Fairfield USD #310. Benefits Information For Plan Year October 1, 2013 to September 30, 2014

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1 BENEFITS ENROLLMENT Fairfield USD #310 Benefits Information For Plan Year October 1, 2013 to September 30, 2014 All benefits and rates represented in this file are applicable only to the benefit period stated above. Benefits and rates are subject to change each benefit period. Please refer to your employer s benefits department for verification. OFG Financial Services, Inc dba Webb & Associates, Inc

2 Marketed Exclusively by OFG Financial Services, Inc Townsite Plaza Bldg. No. 2 Suite SE 6th Ave Topeka, Kansas (785) Fax (785) Represented by: Webb & Associates, Inc Eric Stewart John & Kelli Webb 600 S Santa Fe, Suite C Salina, Kansas webbandassocinc@ofgfinancial.com Someone Still Cares About Quality & Service

3 403(b) PLAN HIGHLIGHTS Fairfield USD 310 Participation When am I eligible to participate in this plan? You are eligible to join this plan on your date of hire and as specified by your employer. Contributions What kinds of contributions may be made to this plan? This plan provides for pre-tax salary reduction contributions, post-tax Roth salary reduction contributions, and rollovers. There are no employer contributions. Pre-tax contributions are deducted before you pay current income taxes. Pre-tax investments grow tax-deferred and the contributions and any earnings are taxed when you take a distribution from this plan. Post-tax Roth contributions are deducted after you pay current income taxes. Earnings on posttax Roth contributions will never be taxed if you are 59 ½, die, or become disabled and have held the Roth account for 5 years at the time of its distribution from this plan. You may transfer benefits from a former employer s eligible retirement plan into this plan. How much may I contribute? You can contribute up to 100% of your compensation to this plan up to the limit allowed under the Internal Revenue Code ($17,500 in 2013). If you are age 50 or older you can contribute a catch-up contribution of up to $5,500 (2013). Can I ever lose my benefits? You are always 100% vested in your salary reduction contributions. This means the value of your contributions and earnings are yours when you terminate employment with your employer, without respect to your years of service. What do I have to do to start contributing? Automatic payroll deduction withdraws your contributions directly from your paycheck after you complete a Salary Reduction Agreement and return it to your financial representative or your employer. You may commence making contributions or modify the amount of your current contributions at any time by modifying your Salary Reduction Agreement. Investments Where are my contributions invested? You may choose the 403(b) custodial account or annuity contract you want from the list of approved investment providers and 403(b) investment products located on the Bay Bridge website, How are my contributions invested? You select how you want your contributions to be invested from among the investment options available under each approved investment provider s product. Your investment provider s custodial account or annuity contract will determine how often you may change your investment mix.

4 Listed below are the approved providers & representatives for your plan. To find more contact information, please go to Baybridge Administrators plan details for USD 310. ( Security Benefit Life John & Kelli Webb Eric Stewart Waddell & Reed, Inc Jeff Jackson Ameriprise Financial Ameriprise Financial As of Plan Year

5 SEC. 125 CAFETERIA FRINGE BENEFIT PLANS QUESTIONS AND ANSWERS The following is provided to answer questions frequently asked concerning a Cafeteria Plan under Internal Revenue Code Section 125. This information is not intended as a substitute for specific legal advice from competent counsel on a specific factual situation. For more information, please refer to your employer s Section 125 Plan Document. Q-1 WHAT IS A SEC. 125 CAFETERIA FRINGE BENEFIT PLAN? A-1 Sec. 125 of the Internal Revenue Code allows an employer to establish an employee benefit plan whereby employees may make a choice between various benefits that are offered under the plan. These benefits may be purchased by employer contributions or by the employee reducing his or her salary to purchase the benefits that the employee selects. In either case, the employee receives the selected benefits free of federal and state income taxes and social security taxes (FICA) since the benefits are purchased with pre-tax dollars. Q-2 WHAT ARE THE TAX ADVANTAGES OF A SEC. 125 PLAN? A-2 Since most Sec. 125 benefits are purchased by a reduction in an employee s salary, the employee will reduce his or her taxable income by the cost of the benefit or benefits selected. This means that you will save income taxes on these benefits at your highest federal and state income tax bracket. Also, you do not pay FICA taxes on these benefits. At 25% federal income tax, 6.5% state income tax and FICA taxes of 7.65%, you could save over 35% in taxes for each dollar used to purchase Sec. 125 benefits. Q-3 HOW MAY AN EMPLOYER ESTABLISH A SEC. 125 PLAN? A-3 First, an eligible employer must adopt a Sec. 125 plan for its employees. In adopting a plan, the employer must establish a plan year. At the beginning of the first and succeeding plan years, the employees are given an opportunity to participate in the Sec. 125 plan by completing a benefit selection form. The benefit selection form must be completed prior to the beginning of the plan year. Q-4 WHAT BENEFITS ARE AVAILABLE UNDER A SEC. 125 PLAN? A-4 Benefits that an employer may make available under Sec. 125 plan on a before-tax basis can include: group term life insurance up to $50,000, health insurance (including hospitalization, dental, vision, disability income, accidental death and dismemberment, indemnity coverages such as cancer and dread disease, and heart and stroke insurance) and flexible spending accounts for reimbursement for non-insured medical expenses and dependent care. Excess life insurance above $50,000, long term care insurance, and other benefits might also be available on an after-tax basis under a Sec. 125 plan. Q-5 HOW DOES A FLEXIBLE SPENDING ACCOUNT WORK? A-5 Flexible Spending Accounts (FSA s) cover two areas. An employee can set aside, on a before-tax basis, money to be reimbursed to the employee to cover medical expenses that aren t covered by their health insurance. The expenses would include such items as insurance deductibles, insurance co-payments, orthodontic expenses and other health related items. (They do not include health insurance premiums such as premiums to be paid for health insurance under a spouse s health insurance plan.) Dependent care expenses of up to $5000 may be set aside on a before-tax basis for childcare. This benefit is for children under age 13 and the care must be provided so that the parent may work or look for work. Payments may not be made to immediate family members such as your spouse or to

6 children under age 19. Dependent care expenses may also be set aside for a dependent spouse or parent who qualifies as your dependent for income tax purposes. Money set aside for medical reimbursement cannot be used for dependent care expenses and money set aside for dependent care expenses cannot be used for medical reimbursement expenses. You should review these benefits carefully each year and set aside only the amount of money that you are sure that you can use in each area. Monies not expended in these accounts are returned to your employer and cannot be returned directly to you. Q-6 WHAT HAPPENS IF MY SPOUSE OR I BECOME ELIGIBLE FOR MEDICARE COVERAGE DURING THE PLAN YEAR? A-6 The Internal Revenue Service has indicated that you are eligible for an election change if you or your spouse becomes eligible for Medicare benefits during the plan year. Q-7 WHEN DO MY BENEFITS BEGIN? A-7 Generally, your benefits become available at the beginning of the plan year. Some of your insurance coverages may have a requirement that you be actively at work at the beginning of the plan year for your benefits to begin. New employees who are eligible to enroll during the plan year will usually begin their benefits on the first of the month following enrollment. Your employer s plan will dictate eligibility and the beginning date for benefits you choose. Q-8 WHEN MUST I NOTIFY MY EMPLOYER IF THERE IS AN ERROR IN MY ENROLLMENT? A-8 Originally, the Internal Revenue Service took the position that all errors must be corrected before the beginning of the plan year. Recent discussion with the Internal Revenue Service has indicated that you would have to notify your employer of any error upon your first identification that an error exists. Presumably this would mean when you receive your first paycheck indicating the error. Q-9 IF I PURCHASE PART OF MY SEC. 125 BENEFITS ON AN AFTER-TAX BASIS, MUST I FOLLOW THE CHANGE IN FAMILY STATUS RULES FOR THESE BENEFITS? A-9 Sec. 125 plans allow both taxable and non-taxable benefits. If a taxable benefit is a part of a Sec. 125 plan, you must follow all of the rules of the Sec. 125 plan in making election changes. Q-10 MAY I PURCHASE A TAX-SHELTERED ANNUITY UNDER MY SEC. 125 PLAN? A-10 Tax-sheltered annuities are not an eligible benefit under a Sec. 125 plan. However, you can purchase a tax-sheltered annuity under the rules applicable to Sec. 403(b) of the Internal Revenue Code. OFG/QA-07-04

7 MAKING CHANGES UNDER YOUR SECTION 125 PLAN The following is provided to answer questions frequently asked concerning a Cafeteria Plan under Internal Revenue Code Section 125. This information is not intended as a substitute for specific legal advice from competent counsel on a specific factual situation. For more information, please refer to your employer s Section 125 Plan Document. Q-1 MAY I CHANGE MY BENEFIT ELECTION DURING THE PLAN YEAR? A-1 The Internal Revenue Service regulations for Sec. 125 plans provide specific rules about changes during a plan year. The rules provide a two-step analysis for determining whether an employee can change his or her election during the year. First, a change in status event must have occurred. Second, the employee s requested election change must be consistent with the event. Following is a list of the qualified status change events. 1. Change in employee s legal marital status including marriage, divorce, death of spouse, legal separation, and annulment. 2. Change in number of dependents including birth, adoption, placement for adoption, and death. Note that dependent is formally defined in the final regulations to be a tax dependent. 3. Change in employment status any of the following events that change the employment status of the employee, the employee s spouse or the employee s dependent would qualify: a termination or commencement of employment; a strike or lockout; a commencement of or return from an unpaid leave of absence; and a change in worksite. In addition, if the eligibility conditions of the benefit plan of the employer of the employee, spouse or dependent depend on the employment status of that individual and there is a change in that individual s employment status with the consequence then that individual becomes (or ceases to be) eligible under the plan, then that change constitutes a change in employment. It is significant to note that this category would not apply if benefit eligibility is not gained or lost as a result of the event. Thus, for example, an individual who moves from full-time to part-time employment status would not be able to change his or her election under this rule if benefit eligibility remains the same. 4. Dependent satisfies (or ceases to satisfy) dependent eligibility requirements an event that causes the dependent to satisfy or cease to satisfy the requirements for coverage due to attainment of age, gain or loss of student status, marriage or any similar circumstances. 5. Residence change a change in the place of residence of an employee spouse or dependent. For this category, it is particularly important to remember that the residence change must affect the employee s eligibility for coverage. 6. Adoption Assistance: Commencement or termination of adoption proceedings would allow an election change under an adoption assistance program. The Consistency Requirement If a change in status event occurs, employees are allowed to make changes consistent with the event. The regulations limit the election changes that will be consistent with the event. Under the regulations, a uniform rule generally applies to all qualified benefits (accident or health coverage and group term life). The threshold question under the consistency requirement is whether the election change is on account of and corresponds with a change in status event that affects coverage eligibility of the employee, spouse or dependent for the qualified benefit. An important exception to this general rule is that an impact on eligibility is not required for marital status or employment status events to support election changes for group term life insurance or long-term disability coverage. Once the threshold standard is met (i.e., the event affects eligibility), two specific consistency tests must be satisfied one when dependent eligibility is lost and another when coverage eligibility is gained through another employer plan. In addition, the regulations have been expanded to recognize that certain changes in life or disability coverage can be consistent even if the requested change does not track the increase or decrease in family size, or result in the gain or loss of eligibility. If the change in status is the employee s divorce, annulment or legal separation from a spouse, the death of a spouse or dependent, or a dependent ceasing to satisfy the eligibility requirements for coverage, the

8 employee can only cancel accident or health insurance coverage for the spouse or dependent, as applicable. Thus, if a dependent dies or ceases to satisfy the eligibility requirements for coverage, the employee s election to cancel accident or health coverage for any other dependent, for the employee or for the employee s spouse fails to correspond with that change in status. If an employee, spouse or dependent gains eligibility for coverage under another employer s cafeteria plan (or qualified benefit plan) as a result of a change in marital status or a change in employment status, an employee s election under the cafeteria plan corresponds with that change in status only if coverage for that individual becomes effective or is increased under the other employer s plan. Q-2 WHEN MUST I NOTIFY MY EMPLOYER IF I HAVE HAD A CHANGE IN STATUS EVENT? A-2 Any change of election because of a change in status event must be made within 30 days of the qualifying event. Q-3 WHAT HAPPENS IF THERE IS A CHANGE IN COST OR COVERAGE DURING THE PLAN YEAR? A-3 Mid year election changes are permitted on account of certain mid-year cost and coverage changes, as provided under IRS Section 125 regulations. It should be noted that these provisions do not apply to health Flexible Spending Accounts. Changes in Cost If the cost of a qualified benefits plan decreases during a period of coverage and, under the terms of the plan, employees are required to make a corresponding change in their payments, the cafeteria plan may, on a reasonable and consistent basis, automatically make a prospective decrease in affected employee s elective contributions for the plan. If the cost of a benefit significantly increases during a period of coverage, the cafeteria plan may permit employees either to make a corresponding prospective increase in their payments, or to revoke their elections and, in lieu thereof, to receive on a prospective basis coverage under another benefit package option providing similar coverage. Change in Coverage Coverage Change Rule #1: Significant curtailment If the coverage under a plan is significantly curtailed or ceases during a period of coverage, the cafeteria plan may permit affected employees to revoke their elections under the plan and make a new election for coverage under another benefit package option providing similar coverage. Coverage under an accident or health plan is significantly curtailed only if there is an overall reduction in coverage provided to participants under the plan so as to constitute reduced coverage to all participants generally. Coverage Change Rule #2: Addition (or elimination) of benefit package option If during a period of coverage a plan adds a new coverage option (or eliminates an existing option) the cafeteria plan may permit affected employees to elect the newly added option (or elect another option if an option has been eliminated) prospectively on a pre-tax basis and make corresponding election changes with respect to other benefit package options providing similar coverage. Coverage Change Rule #3: Change in coverage of spouse of dependent under their plan A cafeteria plan may permit an employee to make a prospective election that is on account of and corresponds with a change made under the plan of the spouse s, former spouse s, or dependent s employer if: (1) a cafeteria plan or qualified benefits plan of the spouse s, former spouse s, or dependent s employer permits participants to make an election change that would be permitted under the proposed and final regulations; or (2) the cafeteria plan permits participants to make an election for a period of coverage that is different from the period of coverage under the cafeteria plan or qualified benefits plan of the spouse s, former spouse s, or dependent s employer. Under either option, a consistency requirement must be satisfied since the new election must be on account of and corresponds to the change under the plan of the spouse s, former spouse s, or dependent s employer.

9 Group Term Life Insurance Special Open Enrollment The group term life insurance offered through your Section 125 plan, as underwritten by Reliance Standard Life Insurance Company, provides a simple way to secure coverage at low group rates. Plan Features: Guarantee issue by attained age (initial enrollment only): Under age $100, to $25, No Guarantee Issue Additional coverage amounts up to 5 times salary, not to exceed $300,000. Additional coverage requires completion of underwriting questionnaire and acceptance by the company. Accelerated death benefit if insured is diagnosed with terminal condition. Portability available for terminations other than retirement if you have not attained age 70. Election must be made within 31 days of termination. New Feature-see brochure for details. Sample Employee Monthly Premiums $25,000 $50,000 $75,000 $100,000 $125,000 $150,000 $175,000 $200,000 $225,000 $250,000 Under Age 19 $1.23 $2.45 $3.68 $4.90 $6.13 $7.35 $8.58 $9.80 $11.03 $ to 24 $1.38 $2.75 $4.13 $5.50 $6.88 $8.25 $9.63 $11.00 $12.38 $ to 29 $1.50 $3.00 $4.50 $6.00 $7.50 $9.00 $10.50 $12.00 $13.50 $ to 34 $1.88 $3.75 $5.63 $7.50 $9.38 $11.25 $13.13 $15.00 $16.88 $ to 39 $2.63 $5.25 $7.88 $10.50 $13.13 $15.75 $18.38 $21.00 $23.63 $ to 44 $3.50 $7.00 $10.50 $14.00 $17.50 $21.00 $24.50 $28.00 $31.50 $ to 49 $6.25 $12.50 $18.75 $25.00 $31.25 $37.50 $43.75 $50.00 $56.25 $ to 54 $11.25 $22.50 $33.75 $45.00 $56.25 $67.50 $78.75 $90.00 $ $ to 59 $18.75 $37.50 $56.25 $75.00 $93.75 $ $ $ $ $ to 64 $28.50 $57.00 $85.50 $ $ $ $ $ $ $ & Older $42.75 $85.50 $ $ $ $ $ $ $ $ Coverage for spouse limited to 50% of Employee s insured amount (less than age 60 guaranteed issue $20,000 for new hires; all others are underwritten). Premiums will change automatically each year when you attain an age that qualifies you for a new age bracket rate. Spouse Monthly Premiums $10,000 $20,000 $30,000 $40,000 $50,000 Under Age 34 $1.87 $3.74 $5.61 $7.48 $ to 39 $2.31 $4.62 $6.93 $9.24 $ to 44 $3.63 $7.26 $10.89 $14.52 $ to 49 $5.61 $11.22 $16.83 $22.44 $ to 54 $8.91 $17.82 $26.73 $35.64 $ to 59 $13.20 $26.40 $39.60 $52.80 $ to 69 $19.80 $39.60 $59.40 $79.20 $99.00 Coverage terminates at age 70. Coverage for children is $2.00 per month. 10 days to 6 months 6 months to age 19 (25 if full-time student) Benefit $500 $10,000 Employees wishing to enroll in this benefit will receive further information in the brochure which will be distributed to you during the enrollment period, from your representative. Form RS-2225.GTL.07.PS13.U100

10 Effect of Prior Coverage If you were participating in and insured by the Participating Employer s prior plan on thedate immediately prior to the Participating Employer s Effective Date shown on the Policy Schedule and are Actively-At-Work on such date, all amounts that were in force under the Participating Employer s prior plan on the date immediately preceding the Participating Employer s Effective Date with the Company are guarantee issue up to the maximum benefit amount available under this plan. Employees currently insured for less than the Guarantee Issue Amount can increase coverage up to the Guarantee Issue Amount during the initial Open Enrollment period without providing Evidence of Insurability. During the Open Enrollment period, currently insured Emplo yees can also request an increase in the amount of coverage in excess of the Guarantee Issue Amount but are required to provide Evidence of Insurability satisfactory to the Company before the amounts in excess of the Guarantee Issue Amount will become effe ctive. For each Insured Person s or Insured Dependent s individual coverage, coverage will be deemed continuous and uninterrupted and no change will have retroactive effect. However, if you elect to increase your amount of coverage, the increased amounts will be subject to any other plan provisions. Bene it Limitations Benefits will reduce 50% at age 70. No Life Insurance benefits will be payable under the Policy for death caused by suicide or self-destruction, or any attempt at it within 24 months after the person s coverage under the Reliance Standard Life Insurance Company Policy becomes effective. Termination of Employee Voluntary Life Insurance Your Voluntary Life Insurance ends if: 1. your employment ends; 2. you are no longer Actively-At-Work; 3. premiums are not paid; 4. you are no longer an eligible employee; 5. Voluntary Life Insurance is no longer provided by the Participating Employer; 6. the policy terminates; 7. you enter the military, naval or air force of a ny country or international organization on a full-time active-duty basis.; or 8. the Participating Employer s coverage under the policy ends. Effective Date of Dependent Coverage You may apply for Family Life Insurance Benefits for your spouse, less than age 70 at the time of application, or child. Such benefit that is less than or equal to the Guarantee Issue Amount begins on the latest of the following: 1. the Participating Employer s Effective Date, if you apply for Family Life Insurance prior to s uch date; 2. your Effective Date if application for Family Life Insurance is made within 31 days of your eligibility date; 3. the date we approve the application for Family Life Insurance, subject to proof of Evidence of Insurability, if application is made more than 31 days after your eligibility date; 4. the date we approve the application for Family Life Insurance, if application is made within 31 days of you acquiring a new spouse or child; 5. the date we approve the application for Family Life Insurance, subject to proof of Evidence of Insurability, if application is made more than 31 days after acquiring a new spouse or child. Any Family Life Insurance benefit that is in excess of the guarantee issue amount will become effective when we approve the required Evidence of Insurability. No Family Life Insurance benefit will be effective until the required premium is paid. Note: Dependent coverage may only be taken in conjunction with Employee coverage. Dependent coverage may not be taken on a stand-alone basis. A spouse or child who is insured as an Employee under this plan cannot also be insured as a dependent. If both you and your spouse are insured under this plan as employees, only one of you may insure your children as dependents. Termination of Family Coverage Your Insured Spouse s or Insured Child s Life Insurance ends if: 1. your coverage ends; 2. the Participating Employer s coverage under the policy ends; 3. you are no longer eligible for Family Life Insurance; 4. you notify us in writing to discontinue the Family Life Insurance; 5. the premium is not paid; 6. Family Life Insurance is no longer provided by the policy; 7. your Insured Spouse or Insured Child ceases to qualify for coverage under the policy, 8. your Insured Spouse or Insured Child enters the military, naval or air force of any country or international organization on a full -time active duty basis; or 9. your Spouse attains age 70 It is important to enroll for RELIANCE STANDARD LIFE INSURANCE COMPANY S Voluntary Term Life Insurance when you are first eligible. If you do not enroll as a new hire, and you decide you d like coverage or increased coverage at a later time, you will be required to provide evidence of insurability. Your future opportunities to enroll in the plan may be li mited, and you may be denied coverage. If you enroll in the plan as a new hire, you will not have to provide medical evidence of insurability to qualify for coverage up to the Guarantee Issue Amount. You will need to provide evidence for amounts over the Guarantee Issue Amount. This is an informational flyer and you will be receiving a brochure containing all of the details of the plan at enrollment. This flyer provides a brief description of the important features of the insurance plan. It is not a contract of insurance. The terms and conditions of coverage are set forth in Policy number VG , on Policy Form number LRS The Policy is subject to the laws of the state in which it is issued. Please keep this information as a reference. Bay Bridge Administrators P.O. Box Austin, Texas Underwritten by: BAY BRIDGE ADMINISTRATORS Your solutions begin at the Bridge Form RS-2225.GTL.07.PS13.U100

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13 OFG Block Dental Highlight Sheet Low Dental Plan Summary Effective Date: 01/1/2013 Coinsurance Type 1 100% Type 2 50% Type 3 0% Deductible $50/Plan Year Type 2 Waived Type 1 No Family Maximum Maximum (per person) $1,000 per plan year Allowance 80th U&C Waiting Period None Sample Procedure Listing (Current Dental Terminology American Dental Association.) Type 1 Type 2 Type 3 Routine Exam (2 per benefit period) Bitewing X-rays (1 per benefit period) Full Mouth/Panoramic X-rays (1 in 5 years) Periapical X-rays Cleaning (2 per benefit period) Fluoride for Children 13 and under (1 per benefit period) Sealants (age 13 and under) Space Maintainers Restorative Amalgams Restorative Composites Denture Repair Simple Extractions NOT COVERED Monthly Rates Employee Only $26.06 Employee + Spouse $51.92 Employee + Children $61.86 Employee + Spouse & Children $96.76 Ameritas Information We're Here to Help This plan was designed specifically for the associates of OFG Block. At Ameritas Group, we do more than provide coverage - we make sure there's always a friendly voice to explain your benefits, listen to your concerns, and answer your questions. Our customer relations associates will be pleased to assist you 7 a.m. to midnight (Central Time) Monday through Thursday, and 7 a.m. to 6:30 p.m. on Friday. You can speak to them by calling toll-free: For plan information any time, access our automated voice response system or go online to ameritasgroup.com/member.

14 OFG Block Dental Highlight Sheet Rx Savings Our valued plan members and their covered dependents (even their pets) can save on prescription medications through any Walmart or Sam's Club pharmacy across the nation. This Rx discount is offered at no additional cost, and it is not insurance. To receive the Walmart Rx discount, Ameritas plan members just need to show their original Ameritas ID card. The identifier is the Ameritas logo. It's that easy. Or members can visit us at ameritasgroup.com and sign into (or create) a secure member account where they can print off an online-only Rx discount savings ID card. Eyewear Savings Ameritas plan members may receive up to 15% off eyewear frames and lenses purchased at any Walmart Vision Center nationwide. Members may also bring in their current vision prescription from any vision care provider and purchase eyewear at Walmart. This savings arrangement is not insurance: it is available to members at no additional cost to their plan premium. To receive the eyewear savings identification card, Ameritas plan members can visit ameritasgroup.com and sign-in (or create) a secure member account. Members must present the Ameritas Eyewear Savings Card at time of purchase to receive the discount. Ameritas Managed Care Products Plan members are free to receive care from any dentist they choose. Their out-of-pocket expenses are generally lower when using PPO dentists, who have agreed to provide dental care at contracted fees. Over 83,000 PPO provider access points are available nationwide. PPO network dentists must meet our credentialing and quality assurance evaluation requirements. Pretreatment While we don't require a pretreatment authorization form for any procedure, we recommend them for any dental work you consider expensive. As a smart consumer, it's best for you to know your share of the cost up front. Simply ask your dentist to submit the information for a pretreatment estimate to our customer relations department. We'll inform both you and your dentist of the exact amount your insurance will cover and the amount that you will be responsible for. That way, there won't be any surprises once the work has been completed. Open Enrollment If a member does not elect to participate when initially eligible, the member may elect to participate at the policyholder's next enrollment period. This enrollment period will be held each year and those who elect to participate in this policy at that time will have their insurance become effective on the 1 st of their renewal month. Dependent Age The Patient Protection and Affordable Care Act signed into law in March 2010 requires that private medical insurers offering dependent coverage allow eligible dependents up to age 26. Although the regulations exempt stand-alone dental and vision plans in most states, we are providing this option to match your medical and ancillary coverage dependent age definitions. So we can make this as easy as possible for you, your policy will automatically be changed to reflect the new dependent age definition to age 26, with no impact to your current rates. If you currently have a dependent age higher than age 26, that will remain in place and only the part of the federal language that expands the dependent definition, e.g. marital status, will be implemented. Section 125 This plan is provided as part of the Policyholder's Section 125 Plan. Each employee has the option under the Section 125 Plan of participating or not participating in this plan. If an employee does not elect to participate when initially eligible, he/she may elect to participate at the Policyholder's next Annual Election Period. This document is a highlight of plan benefits provided by Ameritas Life Insurance Corp. as selected by your employer. It is not a certificate of insurance and does not include exclusions and limitations. For exclusions and limitations, or a complete list of covered procedures, contact your benefits administrator

15 OFG Block Dental Highlight Sheet High Dental Plan Summary Effective Date: 01/1/2013 Coinsurance HIGH w/ ORTHO Type 1 100% Type 2 50% Type 3 50% Deductible $50/Plan Year Type 2 & 3 Waived Type 1 No Family Maximum Maximum (per person) $1,000 per plan year Allowance 80th U&C Waiting Period Type 3 12 months Orthodontia Summary Allowance All Plan Designs: In Network, discounted fee. Out of Network, U&C. Coinsurance 50% Coverage for Adults No Lifetime Maximum (per person) $1,000 Waiting Period 12 months Sample Procedure Listing (Current Dental Terminology American Dental Association.) Type 1 Type 2 Type 3 Routine Exam (2 per benefit period) Bitewing X-rays (1 per benefit period) Full Mouth/Panoramic X-rays (1 in 5 years) Periapical X-rays Cleaning (2 per benefit period) Fluoride for Children 13 and under (1 per benefit period) Sealants (age 13 and under) Space Maintainers Restorative Amalgams Restorative Composites Periodontics (nonsurgical) Denture Repair Simple Extractions Onlays Crowns (1 in 10 years per tooth) Crown Repair Endodontics (nonsurgical) Endodontics (surgical) Periodontics (surgical) Prosthodontics (fixed bridge; removable complete/partial dentures) (1 in 10 years) Complex Extractions Anesthesia Monthly Rates Employee Only $40.30 Employee + Spouse $82.34 Employee + Children $88.28 Employee + Spouse & Children $ Ameritas Information We're Here to Help This plan was designed specifically for the associates of OFG Block. At Ameritas Group, we do more than provide coverage - we make sure there's always a friendly voice to explain your benefits, listen to your concerns, and answer your questions. Our customer relations associates will be pleased to assist you 7 a.m. to midnight (Central Time) Monday through Thursday, and 7 a.m. to 6:30 p.m. on Friday. You can speak to them by calling toll-free: For plan information any time, access our automated voice response system or go online to ameritasgroup.com/member.

16 OFG Block Dental Highlight Sheet Rx Savings Our valued plan members and their covered dependents (even their pets) can save on prescription medications through any Walmart or Sam's Club pharmacy across the nation. This Rx discount is offered at no additional cost, and it is not insurance. To receive the Walmart Rx discount, Ameritas plan members just need to show their original Ameritas ID card. The identifier is the Ameritas logo. It's that easy. Or members can visit us at ameritasgroup.com and sign into (or create) a secure member account where they can print off an online-only Rx discount savings ID card. Eyewear Savings Ameritas plan members may receive up to 15% off eyewear frames and lenses purchased at any Walmart Vision Center nationwide. Members may also bring in their current vision prescription from any vision care provider and purchase eyewear at Walmart. This savings arrangement is not insurance: it is available to members at no additional cost to their plan premium. To receive the eyewear savings identification card, Ameritas plan members can visit ameritasgroup.com and sign-in (or create) a secure member account. Members must present the Ameritas Eyewear Savings Card at time of purchase to receive the discount. Dental Rewards This dental plan includes a valuable feature that allows qualifying plan members to carryover part of their unused annual maximum. A member earns dental rewards by submitting at least one claim for dental expenses incurred during the benefit year, while staying at or under the threshold amount for benefits received for that year. Employees and their covered dependents may accumulate rewards up to the stated maximum carryover amount, and then use those rewards for any covered dental procedures subject to applicable coinsurance and plan provisions. If a plan member doesn't submit a dental claim during a benefit year, all accumulated rewards are lost. But he or she can begin earning rewards again the very next year. Benefit Threshold $500 Dental benefits received for the year cannot exceed this amount Annual Carryover Amount $250 Dental Rewards amount is added to the following year's maximum Maximum Carryover $1,000 Maximum possible accumulation for Dental Rewards Ameritas Managed Care Products Plan members are free to receive care from any dentist they choose. Their out-of-pocket expenses are generally lower when using PPO dentists, who have agreed to provide dental care at contracted fees. Over 83,000 PPO provider access points are available nationwide. PPO network dentists must meet our credentialing and quality assurance evaluation requirements. Pretreatment While we don't require a pretreatment authorization form for any procedure, we recommend them for any dental work you consider expensive. As a smart consumer, it's best for you to know your share of the cost up front. Simply ask your dentist to submit the information for a pretreatment estimate to our customer relations department. We'll inform both you and your dentist of the exact amount your insurance will cover and the amount that you will be responsible for. That way, there won't be any surprises once the work has been completed. Open Enrollment If a member does not elect to participate when initially eligible, the member may elect to participate at the policyholder's next enrollment period. This enrollment period will be held each year and those who elect to participate in this policy at that time will have their insurance become effective on the 1 st of their renewal month. Dependent Age The Patient Protection and Affordable Care Act signed into law in March 2010 requires that private medical insurers offering dependent coverage allow eligible dependents up to age 26. Although the regulations exempt stand-alone dental and vision plans in most states, we are providing this option to match your medical and ancillary coverage dependent age definitions. So we can make this as easy as possible for you, your policy will automatically be changed to reflect the new dependent age definition to age 26, with no impact to your current rates. If you currently have a dependent age higher than age 26, that will remain in place and only the part of the federal language that expands the dependent definition, e.g. marital status, will be implemented. Section 125 This plan is provided as part of the Policyholder's Section 125 Plan. Each employee has the option under the Section 125 Plan of participating or not participating in this plan. If an employee does not elect to participate when initially eligible, he/she may elect to participate at the Policyholder's next Annual Election Period. This document is a highlight of plan benefits provided by Ameritas Life Insurance Corp. as selected by your employer. It is not a certificate of insurance and does not include exclusions and limitations. For exclusions and limitations, or a complete list of covered procedures, contact your benefits administrator

17 Ameritas Dental Insurance U&C We determine the Usual & Customary (U&C) allowance listed on the plan summary page using information including data from Ingenix, a multi-carrier compilation formerly derived by the Health Insurance Association of America (HIAA). Plan members are reimbursed based on the appropriate charges in the dentist s Zip Code area. We review our U&C allowances annually. ~ 80 th U&C means 8 out of 10 dentists in a specific Zip Code area charge at or below the plan allowance for a procedure.

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20 OFG Financial Services, Inc Eye Care Highlight Sheet Focus Plan Summary SIGNATURE PLAN Effective Date: 1/1/2013 VSP Network Out of Network Deductibles $15 Exam $15 Exam $15 Eye Glass Lenses or Frames* $15 Eye Glass Lenses or Frames* Annual Eye Exam Covered in full Up to $52 Lenses (per pair) Single Vision Covered in full Up to $55 Bifocal Covered in full Up to $75 Trifocal Covered in full Up to $95 Lenticular Covered in full Up to $125 Progressive See lens options NA Contacts Fit & Follow Up Exams 15% discount No benefit See Additional Focus Features. Elective Up to $120 Up to $105 Medically Necessary Covered in full Up to $210 Frames $120 Up to $45 Frequencies (months) Exam/Lens/Frame 12/12/24 12/12/24 Based on date of service Based on date of service *Deductible applies to a complete pair of glasses or to frames, whichever is selected. Lens Options (member cost)* VSP Network Out of Network Progressive Lenses $60-$119 No benefit Std. Polycarbonate Covered in full for dependent children No benefit $25 - $35 adults High Luster Edge Polish $14 No benefit Solid Plastic Dye $13 No benefit (except Pink I & II) Plastic Gradient Dye $15 No benefit Photochromatic Lenses $27-$76 No benefit (Glass & Plastic) Scratch Resistant Coating $15-$29 No benefit Anti-Reflective Coating $39-$61 No benefit Ultraviolet Coating $15 No benefit Lasik or PRK Average discount of 15% off retail. See Additional Focus Features. No benefit *Lens Option member costs vary by prescription and option chosen. Monthly Rates for Active Employees Employee Only $15.80 Employee + Spouse $31.50 Employee + Children $30.24 Employee + Spouse & Children $46.84

21 OFG Financial Services, Inc Eye Care Highlight Sheet Additional Focus Features Contact Lenses Elective Additional Glasses Laser VisionCare Low Vision Cost of the fitting and evaluation is deducted from the allowance and any amount left is deducted from the material allowance. Allowance can be applied to disposables, but the dollar amount must be used all at once (provider will order 3 or 6 month supply). Applies when contacts chosen in lieu of glasses. 20% discount off the retail price on additional pairs of prescription glasses (complete pair). VSP offers an average discount of 15% on LASIK and PRK. The maximum out-of-pocket per eye for members is $1,800 for LASIK and $2,300 for custom LASIK using Wavefront technology, and $1,500 for PRK. In order to receive the benefit, a VSP provider must coordinate the procedure. With prior authorization, 75% of approved amount (up to $1,000 is covered every two years). Eye Care Plan Member Service Focus eye care from Ameritas Group features the money-saving eye care network of VSP. Customer service is available to plan members through VSP's well-trained and helpful service representatives. Call or go online to locate the nearest VSP network provider, view plan benefit information and more. Contact us for toll-free benefit questions during your enrollment at After the member is effective, he/she can contact : VSP Call Center: Service representative hours: 7 a.m. to 9 p.m. CST Monday through Friday, 8 a.m. to 4:30 p.m. CST Saturday Interactive Voice Response available 24/7 Locate a VSP provider at: ameritasgroup.com/member View plan benefit information at: vsp.com Section 125 This plan is provided as part of the Policyholder's Section 125 Plan. Each employee has the option under the Section 125 Plan of participating or not participating in this plan. If an employee does not elect to participate when initially eligible, he/she may elect to participate at the Policyholder's next Annual Election Period. This document is a highlight of plan benefits provided by Ameritas Life Insurance Corp. as selected by your employer. It is not a certificate of insurance and does not include exclusions and limitations. For exclusions and limitations, or a complete list of covered procedures, contact your benefits administrator.

22 Tired of rising healthcare costs? Put the power of healthcare savings into your own hands. Flexible Spending Accounts, or FSAs, are a great way for you to take advantage of a pre-tax benefit account offered through your employer. These accounts are a simple way for you to save on outof-pocket healthcare costs not covered by your insurance plan. With healthcare costs continuing to rise, why wouldn t you participate in an FSA? By taking advantage of your FSA, you can: Reduce your taxes Increase your take-home pay Pay for rising healthcare expenses with pre-tax dollars For more information, contact your plan administrator or human resources department. Still unsure about FSAs? Take a look inside. MasterCard is a registered trademark of MasterCard International Incorporated. This card is issued by M&I Bank FSB pursuant to license by MasterCard International Incorporated.

23 FSA popularity is in dollars and sense. A remarkable $20 billion is put into FSA accounts annually by employees just like you. An FSA can be used for healthcare costs, such as doctor co-pays, LASIK surgery, eyeglasses, contact lenses, orthodontics, eligible over-thecounter products *, prescriptions and much more. Let s start with the definition of an FSA. Quite simply, it stands for Flexible Spending Account and it can be an indispensable part of your overall benefits program. Here s how it works. An FSA is an account your employer sets up so you can pay for a variety of healthcare needs, like insurance co-pays, deductibles, specific over-the-counter healthcare products and even some dental and vision-care costs. But here s the best part: your FSA is funded entirely by your pre-tax income. So you can save money and offset rising healthcare costs. And the more dependents you have, the greater your savings! * Effective January 1, 2011, over-the-counter medicines and drugs that are not prescribed by a physician will not qualify as a medical expense under IRS Code Section 213(d). Here s another way to look at an FSA: by setting aside healthcare funds pre-tax, you can increase your savings and ultimately your spending power. Below is an example of the tax savings you could enjoy by taking advantage of an FSA. With Without an FSA an FSA Annual Salary Before Taxes $30,000 $30,000 FSA Contribution - 1,500 0 Taxable Income $28,500 $30,000 Less Taxes - Federal Income Tax* (estimate 15%) - FICA 7.65% - 6,455-6,795 Less Healthcare Expenses 0-1,500 Take-Home Pay 22,045 21,705 Tax Savings $340 $0 * If your federal income tax rate is higher than 15 percent or if you pay state or local income taxes, you can save even more! Savings and convenience Although your FSA will be deducted through your payroll, you ll have access to your entire FSA contribution on the first day of your plan. That means you can cover all your healthcare costs without waiting to accumulate funds throughout the year. You can also plan for large healthcare expenditures, like surgery, because you choose how much to put into your FSA account. In addition, some employers may offer a plan extension that allows you to continue to spend unused FSA funds for an additional period of time after the plan year ends. Instant access and no paperwork. Of course, not all FSAs are created equal. Yours, for instance, is accessed via the Benefits Card Master- Card, provided by your employer. The Benefits Card lets you pay for eligible healthcare expenses virtually everywhere Debit MasterCard cards are accepted. Stretch your money further. Use your FSA dollars to purchase eligible over-the-counter products that you use every day it s simple! The Benefits Card makes using your FSA dollars simple and easy. The card deducts each payment directly from your FSA account. So it s as convenient as using an ordinary credit card. What s more, the Benefits Card virtually eliminates the endless paperwork and reimbursement wait time that used to make FSAs so complex and cumbersome. All you have to do is save receipts for all your FSA purchases in the event they are requested by your plan administrator. In many cases you won t have to send in a receipt, because with the Benefits Card, your purchases will be autosubstantiated at thousands of retailer locations nationwide.* Because they have an Inventory Information Approval System (IIAS) in place, these retailers will know instantly which items you purchase are eligible FSA purchases. With one swipe of your benefits card, approved purchases will be authorized and debited from your FSA account. You will be asked to remit another form of payment for the noneligible items. For optimal convenience, your Benefits Card offers 24/7/365 online access, so you can check your account balance and other vital information with a single click. To learn more about the benefits of FSAs and the Benefits Card, simply ask your employer. Once you know the facts, you ll discover that FSAs and the Benefits Card spell real savings. * For a complete list of retailers, contact your benefits administrator. Your Benefits Card provides instant access to your FSA dollars at the physician s office, emergency room, dentist, pharmacy and other eligible locations. The Benefits Card is fast, convenient, secure and simple to use. So sign up today and look for your Benefits Card in the mail.

24 SM Security Flex 125 Program Enrollment Booklet Save on Your Out-of-Pocket Medical and Dependent Care Expenses Save Money on FICA and Income Tax Handy Flex Card for Easy Payments Instant Access to 100% of Medical Account Value

25 Health Care Reform Changes affecting Security Flex 125 plan Over-the-counter medicines require a doctor s prescription. Effective January 1, 2011 no over-the-counter medicines, other than insulin, are eligible for reimbursement without a prescription. Examples of items that will require a prescription are: pain medication, cold medication and allergy medication. Over-the-counter items that are not medicine are still eligible for reimbursement without a prescription. Examples of items that are still eligible without a prescription are: Bandages, ace wraps, crutches and contact lens solution. Over-the-counter items that require a prescription are not able to be purchased with the flex debit card. These items will require a manual claim to be submitted. Limitation on Salary Reductions Beginning January 1, 2013 Health care reform imposes a $2,500 limit on annual salary reduction contributions to medical reimbursement FSAs effective for taxable years beginning January 1, The $2,500 limit is a calendar-year limit that applies to all plans. The limit is a flat dollar amount and applies on a perparticipant basis. The $2,500 amount is indexed for inflation for taxable years after December 31, Table of Contents Can You Use More Spendable Income? Qualifying expenses Submitting Claims Security Benefit s Flex Convenience Card Security Flex 125 Reimbursement Claim Form...14 Security Flex 125 Employee Benefit New Year Enrollment Form Employee Benefit Worksheet Advantages To You: 1. Save money on taxes by contributing to your account with pre-tax dollars. 2. Security Benefit funds 100% of your medical expense account from day one, so you don t have to wait for the benefits of participating. 3. Avoid the hassle of paperwork by using the handy Flex Card to pay for eligible medical expenses like prescriptions or co-pays. ENROLLMENT BOOKLET Participants in the Security Flex 125 Flexible Benefits plan can experience the following tax savings by funding their medical and dependent care expenses with pre-tax dollars: 1 Federal Income Tax (Filing jointly, taxable income not over $61,300) 15.00% + Social Security 7.65% + Estimate of State Tax Savings % Total Savings 27.65% 1 FICA withholding may vary by state and employer. State income tax savings vary by state and are not applicable in states without income tax and in PA and NJ. 2 Based on estimated rates. Please see page 11 for important information regarding the Security Benefit Flex 125 convenience card. 1 SECURITY FLEX 125 PROGRAM

26 CAN YOU USE MORE SPENDABLE INCOME? Why Pay Taxes That You Don t Have to Pay The Security Flex 125 Program offered through your employer allows you to pay less in taxes and take home more of your hard earned income. Here s how it works. Section 125 of the Internal Revenue Code allows employers to set up Flexible Spending Accounts for medical and child care expenses as part of their cafeteria plans. As an employee, you can set aside part of your income on a pre-tax basis for medical and/or child care expenses that you will incur over the course of the year. Then, after you pay for child care or eligible medical expenses, you simply submit the bill or receipt with the proper form and you will be reimbursed for your expenses from the Flexible Spending Account. Here s how the Security Flex 125 Program can help increase your spendable income: Employee Savings With Medical Care Services Without With 125 Plan 125 Plan Gross Pay $36, $36, Medical and Dental Plan Premiums Non-reimbursed Medical Expenses Total Taxable Income (for Federal Purposes) $36, $34, Deductions From Pay* Federal Withholding $ 5, $ 5, State Withholding 1, , FICA and Medicare Tax 2, , Medical and Dental Plan Premiums Total Income Deductions $ 9, $ 8, Take Home Pay Total Taxable Income $36, $34, Non-reimbursed Medical Expenses Income Deductions 9, , After-Tax Take Home Compensation $25, $25, *Federal, State and FICA tax vary from state to state. By using the Flexible Spending Account for medical expenses, you could have an increase in your spendable income of almost $25 per month. That s an annual increase of almost $300. ENROLLMENT BOOKLET SECURITY FLEX 125 PROGRAM 2

27 Employee Savings With Dependent Care Services Without With 125 Plan 125 Plan Gross Pay $36, $36, Non-reimbursed Dependent Care Expenses , Total Taxable Income (for Federal Purposes) $36, $31, Tax Deductions From Pay* Federal Withholding $ 5, $ 4, State Withholding 1, , FICA and Medicare Tax 2, , Medical and Dental Plan Premiums Total Income Deductions $ 9, $ 8, Take Home Pay Total Taxable Income $36, $31, Non-reimbursed Medical Expenses 4, Income Deductions 9, , After-Tax Take Home Compensation $22, $23, *Federal, State and FICA tax vary from state to state. By using the Flexible Spending Account for child care expenses, you could have an increase of over $90 per month in your spendable income. That s an annual increase of almost $1,100. While most medical and child care expenses are eligible for reimbursement, some restrictions do apply. Read the Security Flex 125 booklet carefully before enrolling in the plan. You must be enrolled by your employer s deadline to participate in the program, so contact your employee benefits personnel today to learn more about how you can benefit from the Security Flex 125 Program! ENROLLMENT BOOKLET 3 SECURITY FLEX 125 PROGRAM

28 What Qualifies Medical Expenses* The medical reimbursement account will set aside part of your income on a pre-tax basis for medical expenses that you will incur during the coverage period. The coverage period is the effective date of the plan or the date the employee enrolls in the plan through the plan year or grace period end date. Expenses are incurred when the service is provided and not when the employee is formally billed, charged for, or pays for the medical care. Medical expenses include payments you make for the diagnosis, treatment or prevention of disease or for the treatment affecting any part or function of the body. Samples of these expenses would include charges and co-pays for medical appointments, Lasik eye surgery and prescription medications. Cosmetic procedures are not eligible for reimbursement. Any expenses reimbursed through your account cannot be claimed for income tax purposes. The following is a partial listing of medical expenses which are allowed and disallowed through your FSA. Please refer to IRC Section 213(d) for a complete listing of allowed expenses. You are also able to find additional details on eligible expenses on our website under the Forms section. ALLOWED MEDICAL EXPENSES Acupuncture Ambulance Chiropractor fees Coinsurance (co-pays and deductibles for health, dental and vision) Corrective eye surgery Crutches (purchase or rental) Hearing aids and hearing aid batteries Hospital services Immunizations Insulin and equipment needed to inject the insulin Laboratory fees Medicines (prescriptions) Organ donation/transplantation Orthodontic fees Over the counter medicines (with prescription) Prescription eyeglasses, sunglasses, Contact Lenses and solutions associated with their care Physical, Dental and Eye exams Reading glasses Surgery/operations Weight-loss program and/or drugs to induce weight loss when prescribed for a specific diagnosis Well-child care Wheelchair X-ray fees DISALLOWED MEDICAL EXPENSES Chapped lip treatments Cosmetic surgery (expenses exceptions if medically necessary) Dancing lessons, swimming lessons, etc., even if recommended for the general improvement of your health Electrolysis or hair removal Face creams, moisturizers, suntan lotions Funeral Expenses Hair transplant (i.e. Rogaine, Propecia) Insurance premiums for individual and/or spouses health, dental, and/or policies covering loss of earnings, loss of a limb or eyesight Maternity clothes Medicated shampoos and soaps (unless prescribed by a doctor) Teeth Bleaching Toiletries Toothbrushes, toothpaste Vitamins and supplements for maintaining general good health ALLOWED OVER-THE-COUNTER MEDICATIONS Reimbursable: Bandaids, bandages, gauze pads, first aid kits Cold/hot packs for injuries, crutches Contact lens solution, cleaners Carpal tunnel wrist supports Condoms, spermicidal foam Insulin Nasal strips for snoring Orthopedic shoe inserts Pregnancy test kits Reading glasses Thermometers (ear or mouth) *It is possible that changes in the IRS rules can affect the Allowed and/or Disallowed Expenses categories. ENROLLMENT BOOKLET SECURITY FLEX 125 PROGRAM 4

29 Dependent/Day Care Expenses* The dependent care account will set aside part of your income on a pre-tax basis for child/dependent care expenses that you incur during the coverage period. The coverage period is the effective date of the plan or the date the employee enrolls in the plan through the plan year or grace period end date. Expenses are incurred when the service is provided and not when the employee is formally billed, charged for, or pays for the dependent care. Expenses include payments made for the care of a child under 13 and/or a dependent regardless of age who requires care due to an inability to care for him or herself, to enable you (and, if married, your spouse) to remain gainfully employed. For dependents to be eligible, they must spend at least eight hours a day in your home. You must declare them as dependents (or have the ability to declare them as dependents except for their level of gross income) on your Federal tax return. Reimbursement for amounts cannot be claimed if paid to your spouse or tax dependent. Any expenses reimbursed through your account cannot be claimed for income tax purposes. Reimbursements can only be received up to the amount deposited for your payroll deductions. The following is a partial listing of dependent care expenses which are allowed and disallowed through your FSA. You are also able to find additional details on eligible expenses on our website under the Forms section. Please remember day care expenses must be incurred to be eligible for reimbursement. ALLOWED DEPENDENT/ DAY CARE EXPENSES Licensed day care facility Preschool program In-home child and dependent care services Day camp expenses Elder care Any other qualified dependent care expenses as defined by the IRS DISALLOWED DEPENDENT/ DAY CARE EXPENSES Overnight camp Services solely for the purpose of household cleaning Day care for children past their 13th birthday ENROLLMENT BOOKLET *It is possible that changes in the IRS rules can affect the Allowed and/or Disallowed Expenses categories. 5 SECURITY FLEX 125 PROGRAM

30 Submitting Claims You may send in claims throughout the year. Only claims for services incurred during the coverage period are eligible for reimbursement. The coverage period is the effective date of the plan or the date the employee enrolls in the plan through the plan year or grace period end date. Expenses are incurred when the service is provided and not when the employee is formally billed, charged for, or pays for the services. Expenses must be incurred before reimbursement can be made. For example, if you prepay your day care provider at the first of the month or if you are required to pay for dental expenses prior to the services being provided, you cannot submit a claim for those expenses until the services have been received. IRS regulations specifically mandate, A flexible spending account cannot make advance reimbursement of future or projected expenses. It is important that you plan your deposits carefully. Please remember that unused amounts may not be carried forward in the next plan year. In accordance with Internal Revenue Service guidelines, money remaining in the plan at the end of the plan year will be forfeited if a claim for reimbursement is not submitted by the end of the run-out period. The run-out period is the 90 day period following the end of the plan year or grace period, if applicable. A claim form must be completed and signed when submitted a flexible spending claim. You must attach legible copies of itemized receipts, statements, or an explanation of benefits from your insurance provider. An itemized receipt must include The provider name and address Date of service For whom the service was provided Charges for the service Service(s) that were provided ENROLLMENT BOOKLET SECURITY FLEX 125 PROGRAM 6

31 Submitting Claims (continued) Common reasons claims may be denied or delayed Statements showing balance due or received on account Claim forms received without a signature Services not incurred during the coverage period The claim form provides a space for you to itemize your claim. This is useful when you have multiple items with varying amounts. The worksheet allows you to review your claims and ensure that they contain all the required information. Medical reimbursement claims are processed within three to five business days after they are received in good order. You should receive reimbursement of your claims within seven to ten business days. Dependent care reimbursement can only be paid up to the amount of deposits received in your account. If a claim is received for more than your deposits the claim will be placed on-hold waiting on additional deposits to be received. You will need the provider s name and address, social security number or tax identification number for your records. Dependent care claims are processed within one to three business days after they are received in good order. You should receive reimbursement of your claims within five to seven business days. Please note: All claims received will be retained at Security Benefit and will not be returned once received. Example John River pays his day care provider on March 1 for March day care. He immediately sends in his claim for reimbursement. Why doesn t he receive his reimbursement until the end of the month? Answer The IRS has indicated that expenses are not reimbursable until the expense has been incurred. Day care expenses claimed are for the time you and your spouse go to work. Therefore, expenses will not be incurred until the end of March. Your claim will be held until the end of the month before being processed. ENROLLMENT BOOKLET You should check with your employer to determine when the dependent care deposits will be sent to Security Benefit. According to IRS regulations, dependent care reimbursements cannot be made until Security Benefit has received the employer s deposit. Therefore, your claim could be received, processed and pended until the employer s deposit is received. Once that deposit and your claim have been received, a payment will be mailed to you or an automatic deposit will be directed to your bank. 7 SECURITY FLEX 125 PROGRAM

32 Reasons Why Claims May Not Be Reimbursed All claims received will be processed. However, only those claims that are eligible for reimbursement according to IRS regulations will be reimbursed. Claims received that are not eligible for reimbursement will be kept in your Security Benefit file. You will receive a letter indicating the reason that the claim is ineligible for payment. If you have some claims that are reimbursable and some that are not, you will receive a statement. The statement of benefits will list the reasons why ineligible claims could not be paid. Many scenarios exist that may prevent or delay processing of a claim. The most frequent reasons are listed below. The boldfaced portion will appear on your statement as listed below. Please refer to this list to troubleshoot your claim. Reasons Cosmetic expense ineligible Per IRS regulations cosmetic procedures do not qualify. This includes cosmetic surgery or other procedures that are for improving the patient s appearance and don t meaningfully promote the proper function of the body or prevent or treat illness /disease. Covered by insurance Explanation of Benefit shows the insurance provider paid the expense. Date of Service in the future Reimbursement for future expenses are not eligible for reimbursement. Duplicate receipt The expense has been received for reimbursement previously. Expense incurred outside of plan dates The expenses submitted were not within your plan year. Only expenses incurred within the plan year, prior to your last date of employment, are eligible for reimbursement. Expense incurred prior to employment or after termination of employment Expenses incurred prior to your employment or after termination date are not eligible for reimbursement. Ineligible Expense Expense not eligible according to IRS requirements. Insufficient funds You have received reimbursement for your maximum election for the current plan year; therefore, no further reimbursement is available. Insurance premium ineligible Insurance premiums are not a qualifying expenses. Itemized receipt required Please submit an itemized statement for the claim. Itemized statements should include: provider name and address, date of service, patient name, unreimbursed charges for the services, services provided or an EOB from your insurance company. Maximum contribution paid out You have received reimbursement for your maximum election for the current plan year; therefore, no further reimbursement is available. ENROLLMENT BOOKLET SECURITY FLEX 125 PROGRAM 8

33 Reasons (continued) No Claim Form Received Please submit a signed claim form with your itemized receipt. Offset ineligible transaction The reimbursement request was used to offset an overpayment on the account. Over-the-counter needs prescription As of January 1, 2011 IRS requires all over-thecounter medications to have a prescription. Plan year deadline expired Claims incurred during your plan year must be submitted no later than 90 days after the plan year ends. We received your claim after this time as a result no payment is available. Receipt unreadable The documentation that was received was not a readable copy. Received on account ineligible Documentation received shows balance due or amount paid. Itemized statements should include: provider name and address, date of service, patient name, unreimbursed charges for the services, services provided or an EOB from your insurance company. Signature required All forms must be signed by the participant. You will have 180 days following receipt of this notification in which to appeal the decision. Appeals should be directed to: Benefit Claims Administration ERISA Appeals Administrator PO Box Topeka KS You may submit written comments, documents, records and other information relating to the claim. If you request, you will be provided reasonable access to and copies of all documents, records and other information relevant to the claim free of charge. Upon receipt of additional information related to the claim, we will review the claim and provide a written response to the appeal within 60 days. (This period may be extended an additional 60 days under certain circumstances.) You also have the right to bring a civil action under section 502 of ERISA following denial of a claim. ENROLLMENT BOOKLET 9 SECURITY FLEX 125 PROGRAM

34 Service Options Web Access The 24-hour website for your Section 125 Flexible Spending Account is You will need to create an account for first-time login. To create your account you will need your Flex Convenience Card number or your Employer Identification Number. The employer identification number can be found on your welcome letter. Fax Access For 24-hour toll-free fax access for flex reimbursement, call: Phone Access For personalized telephone support, call toll free, Monday-Friday from 8:00 am to 5:00 pm Central Time. Paperless Communication You can receive paperless communication regarding your flexible spending account by providing your address. Please login to the website and update your address or and request your address be added to your account. Providing your address will allow you to receive quarterly balance summaries, year-end reminders, communications on your claims once they are processed. If your address is not on file you will not receive quarterly balance statements. You will receive one reminder at year end via mail. ENROLLMENT BOOKLET SECURITY FLEX 125 PROGRAM 10

35 Important Information Regarding the Flex Convenience Card (Mbi Benefits Card ) Purchases made with the Flex Convenience card (Mbi Benefits Card ) may still require proof of charges and claims. Below are some guidelines your must follow when making purchases with your card. IRS regulations require that you keep copies of receipts and invoices on all purchases made with your card or any other submitted claims within your Flex Spending Account. Security Benefit may also request a copy of your receipt and invoices for charges paid through your Flex Convenience card. Your receipt and/or invoices must show: o Name of provider o Date of purchase o The item or services purchased o Your cost o Name of person for whom the purchase was made (i.e. child s doctor appointment, spouse s prescriptions, etc.) If you receive a letter or notification requesting more information/documentation and do not respond, your Flex Card will be turned off. You will typically have 10 days to respond after the date of the notice. If you have a recurring expense that is an odd dollar amount or over $ Please call: and we will enable your card to accept the recurring expense. (e.g. orthodontia, prescriptions, etc.) The Flex Convenience card may not be accepted in all locations. Please check with your pharmacy or drug store before placing your order. As of July 2009, the IRS requires all Drug Stores and Pharmacies to have their UPC Codes on the standardized System. This means some of the smaller stores may no longer accept the Flex Cards if they have not updated their system. If you accidentally use the card for ineligible expenses you will be required to send a check or money order to refund the charge back to the plan. If the refund is not received we will request your employer withhold the amount from your pay on an after-tax basis. If you need further assistance with a claim/card reimbursement please contact us at ENROLLMENT BOOKLET 11 SECURITY FLEX 125 PROGRAM

36 Security Benefit s Flex Convenience Card (Mbi Benefits Card ) FAQ What is the Mbi Benefits Card? The Mbi Benefits Card is a debit card that can simplify the process of paying for eligible expenses. It is an alternative to the traditional method of filing claims. You can use the card at qualifying merchant locations wherever MasterCard is accepted from physician and dental offices to pharmacies and vision service locations. Exactly what is the convenience of the card? The card allows you to pay for eligible expenses at the point of service. The convenience is: Immediate access to FSA account you avoid paying with cash or check Immediate payment of the expense you avoid waiting for a reimbursement check Claim form for documentation provided to you by mail or The ease of use at the point of sale and the reduced burden of having to pay money out-of-pocket, completing a claim form and waiting for a reimbursement has proven to be extremely convenient for plan participants. How does the Mbi Benefits Card work? The Mbi Benefits Card is accepted only at certain merchants. This includes physician offices, hospitals, dental offices, pharmacies (including mail order), hearing/vision care provides, etc. As you incur health care expenses, you present your card for payment. The card system will validate that your coverage is active and that you have available funds to cover the transaction. You must retain documentation of the expense, as you may be required to substantiate transactions in some cases by providing copies of the documentation. We recommend that you keep all documentation in a separate envelope for the entire plan year in the event the information is requested. For example, itemized receipts listing the merchant name, name of the item/product, date and amount will be requested for all over-the-counter purchases. Use the card only for qualifying expenses, otherwise, you ll have to write a check back to the plan or the card will be deactivated. The card works great for prescription drug or office visit co-pays. If you purchase a prescription drug along with non-qualifying items, be sure to ask the merchant to ring up the prescription separately so that you can use the card. You can use the card for other health expenses, including medical, dental, vision and hearing. The card is valid for a three-year period and will contain information regarding your current plan year election. Each year when you re-enroll, the card will reflect that plan year election amount(s). Is this process paperless? No. Although there is no requirement for you to complete conventional claim forms, additional documentation will be required in order to meet IRS guidelines. Therefore, you must keep copies of all receipts and itemized statements (not the credit card receipt) for each purchase for the entire plan year. You ll receive a letter, or , requesting the documentation and you will be required to submit this information to substantiate the expense according to IRS regulations. You will need to return the signed letter, or , along with the documentation. DO NOT SEND IN THE REQUESTED INFORMATION ON A REGULAR CLAIM FORM. In some cases, you will not need to send in documentation. This occurs when your expense matches a copay that is preset to match copays that may apply to your employer s health insurance. What type of additional documentation is required? The documentation is the same information required for traditional paper claim forms. You must keep copies of all transaction receipts for each card purchase so that these can be provided to the administrator upon request. This includes itemized cash register receipts that list the merchant name, name of the item/product, date and amount (for items such as hearing aid batteries, contact lens solutions or over-the-counter medicines/drugs), insurance plan Explanation of Benefit (EOB) statements, and itemized statements (for vision or other health care expenses). (It does not include the credit card receipt.) For prescription drugs purchased at a pharmacy, this would include the pharmacy receipt (or you can request a printout from your pharmacy). Whenever possible, however, you should purchase prescriptions through any available mail-order service as this not only reduces your costs, it can also help reduce or even eliminate the documentation requirements! We recommend you keep all documentation in a separate envelope at home or work for the entire plan year. REMEMBER, THIS DOCUMENTATION NEEDS TO BE RETURNED ALONG WITH THE SIGNED LETTER, OR . ENROLLMENT BOOKLET SECURITY FLEX 125 PROGRAM 12

37 Security Benefit s Flex Convenience Card (Mbi Benefits Card ) FAQ ENROLLMENT BOOKLET What happens if I forget to reply to the letter requesting additional documentation? In the event the request for additional information is ignored, a second letter is generated giving you additional time to respond. If there is no reply to the second request, collection procedures will begin. The card will be deactivated and you will be required to make reimbursement to the plan by personal check. What happens if I accidentally use the card for ineligible or non-qualifying expenses? Be sure to have merchants ring up your qualifying expenses separately from your other personal items so you can use the card. In the event the card is misused, you will be required to write a personal check back to the plan. If you do not reimburse the plan, the card will be deactivated and collection procedures will begin. In addition, your employer will be contacted. Are there any limitations on the usage of the card? Aside from the specific merchant codes and the plan year election amount, there are no limitations. There are no transaction fees, and you have unlimited use of the card. Remember, though, that you must use the card for qualifying items only! Will I receive a cardholder agreement? Yes, you will receive a Fund Transfer Disclosure Statement (cardholder agreement) that you should carefully read and must abide by. You must also read the back of your convenience card, and sign it. By using the card, you agree to the provisions of the cardholder agreement. That is, you agree to use the card only for qualifying expenses, and to provide documentation upon request. Must I use the card for all expenses I incur? No. During the plan year, you can file traditional paper claims or use the Mbi Benefits Card. Remember, the card is valid for a three-year period, so if you choose not to use it at all, we recommend you keep the card in a safe and secure place in the event you wish to use it in future years. Will I receive a statement or an accounting of my Mbi Benefits Card transactions? All transactions, whether they are paper claims or card transactions, will be reflected on your periodic statements provided by Security Benefit. You can also access our web site at How do I report a lost or stolen card? Lost or stolen cards must be reported as soon as possible. During our normal hours of operation, contact us at Before or after business hours and weekends, lost or stolen cards may be reported at There is a $10.00 fee for card replacement for any reason. Can I order a card for my dependents? Yes. You can order an extra convenience card for your spouse or college student by completing the application provided. Please be certain that your dependent fully understands how to appropriately use the card for qualifying expenses only, and that they retain copies of documentation of each transaction. There is a one-time cost of $5.00 for one additional card. What happens if I have a $1,000 limit on my Mbi Benefits Card, but I have a $1,500 transaction? Transactions exceeding your card limit or available balance will be rejected. For this reason, as you use the convenience card throughout the year, you should check your available balance at www. securitybenefit.com. This way you will know how much is available and you can request that the merchant charge only up to the available balance on the card. You may pay for the transaction and file a claim. Your reimbursement would only be for the amount of money you elected, minus the card fee and any other expenses incurred previously. You would not be able to get more reimbursements during the plan year either using the card or by claim forms as you would exceed your election amount. If I terminate employment, can I continue to use the Mbi Benefits Card? No. The card is inactivated at that time. If you have qualifying expenses to submit after your termination of employment, you can use the traditional method of filing a claim form with appropriate documentation. Claim forms are available on the web site. (Remember, though, that your qualifying expenses must be incurred during your period of coverage.) 13 SECURITY FLEX 125 PROGRAM

38 Questions? Call our National Service Center at Security Flex 125 Program Medical/Dependent Care Reimbursement Program Claim Form Instructions Use this form to request medical expense or dependent care reimbursement. Please type or print. 1. Complete all sections of the form and attach legible copies of itemized statements or an Explanation of Benefits from your insurance provider. 2. You must sign Section 2 of this form. If the form is not signed, your claim will not be processed. 3. Claims may be submitted by fax, or postal mail. Please retain a copy for your records. 4. Claims must be submitted in good order prior to the run-out date in your plan. 5. Do not use this claim form for Flex Convenience Card transactions or a claim that was submitted online. 1. Provide Personal Information Employer Name Social Security Number Daytime Phone Name of Employee First MI Last Mailing Address Street Address City State ZIP Code Check if address change Address By providing an address you consent to receive electronic communications regarding your Flexible Spending Account via . You are able to update your address at or by contacting Security Benefit by phone, , or postal mail. 2. Provide Signature I agree: That this claim represents qualifying medical or dependent care expenses not covered/reimbursed by insurance. My signature below confirms my understanding and agreement with this requirement. I further understand that any claim that does not meet these requirements may result in this payment being considered a taxable payment by the IRS. I understand that the direct deposit arrangement will continue until Security Benefit receives written notification from me stating otherwise. This is to certify that I have incurred expenses that qualify for reimbursement under my employer s Security Benefit Medical/Dependent Care Reimbursement Program. None of these expenses have previously been submitted. I certify that these expenses will not be paid or reimbursed by any insurance company or from any other source or I may be subject to IRS fines and/or penalties of perjury. I hereby request reimbursement for these expenses to the extent allowable. I understand that at the end of the plan year all unpaid claims (even if less than $25.00) will be reimbursed in full and that any remaining fund balances at the end of the plan year will be forfeited to my employer. By providing an address, I consent to receive all communications regarding this plan via . x Signature of Employee Date (mm/dd/yyyy) Please Continue /02/12 (1/2)

39 3. Provide Summary of Itemized Bills Dependent Care Expenses (DCA) Provider Name Dependent Name Age Date of Service Requested Amount See IRC Section 129 for qualifying DCA expenses. Total DCA Request Unreimbursed Medical Expenses (FMR/FSA) Provider Name Patient Name Description of Service Date of Service Requested Amount See IRC Section 213 for qualifying FMR/FSA expenses. Total FMR/FSA Request 4. Reimbursement Method Request reimbursement by direct deposit Request reimbursement by check Please provide your bank information below if you wish to have payments from Security Benefit made by direct deposit to your bank account. If any information is missing your request may be delayed. You may also attach a void check to ensure necessary information is provided. Receipt by said bank of such credit entries shall be deemed receipt by you. Bank Account Type (please check one): Checking Savings Bank Name Name on Bank Account Bank Routing Number Bank Account Number (Do not include the check number) DO NOT INCLUDE CHECK NUMBER Routing Number Account Number Date 0001 $ Dollars For additional information on eligible expenses you may also review the Qualified Expense Chart available on our website under the Forms section. Mail to: Security Benefit PO Box Topeka, KS or Fax to: Visit us online at ebdept@securitybenefit.com /02/12 (2/2)

40 EMPLOYEE BENEFIT WORKSHEET Planning to save is easy! This simple worksheet helps you estimate your expenses for the plan year. Estimated Dependent Care Expenses: Dependent care required for you and your spouse to continue working. Total Estimated Dependent Care Expenses for this plan year: $ Estimated Out of Pocket Medical Expenses (for you, your spouse and any tax dependents): Medical Insurance Premiums of any kind are not covered Medical Co-pays: Coinsurance Prescription Drugs $ /plan year $ /plan year $ /plan year Over-the-counter Medication (see eligible expenses) $ /plan year Dental Coinsurance Orthodontia Non-covered (major services) Hearing Coinsurance/Exams Hearing Aid Vision Coinsurance/Exams Glasses Contact Lenses Corrective Eye Surgery $ /plan year $ /plan year $ /plan year $ /plan year $ /plan year $ /plan year $ /plan year $ /plan year $ /plan year Other Miscellaneous $ /plan year $ /plan year $ /plan year $ /plan year Total Estimated Medical Expenses for this plan year: $ ENROLLMENT BOOKLET SECURITY FLEX 125 PROGRAM 18

41 Rules For IRC SEC. 125 Flexible Benefit Plans The Security Flex 125 Program qualifies under Section 125 of the Internal Revenue Code, which allows employers to set up Flexible Spending Accounts (FSA) for dependent care and/or medical expenses as part of their cafeteria plans. These expenses can be paid with before-tax dollars. Below are the rules that the plan must adhere to: Plan Year Rules During the plan year, you are only allowed to make changes in the benefits selected if there is a family status change. (For example marriage, divorce, birth, death, etc.) All dollars set aside in an FSA plan must be used during the plan year. Any dollars not spent by the end of the plan year must be forfeited. Only charges for services provided or expenses incurred during the coverage period year are eligible for reimbursement. Amounts paid under the plan are not eligible as tax deductions on your Federal Income Tax Return. Maximum Contributions The maximum allocation to your Medical Reimbursement account may not exceed the annual plan maximum determined by your employer. The maximum dependent care expense allowed is $5,000 per calendar year per household ($2,500 in the case of a separate return filed by a married person). Eligible Expenses Expenses for you, your spouse and any taxable dependents are eligible. The Dependent Care FSA allows expenses for: (a) your dependent under age 13 for whom you may claim an exemption deduction, or (b) your dependent who is physically or mentally not able to care for himself or herself and who relies on you for the majority of his or her support, or (c) your spouse who is physically or mentally not able to care for himself or herself. Examples of Eligible Medical Expenses Medical expenses not paid by your health insurance including (but not limited to): Co-pays and deductibles for health, dental and vision Prescriptions Orthodontia Prescription eyewear including: eyeglasses, sunglasses, contacts and solutions associated with their care. Under the IRC Sec. 125 Flexible Benefit plan, you designate the amount of dollars that you plan to use at the beginning of the plan year. These dollars are applied to the appropriate account (Medical or Dependent Care) each month. You may submit claims for payment (subject to a minimum reimbursement of $25). You may submit with each claim as many bills or receipts as you have accumulated. Qualifying medical expenses will be reimbursed up to your annual election upon receipt of proper documentation, regardless of your account balance. Dependent Care expenses are reimbursed as funds are available in the account. Your reimbursement may not exceed your account balance /02/12

42 Individual Accident Insurance POLICY FORM HIC-ACC-POL-KS 7/09 Underwritten by Humana Insurance Company Plan Features On and off the job benefits Pays regardless of other coverage Benefits For: Accident Medical Expense Benefit Accident Hospital Indemnity Dislocations and Fractures Accidental Death and Dismemberment Accident Medical Expense Benefit We will pay the Actual Charges incurred up to $250 per unit if, as a result of Injury, a Covered Person requires medical or surgical treatment. Bronze 1 Unit Silver 2 Units Gold 3 Units $250 $500 $750 Accident Hospital Indemnity Benefit We will pay for each day a Covered Person is Confined during one or more periods of Hospital Confinement if: a) the Confinement is due to Injury; or b) the first day of Confinement occurs within 90 days after the accident. $100 $200 $300 Ambulance Service Benefit We will pay for regular ambulance service and for air Ambulance if as a result of an injury, a Covered Person requires ambulance service for transfer; a) to a Hospital; or b) from a Hospital. Regular Ambulance / Air Ambulance $100 / $200 $200/$400 $300/ $600 Dislocation and Fracture Benefit We will pay the following amount shown based on Your selection of coverage: For Fracture of Bone or Bones of: Bronze 1 Unit Silver 2 Units Gold 3 Units For Complete Dislocation of: Bronze 1 Unit Silver 2 Units Gold 3 Units Skull (except Bones of Face or Nose) $1,900 $3,800 $5,700 Hip Joint $2,000 $4,000 $6,000 Hip, Thigh (Femur) $2,000 $4,000 $6,000 Knee Joint (Except Patella) $ 800 $1,600 $2,400 Pelvis (Except Coccyx) $2,000 $4,000 $6,000 Bone or Bones of the Foot, Other than Toes $ 800 $1,600 $2,400 Arm, Between Shoulder and Elbow (Shaft) $1,100 $2,200 $3,300 Ankle Joint $ 800 $1,600 $2,400 Shoulder Blade (Scapula) $1,100 $2,200 $3,300 Wrist Joint $ 700 $1,400 $2,100 Leg (Tibia or Fibula) $1,100 $2,200 $3,300 Elbow Joint $ 600 $1,200 $1,800 Ankle $ 800 $1,600 $2,400 Shoulder Joint $ 400 $ 800 $1,200 Knee Cap (Patella) $ 800 $1,600 $2,400 Bone or Bones of the Hand, Other than Fingers $ 300 $ 600 $ 900 Collar Bone (Clavicle) $ 800 $1,600 $2,400 Collar Bone $ 300 $ 600 $ 900 Forearm (Radius or Ulna) $ 800 $1,600 $2,400 Two or More Fingers $ 140 $ 280 $ 420 Foot (Except Toes) $ 700 $1,400 $2,100 Two or More Toes $ 140 $ 280 $ 420 Hand or Wrist (Except Fingers) $ 700 $1,400 $2,100 One Finger or One Toe $ 60 $ 120 $ 180 Lower Jaw (Except Alveolar Process) $ 400 $ 800 $1,200 Two or More Ribs, Fingers or Toes $ 300 $ 600 $ 900 Bones of Face or Nose $ 300 $ 600 $ 900 Primary Insured Coverage 100%/Spouse Coverage 50%/ Child Coverage 25% One Rib, Finger or Toe $ 140 $ 280 $ 420 Coccyx $ 140 $ 280 $ 420 Form Number: HIC-ACC-SB-KS

43 Accidental Death and Dismemberment Benefit We will pay the following amount shown based on Your selection of coverage: For Loss of: Bronze 1 Unit Silver 2 Units Gold 3 Units Bronze 1 Unit Silver 2 Units Gold 3 Units Life $20,000 $40,000 $60,000 One Hand or One Arm $10,000 $20,000 $30,000 Both Hands or Both Feet or Sight of Both Eyes $20,000 $40,000 $60,000 One Foot or One Leg $10,000 $20,000 $30,000 Both Arms or Both Legs $20,000 $40,000 $60,000 One or More Entire Toes $ 1,000 $ 2,000 $ 3,000 One Hand or Arm and One Foot or Leg $20,000 $40,000 $60,000 One or More Entire Fingers $ 800 $ 1,600 $ 2,400 Sight of One Eye $10,000 $20,000 $30,000 Primary Insured Coverage 100%/Spouse Coverage 50%/ Child Coverage 25% Loss means with regard to: a) hands and feet--actual severance through or above wrist or ankle joints; b) sight, entire and irrecoverable loss thereof; c) toes and fingers--actual severance through or above the metacarpophalangeal joints. If loss is sustained by a Covered Person while riding as a fare-paying passenger on a scheduled Common Carrier, We will pay three times the amount payable under the Accidental Death and Dismemberment Benefit. Covered Persons Family plan coverage may include the following: You; Your spouse; Your unmarried dependent children under age 21 (25 if full-time student); grandchildren dependent upon you for income tax purposes; and children required to be insured under a medical support order by a court. Incapacitated children are covered in accordance with the incapacitated child continuation provision in the policy. Termination of Covered Persons: Your coverage terminates on the earliest of: a) the date the Policy is terminated; b) the date of Your death; c) Your attainment of the Policy Age Limit; or d) Your failure to pay the required premium, subject to the Grace Period. Your spouse, if covered under the policy, becomes the new insured upon Your death or the date Your coverage terminates because You reached the Policy Age Limit. Coverage for Your spouse will terminate on the first to occur of: a) the termination of this Policy: b) the date following your divorce, legal separation or annulment of marriage; c) Your spouse s attainment of the Policy Age Limit; d) the date of Your spouse s death; or e) failure to pay the required premium, subject to the Grace Period. Coverage for Your dependent child(ren) will terminate on the first to occur of: a) the termination of this Policy; b) the policy anniversary date after he or she ceases to be a Dependent; or c) failure to pay the required premium, subject to the Grace Period. Termination will be without prejudice to a claim that begins before termination. Exclusions and Other Limitations This Policy does not cover any loss resulting from: a. intentionally self-inflicted injury; b. suicide or attempted suicide, whether sane or insane; c. injury incurred prior to the effective date of coverage; d. war or act of war, whether declared or undeclared; e. injury sustained while in the armed forces of any country or international authority; f. injury sustained while riding On any aircraft except a Civil or Public Aircraft, or Military Transport Aircraft; g. injury sustained while riding On any aircraft except as a fare-paying passenger in an aircraft provided by a licensed Common Carrier; h. injury sustained while voluntarily taking drugs which federal law prohibits dispensing without a prescription, including sedatives, narcotics, barbiturates, amphetamines, or hallucinogens, unless the drug is taken as prescribed or administered by a licensed physician; i. injury sustained while committing or attempting to commit a felony; j. injury sustained while the Covered Person is operating any motor vehicle while legally intoxicated from the use of alcohol; k. hernia, including complications due to hernia; l. driving in any organized or scheduled race or speed test or while testing an automobile or any vehicle on any racetrack or speedway; m. voluntarily taking poison; n. asphyxiation from voluntarily inhaling gas or fumes. Pre-Existing Condition Limitation If a Covered Person has a pre-existing condition, We will not pay benefits for such condition during the 2 year period beginning on the policy date. Pre-existing Condition means a condition [a] which manifested itself prior to the effective date of coverage; or [b] for which medical advice or treatment was recommended by or received from a physician in the 5 years prior to the effective date of coverage. Right to Return Policy If You are not satisfied with this Policy for any reason, You may return it to us or to the agent from whom it was purchased within 10 days. We will consider it void from the Policy Date and any premium paid will be returned. Renewability Your Policy is Guaranteed Renewable until age 70, by payment of premiums as they become due. This Policy will terminate on the last day of the period for which premium is paid unless continued in force during a Grace Period. Form Number: HIC-ACC-SB-KS

44 Premium Change We have the right to change the table of premium rates for this Policy. The change in premium will apply to all policies of this form number issued to insureds in Your state of residence. Premiums will be charged in accordance with the table of premium rates using the original classification. Additional Benefits Rider HIC-ACC-ABR-KS 7/09 In consideration of an additional premium, We will pay the benefits listed below. Coverage for Primary Insured, Spouse and Child/Children based on Your selection of coverage. Benefit Schedule Bronze, Silver and Gold Options 1 Unit of Coverage Abdominal or Thoracic Surgery Benefit - We will pay $1,000 if a covered person undergoes abdominal or thoracic surgery to repair internal injuries as a result of a covered injury. The surgery must be performed within 3 days of the covered accident. For exploratory surgery done with no surgical repair, We will pay $100. Accident Follow-Up Treatment Benefit - We will pay $50 per day a covered person receives a follow-up treatment provided that a benefit has been paid under the Medical Expense Benefit of the policy. This benefit is limited to 2 treatments per covered accident per covered person. Treatments must be administered by a physician in the physician s office or a hospital on an outpatient basis. Follow-up treatments must begin within 90 days of the covered accident and not take place longer than 6 months after the covered accident. This Benefit is not payable at the same time a benefit is payable under the Physical Therapy Benefit. Eye Injury Benefit - We will pay $100 for surgery or the removal of a foreign object from the eye. Treatment must be performed by a physician and occur within 90 days of the accident. An examination without anesthesia is not considered a surgery. This benefit is payable only once per covered person per covered accident. Family Member Lodging Benefit - We will pay $100 per day for lodging of one adult member of a covered person s family when a covered person is confined in a non-local hospital or speciality free standing treatment center while undergoing treatment for a covered accident. This benefit is payable for 30 days for each covered accident. This benefit is payable only if the Non-local Transportation Benefit is payable under the covered accident. This benefit will not be paid if the family member lives within 60 miles of the treatment facility. Hospital Intensive Care Confinement Benefit - We will pay $400 per day that a covered person is confined to a hospital Intensive Care Unit. Confinement must begin within 3 days after a covered accident and is payable for up to 60 days of continuous confinement in the Intensive Care Unit. For a partial day confinement, the daily benefit will be pro-rated based on the number of hours confined divided by 24 hours. Immediate Hospitalization Benefit - We will pay $1,000 upon the first confinement to a hospital during a calendar year for a covered accident providing that a benefit is payable under the Hospital Confinement Benefit of the policy. The covered person must be confined to the hospital within 3 days of a covered accident and is payable only once per covered person per hospital confinement and only once per calendar year. Laceration Benefit - We will pay $50 for lacerations or cuts treated by a physician within 3 days of a covered accident. This benefit is only payable once per covered person per calendar year. Appliance Benefit - We will pay $125 for prescribed medical appliances that aid in personal mobility including wheelchair, crutches or walker. Use of these devices must begin within 90 days after a covered accident and the Benefit is payable only once per covered person per covered accident. Blood and Plasma Benefit - We will pay $300 for blood or plasma for a transfusion required for a covered accident. The transfusion must be within 3 days of the covered accident and is payable only once per covered person per accident. Brain Injury Diagnosis Benefit - We will pay $150 for the first diagnosis of the following traumatic brain injuries: cerebral contusion; cerebal laceration; concussion; or intercranial hemorrage. The covered person must be treated within 3 days of a covered accident; and diagnosis made by computed tomography (CT) scan, electroencephalogram (EEG), magnetic resonance imaging (MRI), positron emission tomography (PET) scan or X-ray must occur within 30 days of the accident. This benefit is payable only once per covered person. Burn Benefit - We will pay $100 if burns cover less than 15% of the body surface and $500 if burns cover more than 15% of the body surface for one or more second or third degree burns other than sunburn. Treatment must be within 3 days of the covered accident and the benefit is payable only once per covered person per covered accident. Coma Benefit - We will pay $15,000 if a covered person is in a Coma as defined in this rider which lasts 5 or more consecutive days as a result of a covered accident. This benefit is payable only once per covered person. Non Local Transportation Benefit - We will pay $300 per trip for non-local treatment at a hospital or speciality free-standing treatment center nearest the covered person s home. Treatment must be prescribed by a physician and the same treatment or care cannot be obtained locally. Non-local is treatment that is 60 miles or more one way from the covered person s home. We do not pay for visits to a physician s office or clinic or for services other than actual treatment. This benefit is payable 3 times per covered accident. This benefit does not cover ground or air ambulance. Paralysis Benefit - We will pay $10,000 for paraplegia and $20,000 for quadriplegia if a covered person receives a spinal cord injury resulting in complete and permanent loss of use of two or more limbs. An attending physician must confirm the paralysis within 3 days of a covered accident and the paralysis must last for at least 90 consecutive days. This benefit is payable only once per covered person. Physical Therapy Benefit - We will pay $30 per day a covered person receives physical therapy treatment. This benefit is only payable if a benefit has been paid under the Medical Expense Benefit of the policy. We will pay for a maximum of one treatment per day with a maximum of 6 treatments per covered accident per covered person. This benefit is only payable for injuries resulting from a covered accident where benefits begin within 90 days of the covered accident. Treatments after 6 months after a covered accident are not covered. This benefit is not payable for a same visit for which a benefit is payable under the Accident Follow-Up Treatment Benefit. Form Number: HIC-ACC-SB-KS

45 Prosthesis Benefit - We will pay $500 for one device and $1,000 for 2 or more devices for a prosthetic hand, foot, or eye that is prescribed by a physician. This benefit is payable if a benefit is paid for the loss of hand, foot, or eye under the Accidental Dismemberment benefit of the policy. The device or devices must be received within 180 days of a covered accident. This benefit is payable only once per covered person per covered accident. Ruptured Disc Benefit - We will pay $500 for a ruptured disc of the spine. The ruptured disc must be diagnosed as a result of a covered accident and surgically repaired by a physician within 180 days of the date of the covered accident. Skin Graft Benefit - We will pay 50% of the Burn Benefit under this rider if a covered person receives a skin graft for a burn for which a benefit is paid under the Burn Benefit. The skin graft must be performed by a physician to treat a covered burn within 90 days of a covered accident. This benefit is payable only once per covered person per covered accident. Tendon, Ligament, Rotator Cuff or Knee Cartilage Benefit - We will pay $500 per injury for an injured tendon, ligament, rotator cuff or knee cartliage. The injury site must be torn, ruptured, or severed and surgically repaired by a physician within 180 days of a covered accident. If exploratory surgery. using arthroscopy is done and no surgical repair is done, we will pay $150 for the exploratory surgery. This benefit is not paid if a benefit is paid under the Ruptured Disc Benefit of the rider for the same covered accident. The benefits under this rider are subject to the Pre-existing Condition Limitation of the policy. All other general provisions of the Policy to which this rider is attached apply to this rider. RIDER RENEWAL PROVISION This rider is renewable in the same manner as the Policy to which it is attached. TERMINATION This rider terminates: a) when coverage terminates under the Policy to which this rider is attached; b) when the premium for this rider is not paid before the end of the Grace Period; or c) when the Insured Person gives Us Written Notice to terminate this rider. Upon receipt of your policy, please review it and your application. If any information is incorrect, please contact: Bay Bridge Administrators P.O. Box Austin, Texas Form Number: HIC-ACC-SB-KS

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