SCHULTE HOSPITALITY GROUP INC

Transcription

1 The Guardian Life Insurance Company of America, New York, NY Group Number: SCHULTE HOSPITALITY GROUP INC All Eligible Employees Here you'll find information about your following employee benefit(s). Be sure to review the enclosed - it provides everything you need to sign up for your Guardian benefits. PLAN HIGHLIGHTS Dental Vision Critical Illness Accident

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3 SCHULTE HOSPITALITY GROUP INC Group Number: Dental Benefit Summary About Your Benefits: A visit to your dentist can help you keep a great smile and prevent many health issues. But dental care can be costly and you can be faced with unforeseen expenses. Did you know, a crown can cost as much as $1,400 1? Guardian dental insurance will help you pay for it. With access to one of the largest network of dental providers in the country, who agreed to charge negotiated fees for their services of up to 30% less than average charges in the same community, you will benefit from lower out-of-pocket costs, quality care from screened and reviewed dentist, no claim forms to file, and excellent customer service. Enroll today and smile next time you see your dentist! 1 Option 1: With your PPO plan, you can visit any dentist; but you pay less out-of-pocket when you choose a PPO dentist. Out-of-network benefits are limited to 90th percentile of usual & Customary. Option 2: With your PPO plan, you can visit any dentist; but you pay less out-of-pocket when you choose a PPO dentist. Your Dental Plan Option 1: PPO Option 2: PPO Your Network is DentalGuard Preferred DentalGuard Preferred Calendar year deductible In-Network Out-of-Network In-Network Out-of-Network Individual $50 $100 $50 $50 Family limit 3 per family 3 per family Waived for Preventive Preventive Preventive Preventive Charges covered for you (co-insurance) In-Network Out-of-Network In-Network Out-of-Network Preventive Care 100% 80% 100% 100% Basic Care 80% 70% 100% 80% Major Care 50% 40% 60% 50% Orthodontia 50% 50% 50% 50% Annual Maximum Benefit $1000 $1000 $2500 $2500 Maximum Rollover Yes Yes Rollover Threshold $500 $900 Rollover Amount $250 $450 Rollover In-network Amount $350 $700 Rollover Account Limit $1000 $1500 Lifetime Orthodontia Maximum $1000 $1000 Dependent Age Limits Benefit information illustrated within this material reflects the plan covered by Guardian as of 11/15/2015 SCHULTE HOSPITALITY GROUP INC All Eligible Employees Benefit Summary The Guardian Life Insurance Company of America, 7 Hanover Square, New York, NY

4 A Sample of Services Covered by Your Plan: Option 1: PPO Option 2: PPO Plan pays (on average) Plan pays (on average) In-network Out-of-network In-network Out-of-network Preventive Care Cleaning (prophylaxis) 100% 80% 100% 100% Frequency: Once Every 6 Months Once Every 6 Months Fluoride Treatments 100% 80% 100% 100% Limits: Under Age 14 Under Age 14 Oral Exams 100% 80% 100% 100% Sealants (per tooth) 100% 80% 100% 100% X-rays 100% 80% 100% 100% Basic Care Anesthesia* 80% 70% 100% 80% Fillings 80% 70% 100% 80% Perio Surgery 80% 70% 100% 80% Periodontal Maintenance 80% 70% 100% 80% Frequency: Once Every 6 Months Once Every 6 Months (Standard) (Standard) Repair & Maintenance of Crowns, Bridges & Dentures 80% 70% 100% 80% Root Canal 80% 70% 100% 80% Scaling & Root Planing (per quadrant) 80% 70% 100% 80% Simple Extractions 80% 70% 100% 80% Surgical Extractions 80% 70% 100% 80% Major Care Bridges and Dentures 50% 40% 60% 50% Inlays, Onlays, Veneers** 50% 40% 60% 50% Single Crowns 50% 40% 60% 50% Orthodontia Orthodontia 50% 50% 50% 50% Limits: Child(ren) Child(ren) This is only a partial list of dental services. Your certificate of benefits will show exactly what is covered and excluded. **For PPO and or Indemnity members, Crowns, Inlays, Onlays and Labial Veneers are covered only when needed because of decay or injury or other pathology when the tooth cannot be restored with amalgam or composite filing material. When Orthodontia coverage is for "Child(ren)" only, the orthodontic appliance must be placed prior to the age limit set by your plan; If full-time status is required by your plan in order to remain insured after a certain age; then orthodontic maintenance may continue as long as full-time student status is maintained. If Orthodontia coverage is for "Adults and Child(ren)" this limitation does not apply. The total number of cleanings and periodontal maintenance procedures are combined in a 12 month period. *General Anesthesia restrictions apply. For PPO and or Indemnity members, Fillings restrictions may apply to composite fillings. This handout is for illustrative purposes only and is an approximation. If any discrepancies between this handout and your paycheck stub exist, your paycheck stub prevails. Manage Your Benefits: Go to to access secure information about your Guardian benefits including access to an image of your ID Card. Your on-line account will be set up within 30 days after your plan effective date.. Find A Dentist: Visit Click on Find A Provider ; You will need to know your plan and dental network, which can be found on the first page of your dental benefit summary. EXCLUSIONS AND LIMITATIONS n Important Information about Guardian s DentalGuard Indemnity and DentalGuard Preferred PPO plans: This policy provides dental insurance only. Coverage is limited to those charges that are necessary to prevent, diagnose or treat dental disease, defect, or injury. Deductibles apply. The plan does not pay for: oral hygiene services (except as covered under preventive services), orthodontia (unless expressly provided for), cosmetic or experimental treatments (unless they are expressly provided for), any treatments to the extent benefits are payable by any other payor or for which no charge is made, prosthetic devices unless certain conditions are met, and services ancillary to surgical treatment. The plan limits benefits for diagnostic consultations and for n preventive, restorative, endodontic, periodontic, and prosthodontic services. The services, exclusions and limitations listed above do not constitute a contract and are a summary only. The Guardian plan documents are the final arbiter of coverage. Contract # GP-1-DG2000 et al. PPO and or Indemnity Special Limitation: Teeth lost or missing before a covered person becomes insured by this plan. A covered person may have one or more congenitally missing teeth or have lost one or more teeth before he became insured by this plan. We won t pay for a prosthetic device which replaces such teeth unless the device also replaces one or more natural teeth lost or extracted after the covered person became insured by this plan. R3 DG2000 SCHULTE HOSPITALITY GROUP INC All Eligible Employees Benefit Summary The Guardian Life Insurance Company of America, 7 Hanover Square, New York, NY

5 SCHULTE HOSPITALITY GROUP INC Group Number: Vision Benefit Summary About Your Benefits: Eye care is a vital component of a healthy lifestyle. With vision insurance, having regular exams and purchasing contacts or glasses is simple and affordable. The coverage is inexpensive, yet the benefits can be significant! Guardian provides rich, flexible plans that allow you to safeguard your health while saving you money. Review your plan options and see why vision insurance may be a great benefit for you. Option 1: Visit any doctor with your Full Feature plan, but save by visiting any of the 50,000+ locations in the nation's largest vision network. Option 2: Significant out-of-pocket savings available with your Full Feature plan by visiting one of Davis Vision's network locations including retail centers such as Wal-Mart, JCPenney, Sears, Target, Sam s Club, and Pearle. Your Vision Plan Option 1: VSP Choice Option 2: Full Feature - Designer Your Network is VSP Choice Network Davis Vision Copay Exams Copay $ 10 $ 10 Materials Copay (waived for non-formulary elective contact lenses) $ 20 $ 20 Sample of Covered Services You pay (after copay if applicable): You pay (after copay if applicable): In-network Out-of-network In-network Out-of-network Eye Exams $0 Amount over $39 $0 Amount over $50 Single Vision Lenses $0 Amount over $23 $0 Amount over $48 Lined Bifocal Lenses $0 Amount over $37 $0 Amount over $67 Lined Trifocal Lenses $0 Amount over $49 $0 Amount over $86 Lenticular Lenses $0 Amount over $64 $0 Amount over $126 Frames 80% of amount over $150 Amount over $46 SCHULTE HOSPITALITY GROUP INC All Eligible Employees Benefit Summary The Guardian Life Insurance Company of America, 7 Hanover Square, New York, NY % of amount over $150* Contact Lenses (Elective) Amount over $150 Amount over $100 N/A N/A Contact Lenses (Elective and conventional) N/A N/A 85% of amount over $150* Contact Lenses (Planned replacement and disposable) N/A N/A 85% of amount over $150* Amount over $48 Amount over $105 Amount over $105 Contact Lenses (Medically Necessary) $0 After Copay Amount over $210 $0 Amount over $210 Contact Lenses (Evaluation and fitting) 15% off UCR No discounts No discounts No discounts Cosmetic Extras Avg % off retail No discounts price Glasses (Additional pair of frames and lenses) 20% off retail price** No discounts Courtesy discount from most providers Laser Correction Surgery Discount Service Frequencies Avg. 30% off retail price Up to 15% off the usual charge or 5% off promotional price No discounts No discounts Up to 25% off the usual charge or 5% off promotional price Exams Every calendar year Every calendar year Lenses (for glasses or contact lenses) Every calendar year Every calendar year No discounts No discounts 5

6 Your Vision Plan Option 1: VSP Choice Option 2: Full Feature - Designer Frames Every two calendar years Every two calendar years Network discounts (cosmetic extras, glasses and contact lenses.) Limitless within 12 months of exam. Dependent Age Limits Benefit includes coverage for glasses or contact lenses, not both. Applies to first purchase & courtesy discount from most providers on subsequent purchases. The VSP system considers contact lenses to be the equivalent of a full pair of eyeglasses (lenses and frames) so while the member can obtain contact lenses one year and standard eyeglass lenses the next year, the frames benefit would not be available until 24 months or two calendar years, depending on the plan design, after the date the member obtained the contact lenses. With Dual Option a member can change the vendor elected during any open enrollment except if the plan has a 24 month or 2 calendar year materials frequency the member is locked into the vendor they choose for a benefit period of two years. This is only a partial list of vision services. Your certificate of benefits will show exactly what is covered and excluded. ** For the discount to apply your purchase must be made within 12 months of the eye exam. With the Davis Vision Designer plans, frames from the Fashion or Designer collections are covered in full in excess of the plan s materials copay, if applicable. Frames from the Premier collection are covered in full in excess of a $25 copay applied in addition to the plan s materials copay, if applicable. Frames from a network provider that are not in the collections are covered up to the plan s retail allowance in excess of the plan s materials copay, if applicable. Contact lenses from Davis Vision's Collection are available at most private practice locations with Full Feature and Materials Only plans. Contacts from the collection are covered in full including fitting and evaluation, in excess of the plan's materials copay. Elective contacts that are not part of the Collection are covered up to the plan's elective contact lens allowance and the materials copay is waived. For Davis Vision, complete eyeglasses must be purchased at one time from one provider. For example, if a member purchases only lenses, he or she cannot purchase frames later in the same benefit period. The member is not eligible for new vision materials until the next benefit period. Only charges for an initial purchase can be used toward the material allowance. Any unused balance remaining after the initial purchase cannot be banked for future use. For VSP, only charges for an initial purchase can be used toward the material allowance. Any unused balance remaining after the initial purchase cannot be banked for future use. The only exception would be if a member purchases contact lenses from an out of network provider, members can use the balance towards additional contact lenses within the same benefit period. *Due to lower prices available at Wal-mart and Sam's Club locations, discounts do not apply. Members will pay 100% of the amount over their allowance. This handout is for illustrative purposes only and is an approximation. If any discrepancies between this handout and your paycheck stub exist, your paycheck stub prevails. Manage Your Benefits: Go to to access secure information about your Guardian benefits including access to an image of your ID Card. Your on-line account will be set up within 30 days after your plan effective date. Find A Vision Provider Visit Click on Find A Provider ; You will need to know your plan and vision network, which can be found on the first page of your vision benefit summary. EXCLUSIONS AND LIMITATIONS Important Information: This policy provides vision care limited benefits health insurance only. It does not provide basic hospital, basic medical or major medical insurance as defined by the New York State Insurance Department. Coverage is limited to those charges that are necessary for a routine vision examination. Co-pays apply. The plan does not pay for: orthoptics or vision training and any associated supplemental testing; medical or surgical treatment of the eye; and eye examination or corrective eyewear required by an employer as a condition of employment; replacement of lenses and frames that are furnished under this plan, which are lost or broken (except at normal intervals when services are otherwise available or a warranty exists). The plan limits benefits for blended lenses, oversized lenses, photochromic lenses, tinted lenses, progressive multifocal lenses, coated or laminated lenses, a frame that exceeds plan allowance, cosmetic lenses; U-V protected lenses and optional cosmetic processes. The services, exclusions and limitations listed above do not constitute a contract and are a summary only. The Guardian plan documents are the final arbiter of coverage. Contract #GP-1-DAVIS-05-VIS et al. Contract #GP-1-VSN-96-VIS et al. Laser Correction Surgery: Laser surgery is not an insured benefit. The surgery is available at a discounted fee. The covered person must pay the entire discounted fee. In addition, the laser surgery discount may not be available in all states. SCHULTE HOSPITALITY GROUP INC All Eligible Employees Benefit Summary The Guardian Life Insurance Company of America, 7 Hanover Square, New York, NY

7 SCHULTE HOSPITALITY GROUP INC Critical Illness Benefit Summary Group Number: About Your Benefits: It takes a lot to beat a serious illness. Unfortunately, it can also cost a lot. When you or a family member suffers a serious illness like a stroke or heart attack, Critical Illness Insurance can help with expenses that medical insurance doesn't cover like deductibles or out of pocket costs, or services like experimental treatment. Critical Illness supplements your medical and your disability income insurance. The lump sum benefit is paid when you need it most, upon diagnosis, so you can rest assured that you will have funds to offset upcoming out of pocket costs, and that you'll have the flexibility to elect treatments with less worry about the cost. Review your options and enroll today! What Your Benefits Cover: CRITICAL ILLNESS Benefit Amount(s) Employee may choose a lump sum benefit up to $20,000. Please see your cost illustration for a full list of available benefit amounts. CONDITIONS Cancer 1st OCCURRENCE 2nd OCCURRENCE Invasive Cancer 100% 0% Carcinoma In Situ 30% 0% Benign Brain Tumor 75% 0% Skin Cancer $250 per lifetime Not Covered Vascular Heart Attack 100% 0% Stroke 100% 0% Heart Failure 100% 0% Arteriosclerosis 30% 0% Other Organ Failure 100% 0% Kidney Failure 100% 0% ADDITIONAL CONDITIONS SCHULTE HOSPITALITY GROUP INC All Eligible Employees Benefit Summary The Guardian Life Insurance Company of America, 7 Hanover Square, New York, NY st OCCURRENCE ONLY Addison's Disease 30% ALS (Lou Gehrig's Disease) 100% Alzheimer's Disease 50% Coma 100% Huntington's Disease 30% Loss of Hearing 100% Loss of Sight 100% Loss of Speech 100% Multiple Sclerosis 30% Parkinson's Disease 100% Permanent Paralysis 50% for 1 limb, 100% for 2 limbs Severe Burns 100% Childhood Conditions 1st OCCURRENCE ONLY Cerebral Palsy 100% 7

8 CRITICAL ILLNESS Cleft Lip/Palate 100% Club Foot 100% Cystic Fibrosis 100% Down's Syndrome 100% Muscular Dystrophy 100% Spina Bifida 100% Type 1 Diabetes 100% Spouse/Domestic Partner Benefit Child Benefit- children age Birth to 26 years Benefit Reductions: Benefits are reduced by a certain percentage as an employee ages Guarantee Issue: The guarantee means you are not required to answer health questions to qualify for coverage up to and including the specified amount, when you sign up for coverage during the initial enrollment period. 50% of employee's lump sum benefit 25% of employee's lump sum benefit 50% at age 70 We Guarantee Issue up to: Less than age 70 $20,000 For a spouse: Less than age 70 $7,500 Portability: Allows you to take your Critical Illness coverage with you if you terminate employment. Pre-Existing Condition Limitation: A pre-existing condition includes any condition for which you, in the specified time period prior to coverage in this plan, consulted with a physician, received treatment, or took prescribed drugs. Cancer Vaccine Benefit WELLNESS BENEFIT Employee Per Year Limit $50 Spouse Per Year Limit $50 Child Per Year Limit $50 For a child: All Amounts Health questions are required if the elected amount exceeds the Guarantee Issue, as well as for all applicants age 70+ regardless of elected amount. Included 3 months prior, 12 months after $50 per lifetime for receiving a cancer vaccine Manage Your Benefits: Go to to access secure information about your Guardian benefits. Your on-line account will be set up within 30 days after your plan effective date. SCHULTE HOSPITALITY GROUP INC All Eligible Employees Benefit Summary The Guardian Life Insurance Company of America, 7 Hanover Square, New York, NY

9 EXCLUSIONS AND LIMITATIONS A SUMMARY OF PLAN LIMITATIONS AND EXCLUSIONS FOR CRITICAL ILLNESS: We will not pay benefits for the First Occurrence of a Critical Illness if it occurs less than 3 months after the First Occurrence of a related Critical Illness for which this Plan paid benefits. By related we mean either: (a) both Critical Illnesses are contained within the Cancer Related Conditions category; or (b) both Critical Illnesses are contained within the Vascular Conditions category. We will not pay benefits for a Second occurrence (recurrence) of a Critical Illness unless the Covered Person has not exhibited symptoms or received care or treatment for that Critical Illness for at least 12 months in a row prior to the recurrence. For purposes of this exclusion, care or treatment does not include: (1) preventive medications in the absence of disease; and (2) routine scheduled follow-up visits to a Doctor. We do not pay benefits for claims relating to a covered person: taking part in any war or act of war (including service in the armed forces) committing a felony or taking part in any riot or other civil disorder or intentionally injuring themselves or attempting suicide while sane or insane. Employees must be legally working in the United States in order to be eligible for coverage. Underwriting must approve coverage for employees on temporary assignment: (a) exceeding 1 year; or (b) in an area under travel warning by the US Department of State, subject to state specific variations. Guardian s Critical Illness plan does not provide comprehensive medical coverage. It is a basic or limited benefit and is not intended to cover all medical expenses. It does not provide basic hospital, basic medical, or medical insurance as defined by the New York State Insurance Department. Health questions are required on 1) late enrollees and 2) enrollees over age 69 (not applicable in FL). This coverage will not be effective until approved by a Guardian underwriter. The policy has exclusions and limitations that may impact the eligibility for or entitlement to benefits under each covered condition. See your certificate booklet for a full listing of exclusions & limitations.. If Critical Illness insurance premium is paid for on a pre tax basis, the benefit may be taxable. Please contact your tax or legal advisor regarding the tax treatment of your policy benefits.. This handout is for illustrative purposes only and is an approximation. If any discrepancies between this handout and your paycheck stub exist, your paycheck stub prevails. Your company has selected Guardian to provide Critical Illness coverage to eligible employees & dependents according to plan terms which have been mutually agreed upon. As an eligible employee, you can purchase this coverage at the group premium levels illustrated above. SCHULTE HOSPITALITY GROUP INC All Eligible Employees Benefit Summary The Guardian Life Insurance Company of America, 7 Hanover Square, New York, NY

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11 SCHULTE HOSPITALITY GROUP INC Group Number: Accident Benefit Summary About Your Benefits: Accidents happen every day. Did you know almost 39 Million emergency room visits a year are due to an injury?¹ If you were injured from an accident, chances are you will have expenses that you were not anticipating-will you be prepared? Accident Insurance can help you deal with those expenses. Benefit payments can help you with your medical deductibles and co-pays, and cover household expenses like groceries, mortgage payments and childcare, which can begin to pile up if you have to take some time off from work. You are guaranteed coverage, so please enroll today! 1 Injury Facts, 2011 Edition, National Safety Council. What Your Benefits Cover: ACCIDENT COVERAGE - DETAILS Option 1: Advantage Plan Option 2: Premier Plan Accident Coverage Type Off Job Off Job Portability - Allows you to take your Accident coverage with you if you terminate employment. Ported Accident plan terminates at age 70. ACCIDENTAL DEATH AND DISMEMBERMENT Benefit Amount(s) Catastrophic Loss Included Employee $25,000 Spouse $12,500 Child $5,000 Included Employee $50,000 Spouse $25,000 Child $5,000 Quadriplegia, Loss of speech & Quadriplegia, Loss of speech & hearing (both ears), Loss of hearing (both ears), Loss of Cognitive function: 100% of AD&D Cognitive function: 100% of AD&D Hemiplegia & Paraplegia: 50% of Hemiplegia & Paraplegia: 50% of AD&D AD&D Common Carrier 200% of AD&D benefit 200% of AD&D benefit Common Disaster 200% of Spouse AD&D benefit 200% of Spouse AD&D benefit Dismemberment - Hand, Foot, Sight Dismemberment - Thumb/Index Finger Same Hand, Four Fingers Same Hand, All Toes Same Foot Seatbelts and Airbags Single: 50% of AD&D benefit Multiple: 100% of AD&D benefit Single: 50% of AD&D benefit Multiple: 100% of AD&D benefit 25% of AD&D benefit 25% of AD&D benefit Seatbelts: $10,000 & Airbags: $15,000 Reasonable Accommodation to Home or Vehicle $2,500 $2,500 WELLNESS BENEFIT - Per Year Limit $50 $50 Seatbelts: $10,000 & Airbags: $15,000 Child(ren) Age Limits Children age birth to 26 years Children age birth to 26 years FEATURES Accident Emergency Room Treatment $175 $200 Accident Follow-Up Visit - Doctor $50 up to 6 treatments $75 up to 6 treatments Air Ambulance $1,000 $1,500 Ambulance $150 $200 Appliance - Wheelchair, leg or back brace, crutches, walker, walking boot that extends above the ankle or brace for the neck. $125 $125 Blood/Plasma/Platelets $300 $300 SCHULTE HOSPITALITY GROUP INC All Eligible Employees Benefit Summary The Guardian Life Insurance Company of America, 7 Hanover Square, New York, NY

12 FEATURES (Cont.) Option 1: Advantage Plan Option 2: Premier Plan Burns (2nd Degree/3rd Degree) 9 sq inches to 18 sq inches: $0/$2, sq inches to 35 sq inches: $1,000/$4,000 Over 35 sq inches: $3,000/$12,000 9 sq inches to 18 sq inches: $0/$2, sq inches to 35 sq inches: $1,000/$4,000 Over 35 sq inches: $3,000/$12,000 Burn - Skin Graft 50% of burn benefit 50% of burn benefit Child Organized Sport - Benefit is paid if the covered accident occurred while your covered child is participating in an organized sport that is governed by an organization and requires formal registration to participate. 20% increase to child benefits 20% increase to child benefits Chiropractic Visits $25 per visit up to 6 visits $50 per visit up to 6 visits Coma $10,000 $12,500 Concussions $75 $100 Dislocations Schedule up to $4,400 Schedule up to $4,800 Diagnostic Exam (Major) $150 $200 Emergency Dental Work $300/Crown, $75/Extraction $400/Crown, $100/Extraction Epidural pain management $100, 2 times per accident $100, 2 times per accident Eye Injury $300 $300 Family Care $20/day up to 30 days $20/day up to 30 days Fracture Schedule up to $5,500 Schedule up to $6,000 Hospital Admission $1,000 $1,250 Hospital Confinement $225/day - up to 1 year $250/day - up to 1 year Hospital ICU Admission $2,000 $2,500 Hospital ICU Confinement $450/day - up to 15 days $500/day - up to 15 days Initial Physician's office/urgent Care Facility Treatment $75 $100 Joint Replacement (hip/knee/shoulder) $2,500/$1,250/$1,250 $3,500/$1,750/$1,750 Knee Cartilage $500 $750 Laceration Schedule up to $400 Schedule up to $500 Lodging - The hospital must be more than 50 miles from the insured's residence. $125/day, up to 30 days for companion hotel stay $150/day, up to 30 days for companion hotel stay Occupational or Physical Therapy $25/day up to 10 days $35/day up to 10 days Prosthetic Device/Artificial Limb 1: $500 2 or more: $1,000 1: $750 2 or more: $1,500 Rehabilitation Unit Confinement $150/day up to 15 days $150/day up to 15 days Ruptured Disc With Surgical Repair $500 $750 Surgery Schedule up to $1,250 Hernia: $150 Surgery - Exploratory or Arthroscopic $250 $350 Tendon/Ligament/Rotator Cuff Transportation - Benefit is paid if you have to travel more than 50 miles one way to receive special treatment at a hospital or facility due to a covered accident. 1: $500 2 or more: $1,000 Schedule up to $1,500 Hernia: $200 1: $750 2 or more: $1,500 $500, 3 times per accident $600, 3 times per accident X - Ray $30 $40 UNDERSTANDING YOUR BENEFITS: Common Carrier Benefit is paid if an insured's death occurs due to an accident while riding as a fare-paying passanger in a public conveyance. If this is paid, we do not pay the Accidental Death benefit. Common Disaster Benefit is paid if both you & your spouse die in a covered accident or separate covered accidents within the same 24 hour period. SCHULTE HOSPITALITY GROUP INC All Eligible Employees Benefit Summary The Guardian Life Insurance Company of America, 7 Hanover Square, New York, NY

13 UNDERSTANDING YOUR BENEFITS (Cont.): Reasonable Accomodation Benefit is payable if a modification is required to an insured's place of residence or vehicle due to an Accidental Dismemberment or Catastrophic loss. This handout is for illustrative purposes only and is an approximation. If any discrepancies between this handout and your paycheck stub exist, your paycheck stub prevails. Manage Your Benefits: Go to to access secure information about your Guardian benefits. Your on-line account will be set up within 30 days after your plan effective date. LIMITATIONS AND EXCLUSIONS: A SUMMARY OF ACCIDENT LIMITATIONS AND EXCLUSIONS: Employees must be working in the United States in order to be eligible for coverage. Underwriting must approve coverage for employees on temporary assignment: (a) exceeding 1 year; or (b) in an area under travel warning by the US Department of State, subject to state specific variations. This proposal summarizes the major features of the Guardian Accident benefit plan. It is not intended to be a complete representation of the proposed plan. For full plan features, including exclusions and limitations, please refer to your Policy. This proposal is hedged subject to satisfactory financial evaluation. This plan will not pay benefits for any injury caused by or related to: declared or undeclared war, act of war or armed aggression; taking part in a riot or civil disorder; or commission of, or attempt to commit a felony; intentionally self inflicted injury, while sane or insane; suicide, while sane or insane. The covered person being legally intoxicated. Treatment rendered or hospital confinement outside the United States or Canada. Travel of flight in any kind of aircraft including any aircraft owned by or for the employer except as a fare paying passenger on a common carrier. Participation in any kind of sporting activity for compensation or profit including coaching or officiating. Riding in or driving any motor-driven vehicle in a race, stunt show or speed test. Participation in hang gliding, bungee jumping, sailgliding, parasailing, parakiting, ballooning, parachuting, and/or skydiving. Injuries to a dependent child received during the birth. An accident that occurred before the covered person is covered by this plan. Sickness, disease, mental infirmity or medical or surgical treatment. If Accident insurance premium is paid for on a pre tax basis, the benefit may be taxable. Please contact your tax or legal advisor regarding the tax treatment of your policy benefits. SCHULTE HOSPITALITY GROUP INC All Eligible Employees Benefit Summary The Guardian Life Insurance Company of America, 7 Hanover Square, New York, NY

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15 The Guardian Life Insurance Company of America Enrollment/Change Form Page 1 of 6 Guardian Life, P.O. Box 14319, Lexington, KY Please print clearly and mark carefully. Employer Name: SCHULTE HOSPITALITY GROUP INC Group Plan Number: Benefits Effective: PLEASE CHECK APPROPRIATE BOX q Initial Enrollment q Re-Enrollment q Add Employee/Dependents q Drop/Refuse Coverage q Information Change q Increase Amount q Family Status Change Class: All Eligible Employees Division: Subtotal Code: (Please obtain this from your Employer) About You: First, MI, Last Name: Social Security Number - - Address City State Zip Gender: q M q F Date of Birth (mm-dd-yy): - - Phone: ( ) - Address: Are you married or do you have a spouse? q Yes q No Date of marriage/union: - - Do you have children or other dependents? q Yes q No Placement date of adopted child: - - About Your Job: Hours worked per week: Job Title: Work Status: q Active q Retired q Cobra/State Continuation Date of full time hire: - - About Your Family: Please include the names of the dependents you wish to enroll for coverage. A dependent is a person that you, as a taxpayer, claim; who relies on you for financial support; and for whom you qualify for a dependency tax exception. Dependency tax exemptions are subject to IRS rules and regulations. Additional information may be required for non-standard dependents such as a grandchild, a niece or a nephew. Spouse (First, MI, Last Name) Address/City/State/Zip: Phone: ( ) - Child/Dependent 1: Address/City/State/Zip: Gender q M q F q Add q Drop Gender q M q F Social Security Number - - Date of Birth (mm-dd-yyyy) - - Social Security Number - - Status (check all that apply) q Student (post high school) q Disabled q Non standard dependent Phone: ( ) - Child/Dependent 2: Address/City/State/Zip: Phone: ( ) - q Add q Drop Gender q M q F Date of Birth (mm-dd-yyyy) - - Social Security Number - - Date of Birth (mm-dd-yyyy) - - Status (check all that apply) q Student (post high school) q Disabled q Non standard dependent CEF2014-KY DETACH ENTIRE FORM AND RETURN TO YOUR EMPLOYER DATE FORM PUBLISHED: Nov 15,

16 Child/Dependent 3: Address/City/State/Zip: q Add q Drop Gender q M q F Social Security Number - - Status (check all that apply) q Student (post high school) q Disabled q Non standard dependent Phone: ( ) - Child/Dependent 4: Address/City/State/Zip: Phone: ( ) - q Add q Drop Gender q M q F Date of Birth (mm-dd-yyyy) - - Social Security Number - - Date of Birth (mm-dd-yyyy) - - Status (check all that apply) q Student (post high school) q Disabled q Non standard dependent Drop Coverage: q Drop Employee q Drop Dependents The date of withdrawal cannot be prior to the date this form is completed and signed. Last Day of Coverage: - - q Termination of Employment q Retirement Last Day Worked: - - q Other Event: Date of Event: - - Loss Of Other Coverage: I and/or my dependents were previously covered under another insurance plan. Loss of coverage was due to: q Termination of Employment: - - q Divorce - - q Death of Spouse - - q Termination/Expiration of Coverage - - Coverage Lost q Dental q Vision Coverage Being Dropped: q Dental q Vision q Critical Illness q Accident q Employee q Spouse q Child(ren) q Employee q Spouse q Child(ren) q Employee q Spouse q Child(ren) I have been offered the above coverage(s) and wish to drop enrollment for the following reasons: q Covered under another insurance plan q Other (additional information may be required) Dental Coverage: You must be enrolled to cover your dependents. Check only one box. Employee Only EE & Spouse EE & Dependent/Child(ren) EE, Spouse & Dependent/Child(ren) Option 1: PPO q q q q Option 2: PPO q q q q q I do not want this coverage. If you do not want this Dental Coverage, please mark all that apply: q I am covered under another Dental plan q My spouse is covered under another Dental plan q My dependents are covered under another Dental plan Vision Coverage: You must be enrolled to cover your dependents. Check only one box. Employee Only EE & Spouse EE & Dependent/Child(ren) EE, Spouse & Dependent/Child(ren) Option 1: VSP Choice q q q q Option 2: Full Feature - Designer q q q q q I do not want this coverage. If you do not want this Vision Coverage, please mark all that apply: q I am covered under another Vision plan q My spouse is covered under another Vision plan q My dependents are covered under another Vision plan Critical Illness Coverage: You must be enrolled to cover your dependents Benefit reductions apply. Please see plan administrator. Employee Insurance Amount: q $5,000 q $10,000 q $15,000 q $20,000 q I do not want this coverage. 2 DETACH ENTIRE FORM AND RETURN TO YOUR EMPLOYER

17 Guardian Group Plan Number: Please print employee name: Spouse Insurance Amount: q 50% of the employee's amount q I do not want this coverage. Dependent/Child(ren) Insurance Amount: q 25% of the employee's amount q I do not want this coverage. IMPORTANT NOTES: Based on your plan benefits and age, you may be required to complete an additional evidence of insurability form for Critical Illness. Accident Coverage You must be enrolled to cover your dependents. Your Bi-weekly premium Employee Only EE & Spouse EE & Dependent/Child(ren) EE, Spouse & Dependent/Child(ren) Option 1: Advantage Plan q q q q Option 2: Premier Plan q q q q q I do not want this coverage. Name your beneficiaries: (Primary beneficiary percentages must total 100%) Primary Beneficiaries: Name: Social Security Number: - - % Date of Birth (mm-dd-yy): - - Address/City/State/Zip: Phone: ( ) - Relationship to Employee:_ Name: Social Security Number: - - % Date of Birth (mm-dd-yy): - - Address/City/State/Zip: Phone: ( ) - Relationship to Employee:_ Contingent Beneficiary: Social Security Number: - - Date of Birth (mm-dd-yy): - - Address/City/State/Zip: Phone: ( ) - Relationship to Employee:_ (In the event the primary beneficiaries are deceased, the contingent beneficiary will receive the benefit. Employer maintains beneficiary information.) Signature l l l l l l l l An employee's decision to elect Vision or not elect Vision must be retained until the next plan's Open Enrollment period. If the employee elects not to enroll in vision coverage, they are not eligible to enroll until the plan's next Open Enrollment period. I understand that my dependent(s) cannot be enrolled for a coverage if I am not enrolled for that coverage. Submission of this form does not guarantee coverage. Among other things, coverage is contingent upon underwriting approval and meeting the applicable eligibility requirements as set forth in the applicable benefit booklet. If coverage is waived and you later decide to enroll, late entrant penalties may apply. You may also have to provide, at your own expense, proof of each person's insurability. Guardian or its designee has the right to reject your request. Plan design limitations and exclusions may apply. For complete details of coverage, please refer to your benefit booklet. State limitations may apply. Your coverage will not be effective until approved by a Guardian or its designated underwriter. I hereby apply for the group benefit(s) that I have chosen above. I understand that I must meet eligibility requirements for all coverages that I have chosen above. 3 DETACH ENTIRE FORM AND RETURN TO YOUR EMPLOYER

18 l l l I agree that my employer may deduct premiums from my pay if they are required for the coverage I have chosen above. I acknowledge and consent to receiving electronic copies of applicable insurance related documents, in lieu of paper copies, to the extent permitted by applicable law. I may change this election only by providing thirty (30) day prior written notice. I state that the information provided above is true and correct to the best of my knowledge. Any person who with intent to defraud any insurance company or other person files an application for insurance or statements of claim containing any materially, false information or conceals for purpose of misleading information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime, and may also be subject to civil penalties, or denial of insurance benefits. The state in which you reside may have a specific state fraud warning. Please refer to the attached Fraud Warning Statements page. The laws of New York require the following statement appear: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation. (Does not apply to Life Insurance.) SIGNATURE OF EMPLOYEE X DATE Enrollment Kit , 0007, EN Fraud Warning Statements The laws of several states require the following statements to appear on the enrollment form: Alabama: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or who knowingly presents false information in an application for insurance is guilty of a crime and may be subject to restitution fines or confinement in prison, or any combination thereof. Arizona: For your protection Arizona law requires the following statement to appear on this form. Any person who knowingly presents a false or fraudulent claim for payment of a loss is subject to criminal and civil penalties. California: For your protection California law requires the following to appear on this form: The falsity of any statement in the application shall not bar the right to recovery under the policy unless such false statement was made with actual intent to deceive or unless it materially affected either the acceptance of the risk or the hazard assumed by the insurer. Colorado: It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance, and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policy holder or claimant for the purpose of defrauding or attempting to defraud the policy holder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies. Connecticut, Iowa, Nebraska, and Oregon: Any person who knowingly, and with intent to defraud any insurance company or other person, files an application of insurance or statement of claim containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto, may be guilty of a fraudulent insurance act, which may be a crime, and may also be subject to civil penalties. Delaware, Indiana and Oklahoma: WARNING: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony. District of Columbia: WARNING: It is a crime to provide false or misleading information to an insurer for the purpose of defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance benefits, if false information materially related to a claim was provided by the applicant. Florida: Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a felony of the third degree. Kansas: Any person who knowingly, and with intent to defraud any insurance company or other person, files an application of insurance or statement of claim containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto, may be guilty of insurance fraud as determined by a court of law. Kentucky: Any person who knowingly and with intent to defraud any insurance company or other person files a statement of claim containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime. Louisiana and Texas: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit is guilty of a crime and may be subject to fines and confinements in state prison. Maine, Tennessee and Washington: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties may include imprisonment, fines or a denial of insurance benefits. Maryland : Any person who knowingly or willfully presents a false or fraudulent claim for payment of a loss or benefit or knowingly or willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. Rhode Island: Any person who knowingly and willfully presents a false or fraudulent claim for payment of a loss or benefit or knowingly and willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. 4

19 Guardian Group Plan Number: Please print employee name: Minnesota: A person who files a claim with intent to defraud or helps commit a fraud against an insurer is guilty of a crime. New Hampshire: Any person who, with a purpose to injure, defraud or deceive any insurance company, files a statement of claim containing any false, incomplete or misleading information is subject to prosecution and punishment for insurance fraud, as provided in N.H. Rev. Stat. Ann. 638:20 New Jersey: Any person who knowingly files a statement of claim containing any false or misleading information is subject to criminal and civil penalties. New Mexico: Any person who knowingly presents a false or fraudulent claim for payment or a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to civil fines and criminal penalties or denial of insurance benefits. Ohio: Any person who with intent to defraud or knowing that he/she is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud. Pennsylvania: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties. Vermont: Any person who knowingly presents a false statement in an application for insurance may be guilty of a criminal offense and subject to penalties under state law. Virginia: Any person who with intent to defraud or knowing that he/she is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement may have violated state law. 5 DETACH ENTIRE FORM AND RETURN TO YOUR EMPLOYER

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