11 (8/14)

6 Employee Additional Life with AD&D Bi-Weekly Premiums Employee s Age as of the pay period coinciding with or next following the employee s last birthday Amount < * 70-74* 75+* $10, See pages 9 & 10 for age reduction grid. $20, $30, $40, $50, $60, $70, $80, $90, $100, $110, $120, $130, $140, $150, $160, $170, $180, $190, $200, $210, $220, $230, $240, $250, $260, $270, $280, $290, $300, $310, $320, $330, $340, $350, $360, $370, $380, $390, $400, $410, $420, $430, $440, $450, $460, $470, $480, $490, $500, SI of 11 (8/14)

7 Employee Additional Life with AD&D Bi-Weekly Premiums (Continued) Employee s Age as of the pay period coinciding with or next following the employee s last birthday Amount < * 70-74* 75+* $510, See pages 9 & 10 for age reduction grid. $520, $530, $540, $550, $560, $570, $580, $590, $600, $610, $620, $630, $640, $650, $660, $670, $680, $690, $700, $710, $720, $730, $740, $750, SI of 11 (8/14)

8 Spouse Dependents Life with AD&D Bi-Weekly Premiums Employee s Age as of the pay period coinciding with or next following the employee s last birthday Amount < * 70-74* 75+* $5, See page 11 for age reduction grid. $10, $15, $20, $25, $30, $35, $40, $45, $50, $55, $60, $65, $70, $75, $80, $85, $90, $95, $100, $105, $110, $115, $120, $125, $130, $135, $140, $145, $150, Child Dependents Life with AD&D Bi-Weekly Premiums Amount Premium $2, $4, $6, $8, $10, SI of 11 (8/14)

9 Age Reductions - Employee Additional Life with AD&D Bi-Weekly Premiums The Requested Amount below will be reduced due to age reduction. For example: If you are 66 years old and request $20,000; you are eligible to receive $13,000 of coverage. Original Amount Employee s Age as of the pay period coinciding with or next following the employee s last birthday Amount 65-69* Amount 70-74* Amount 75+* $10,000 $6, $5, $3, $20,000 $13, $10, $7, $30,000 $19, $15, $10, $40,000 $26, $20, $14, $50,000 $32, $25, $17, $60,000 $39, $30, $21, $70,000 $45, $35, $24, $80,000 $52, $40, $28, $90,000 $58, $45, $31, $100,000 $65, $50, $35, $110,000 $71, $55, $38, $120,000 $78, $60, $42, $130,000 $84, $65, $45, $140,000 $91, $70, $49, $150,000 $97, $75, $52, $160,000 $104, $80, $56, $170,000 $110, $85, $59, $180,000 $117, $90, $63, $190,000 $123, $95, $66, $200,000 $130, $100, $70, $210,000 $136, $105, $73, $220,000 $143, $110, $77, $230,000 $149, $115, $80, $240,000 $156, $120, $84, $250,000 $162, $125, $87, $260,000 $169, $130, $91, $270,000 $175, $135, $94, $280,000 $182, $140, $98, $290,000 $188, $145, $101, $300,000 $195, $150, $105, $310,000 $201, $155, $108, $320,000 $208, $160, $112, $330,000 $214, $165, $115, $340,000 $221, $170, $119, $350,000 $227, $175, $122, $360,000 $234, $180, $126, $370,000 $240, $185, $129, $380,000 $247, $190, $133, $390,000 $253, $195, $136, $400,000 $260, $200, $140, $410,000 $266, $205, $143, $420,000 $273, $210, $147, $430,000 $279, $215, $150, $440,000 $286, $220, $154, $450,000 $292, $225, $157, $460,000 $299, $230, $161, $470,000 $305, $235, $164, $480,000 $312, $240, $168, $490,000 $318, $245, $171, $500,000 $325, $250, $175, SI of 11 (8/14)

10 Age Reductions - Employee Additional Life with AD&D Bi-Weekly Premiums (Continued) The Requested Amount below will be reduced due to age reduction. For example: If you are 66 years old and request $20,000; you are eligible to receive $13,000 of coverage. Original Amount Employee s Age as of the pay period coinciding with or next following the employee s last birthday Amount 65-69* Amount 70-74* Amount 75+* $510,000 $331, $255, $178, $520,000 $338, $260, $182, $530,000 $344, $265, $185, $540,000 $351, $270, $189, $550,000 $357, $275, $192, $560,000 $364, $280, $196, $570,000 $370, $285, $199, $580,000 $377, $290, $203, $590,000 $383, $295, $206, $600,000 $390, $300, $210, $610,000 $396, $305, $213, $620,000 $403, $310, $217, $630,000 $409, $315, $220, $640,000 $416, $320, $224, $650,000 $422, $325, $227, $660,000 $429, $330, $231, $670,000 $435, $335, $234, $680,000 $442, $340, $238, $690,000 $448, $345, $241, $700,000 $455, $350, $245, $710,000 $461, $355, $248, $720,000 $468, $360, $252, $730,000 $474, $365, $255, $740,000 $481, $370, $259, $750,000 $487, $375, $262, SI of 11 (8/14)

11 Age Reductions - Spouse Dependents Life with AD&D Bi-Weekly Premiums The Requested Amount below will be reduced due to age reduction. For example: If you are 66 years old and request $20,000 for your spouse; your spouse is eligible to receive $13,000 of coverage. Original Amount Employee s Age as of the pay period coinciding with or next following the employee s last birthday Amount 65-69* Amount 70-74* Amount 75+* $5,000 $3, $2, $1, $10,000 $6, $5, $3, $15,000 $9, $7, $5, $20,000 $13, $10, $7, $25,000 $16, $12, $8, $30,000 $19, $15, $10, $35,000 $22, $17, $12, $40,000 $26, $20, $14, $45,000 $29, $22, $15, $50,000 $32, $25, $17, $55,000 $35, $27, $19, $60,000 $39, $30, $21, $65,000 $42, $32, $22, $70,000 $45, $35, $24, $75,000 $48, $37, $26, $80,000 $52, $40, $28, $85,000 $55, $42, $29, $90,000 $58, $45, $31, $95,000 $61, $47, $33, $100,000 $65, $50, $35, $105,000 $68, $52, $36, $110,000 $71, $55, $38, $115,000 $74, $57, $40, $120,000 $78, $60, $42, $125,000 $81, $62, $43, $130,000 $84, $65, $45, $135,000 $87, $67, $47, $140,000 $91, $70, $49, $145,000 $94, $72, $50, $150,000 $97, $75, $52, SI of 11 (8/14)