Enroll Now. Help Protect Your Loved Ones And Your Income. All Employees. Optional Term Life Insurance Optional Dependent Life Insurance F R P F R P

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1 Enroll Now Help rotect Your Loved nes And Your Income UNIVESITY SUTHEN INDIANA All Employees ptional Term Life Insurance ptional Dependent Life Insurance The rudential Insurance Company of America IS-A Ed ECEd Exp

2 What's Inside Welcome Letter...2 Why you may need more life insurance...3 Why you should buy it at work...4 you How much may need...6 How much insurance can I buy...7 How much it will cost...8 How to enroll

3 Welcome Letter Dear Valued Employee: After careful review, we ve selected a group plan issued by The rudential Insurance Company of America (rudential)--a name you know and trust. An insurance leader for over 130 years, they have financial strength. With your family s future at stake, you owe it to them to consider the opportunity described in this kit. Because you may need additional coverage, we offer you an opportunity to purchase-- at competitive group rates--extra financial security, including: ptional Term Life --or you. ptional Dependent Life --or your eligible spouse / domestic partner and children. How can I enroll? Complete the attached Enrollment orm and return it. Don t miss out on this valuable employee benefit! 2

4 Why you may need more life insurance ENLL NW with the enclosed Enrollment orm! Why do I need life insurance? Life is full of pleasant surprises and, at the same time, life holds uncertainties. It s easier to plan for happy events you know will occur, and more difficult to plan for the unexpected--such as a death. If you were no longer there to help support your family, how would they be able to ü ay off loans--credit cards, mortgage, and auto? ü Maintain their standard of living--utilities, food, clothing, and personal expenses? ü ay monthly rent or mortgage? ü rovide for your children s future--tuition for their education and weddings? ü ay your final expenses--medical care, burial, estate settlement, and inheritance taxes? A sufficient amount of life insurance can give you peace of mind now and help your family financially recover from your loss during a very stressful time. I already have life insurance- I need more? whydo esearch has shown that 77% of households, earning between $35,000 and $125,000 per year, say they do not have adequate resources to replace lost income. Thirty-four percent of households within the same range of earnings report not having enough life insurance.1 You may be underinsured if your salary has increased since you last purchased insurance. lus, when you consider new family responsibilities - a life new home or child - and inflation, the insurance coverage you have now may not offer enough protection foryour family. How can I help protect my loved ones? Buy life insurance at work. Your employer offers you the opportunity to purchase ptional Term Life Insurance issued by The rudential Insurance Company of America. As millions of Americans have discovered, insurance at group rates from rudential is a smart choice. 3 1 LIMA's actbook, 2011 Trends in the United States

5 Why you should buy it at work "What are the advantages of buying life insurance at work?" ü ü ü ü It s convenient. There are no confusing quotes to sort through. And with automatic payroll deductions, you never have to worry about late payments. It s economical. The cost of group insurance may be lower than insurance you could find on your own. It s flexible. You may choose the level of coverage that s right for you and your family. It s convertible. You and your family can convert your coverage to an individual rudential insurance policy if you leave the company for any reason. ead on to help select the amount of insurance that's right for you! eace of Mind from rudential rudential s resources, financial strength, and stability allow us to honor long-term commitments, which means that we ll be here when you and your family need us. We ve been a top insurance provider for over 130 years. lus, we have caring professionals to provide your beneficiaries with the kind of customer support they want and deserve. ur Customer Service epresentatives are well-trained, knowledgeable professionals who can quickly answer your family s questions. By choosing the insurance protection from rudential, you give yourself peace of mind, knowing you are providing for your loved ones. or more information about rudential s Group Insurance, visit us online at: 4

6 The Booklet-Certificate you will receive after your insurance becomes effective gives more details. or your convenience, visit our website to use an online life insurance needs calculator. chdoineed What does group insurance offer my family? You get affordable premiums for yourself, your spouse / domestic partner, and each of your children. lus, you ll get the special features mentioned below. Accelerated Benefit ption - If terminally ill, you can get a partial payment of your group term life insurance benefit. You can use this payment as you the event of your death, your beneficiary will receive a benefit see fit.in payout which has been reduced by the amount you receive. Waiver of remium - ayment of your premium can be waived if you meet all these conditions: 1) you are less than 60 years old when your disability begins, 2) you are totally disabled and unable to work for at least 9 continuous months, and 3) you continue to be totally disabled. The Waiver of remium Benefit terminates at age 65. This provision may vary by state. Conversion to Individual Insurance Coverage - Upon termination of employment, you may convert your coverage to a rudential individual life insurance policy, without having to provide evidence of good health.. 5

7 How much you may need How much life insurance is enough? The right amount of insurance can help your family. It helps replace your income for a number of years to maintain their standard of living and pay for major financial obligations, such as home mortgage and college tuition. According to a recent LIMA report, 39% of households believe they do not have enough life insurance ("Life in a Tough Economy," LIMA, 2010). While rules of thumb may be helpful, they do not take each Insurance individual s personal situation into consideration. This worksheet provides a simple method to estimate the amount of life insurance you may need. Income Needs 1. Your annual income. (What your family would need if you die today.) Enter a number that s between 60 70% of your total income. 1. $ 2. Annual replacement income. (Available to your family after you die.) Enter a number that includes Social Security benefits, if applicable. 2. $ 3. Total annual income to be replaced. Subtract line 2 from line $ 4. unds needed to provide income for years. Choose the number of years your family needs your replacement income. Multiply line 3 by the appropriate factor below. 10 yrs x yrs x yrs x yrs x yrs x yrs x yrs x $ Expenses 5. Burial expenses. (The average cost of an adult funeral is about $10,000.) 5. $ 6. Mortgage and other major debts. Include mortgage, credit card debt, car loan, home equity loans, etc. 6. $ costs. (Current cost of a 4 year education: public $62,264; private $127,664.) 7. College Multiply the college costs by the appropriate factor, based on the number of years between now and when your child begins college. 5 yrs x yrs x yrsx.56 Child 1: $ Child 2: $ 20 yrs x $ Child 3: $ Child 4: $ 8. $ 8. Total capital required. Add lines 4, 5, 6 and 7. Assets 9. Savings funds, and investments. Include bank accounts, CDs, stocks, bonds, mutual real estate/rental property, etc. 10. etirement savings. Include 401(k) plans, Keogh, pension and profit sharing plans. 11. resent amount of life insurance. Include group insurance and personal insurance purchased on your own. 9. $ 10. $ 11. $ 12. Total of all assets. Add lines 9, 10 and $ 13. Estimated amount of life insurance needed. Subtract line 12 from line $ Inflation is assumed to be 4%. The rate of return on investments is assumed to be 8%. The College Board, Trends in College ricing Costs include tuition, room, board, books and transportation, and other expenses. supplies, 6

8 How much insurance can I buy How much insurance can I buy? You can customize coverage to fit your family's needs. Your salary determines the maximum coverage amount available to you. See the chart below for details. Coverage ptions EMLYEE n urchase coverage in increments of $10,000 to $500,000, not to exceed 8.0 times your covered annual earnings. n New Hires: Get up to $200,000 - no medical questions asked - when enrolling when first eligible in ptional Group Term Life. n Current articipants: Your current coverage amount will be continued. Evidence of insurability satisfactory to The rudential Insurance Company of America is required for all increases in coverage amounts. n Current Employees who were denied coverage in the past, Current Employees who waived coverage in the past or Late Entrants (did not enroll when first eligible): Evidence of insurability satisfactory to The all coverage amounts. rudential Insurance Company of America is required for n Coverage will be reduced as you age - Age 65 - Coverage reduced to 65% of the pre-age 65 amount. Age of the pre-age 65 amount. Age 75 - Coverage reduced to 25% of the pre-age 70 - Coverage reduced to50% 65 amount. Age 80 - Coverage amount will be the lesser of $5,000 or 25% of the amount at age 65.. SUSE / DMESTIC ATNE n urchase coverage for your spouse in increments of $5,000 to $200,000, not to exceed 50% of your ptional Term Life coverage amount. n n New Hires: Get up to $20,000 for your spouse- no medical questions asked - when enrolling when first eligible in ptional Dependent Group Term Life. Current Spouse articipants: Your spouse's current coverage amount will be continued. Evidence of insurability satisfactory to the rudential Insurance Company of America is required for all increases in coverage amounts. n Current Employees whose spouse has been denied coverage in the past, Current Employees who waived spouse coverage in the past or Late Entrants (did not enroll when first eligible): Evidence of insurability satisfactory to The rudential Insurance Company of America is required for all coverage amounts. n Coverage will be reduced based on employee's age - Age 65 - Coverage reduced to 65% of the pre-age 65 amount. Age 70 - Coverage reduced to 50% of the pre-age 65 amount. Age 75 - Coverage reduced to 25% of the pre-age 65 amount. Age 80 - Coverage amount will be the lesser of $5,000 or 25% of the amount at age 65. CHILDEN $10,000, not to exceed 50% of your n urchase coverage for your children in increments of $2,500to ptional Term Life coverage amount. There are no health requirements for this coverage. n Coverage begins from live birth, and continues to age 26, if unmarried. This age limit will not apply until in which your Qualified Dependent child attains this age. the end of the calendaryear xxxxxx 7

9 How much it will cost How much does life insurance cost? insurance for yourself, your spouse / domestic partner, and each of Use the grids below to find the cost of your children. ptional Term Life - Employee Monthly Cost per Coverage Amount Age $10,000 $20,000 $30,000 $40,000 $50,000 $60,000 $70,000 $80,000 $90,000 $100,000 $110,000 $120,000 $130,000 < 25 $ $ $0.70 $1.00 $1.50 $2.00 $2.50 $3.00 $3.50 $4.00 $4.50 $5.00 $5.50 $6.00 $6.50 $1.20 $1.80 $2.40 $3.00 $3.60 $4.20 $5.40 $6.00 $6.60 $7.20 $7.80 $1.40 $2.10 $2.80 $3.50 $4.20 $4.90 $4.80 $5.60 $6.30 $7.00 $7.70 $8.40 $ $0.80 $1.60 $2.40 $3.20 $4.00 $4.80 $5.60 $6.40 $7.20 $8.00 $8.80 $9.60 $ $0.90 $1.80 $2.70 $3.60 $5.40 $6.30 $7.20 $8.10 $9.00 $ $1.40 $2.80 $ $2.40 $4.80 $ $4.50 $ $ $11.80 $4.50 $5.60 $7.00 $11.70 $16.80 $18.20 $10.80 $8.40 $9.80 $11.20 $12.60 $14.00 $15.40 $9.60 $12.00 $14.40 $16.80 $19.20 $21.60 $24.00 $26.40 $28.80 $31.20 $13.50 $18.00 $22.50 $27.00 $31.50 $36.00 $40.50 $45.00 $49.50 $54.00 $58.50 $12.20 $18.30 $24.40 $30.50 $36.60 $42.70 $48.80 $54.90 $61.00 $67.10 $73.20 $79.30 $23.60 $35.40 $47.20 $59.00 $70.80 $82.60 $94.40 $ $ $ $ $ $19.20 $38.40 $57.60 $76.80 $96.00 $ $ $ $ $ $ $ $ Age $140,000 $150,000 $160,000 $170,000 $180,000 $190,000 $200,000 $250,000 $300,000 $350,000 $400,000 $450,000 $500,000 $7.50 $8.00 $8.50 $9.00 $9.50 $10.00 $12.50 $17.50 $20.00 $22.50 $25.00 $9.00 $9.60 $10.20 $10.80 $11.40 $12.00 $21.00 $24.00 $27.00 $30.00 $12.60 $13.30 $14.00 $35.00 $15.20 $7.00 < $ $9.80 $10.50 $11.20 $ $11.20 $12.00 $12.80 $ $12.60 $13.50 $ $19.60 $21.00 $ $33.60 $36.00 $ $63.00 $67.50 $72.00 $76.50 $ $85.40 $91.50 $97.60 $ $ $ $ $ $ $ $ $ $ $ $ $14.40 $15.30 $16.20 $15.00 $18.00 $15.00 $17.50 $21.00 $24.50 $28.00 $31.50 $16.00 $20.00 $24.00 $28.00 $32.00 $36.00 $40.00 $40.50 $45.00 $17.10 $18.00 $22.50 $27.00 $31.50 $36.00 $23.80 $25.20 $26.60 $28.00 $35.00 $42.00 $49.00 $56.00 $63.00 $70.00 $40.80 $43.20 $45.60 $48.00 $60.00 $72.00 $84.00 $96.00 $ $ $85.50 $90.00 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ change as the insured enters a higher age category. Also, rates ates may may change if plan requires a change for all insureds. experience ptional Dependent Life - Spouse / Domestic artner Monthly Cost per Coverage Amount Spouse / Domestic artner rate is based on spouse's age Age $5,000 $10,000 $15,000 $20,000 $25,000 $30,000 $35,000 $40,000 $45,000 $50,000 $55,000 $60,000 < 25 $0.25 $0.50 $0.75 $1.00 $1.25 $1.50 $1.75 $2.00 $2.25 $2.50 $2.75 $ $0.30 $0.60 $0.90 $1.20 $1.50 $1.80 $2.10 $2.40 $2.70 $3.00 $3.30 $ $0.35 $0.70 $1.05 $1.40 $1.75 $2.10 $2.45 $2.80 $3.15 $3.50 $3.85 $ $0.40 $0.80 $1.20 $1.60 $2.00 $2.40 $2.80 $3.20 $3.60 $4.00 $4.40 $4.80 $ $0.70 $0.90 $1.35 $1.80 $2.25 $2.70 $3.15 $3.60 $4.05 $4.50 $4.95 $5.40 $1.40 $2.10 $2.80 $3.50 $4.20 $ $1.20 $2.40 $3.60 $4.80 $6.00 $ $2.25 $4.50 $6.75 $9.00 $3.05 $6.10 $9.15 $ $ $5.90 $11.80 $17.70 $ $9.60 $19.20 $ $6.30 $7.00 $7.70 $8.40 $8.40 $5.60 $9.60 $10.80 $12.00 $13.20 $14.40 $13.50 $15.75 $18.00 $20.25 $22.50 $24.75 $18.30 $21.35 $24.40 $27.45 $30.50 $27.00 $29.50 $35.40 $41.30 $47.20 $53.10 $59.00 $38.40 $48.00 $57.60 $67.20 $76.80 $86.40 $12.20 $33.55 $36.60 $64.90 $70.80 $96.00 $ $ Age $65,000 $70,000 $75,000 $80,000 $85,000 $90,000 $95,000 $100,000 $125,000 $150,000 $175,000 $200,000 < 25 $3.25 $3.50 $3.75 $4.00 $4.25 $4.50 $4.75 $5.00 $6.25 $7.50 $8.75 $ $3.90 $4.20 $4.50 $4.80 $5.10 $5.40 $5.70 $6.00 $7.50 $9.00 $10.50 $ $4.55 $4.90 $5.25 $5.60 $5.95 $6.30 $6.65 $7.00 $8.75 $10.50 $12.25 $ $5.20 $5.60 $6.00 $6.40 $6.80 $7.20 $7.60 $8.00 $10.00 $12.00 $14.00 $ $5.85 $6.30 $6.75 $7.20 $7.65 $8.10 $8.55 $9.00 $11.25 $13.50 $15.75 $ $9.10 $9.80 $10.50 $11.20 $11.90 $12.60 $13.30 $14.00 $17.50 $21.00 $24.50 $28.00 $16.80 $18.00 $19.20 $20.40 $21.60 $22.80 $30.00 $36.00 $42.00 $48.00 $ $

10 "How much it will cost?" (continued from previous page) $29.25 $31.50 $33.75 $36.00 $38.25 $40.50 $90.00 $42.75 $45.00 $56.25 $67.50 $ $39.65 $42.70 $45.75 $48.80 $51.85 $54.90 $57.95 $61.00 $76.25 $91.50 $ $76.70 $82.60 $88.50 $94.40 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ ates maychange as the insured enters a higher age category. Also, rates may change if plan experience requires a change for all insureds. ptional Dependent Life - Children Monthly Cost per Coverage Amount ne premium rate covers all eligible children $2,500 $5,000 $7,500 $10,000 $0.23 $0.45 $0.68 $0.90 ates may change if plan experience requires a change for all insureds. 9 $122.00

11 Who can answer my questions? Here are the answers to some common questions regarding these insurance coverages. or additional information, contact your Human esources Department or Benefits Administrator. Does this plan pay ptional Term Life benefits in addition to my basic plan?" Yes, this plan pays in addition to any Basic Term Life Insurance coverage offered by your employer. When can I enroll for life insurance coverage? way to enroll and guarantee a certain level of coverage isto The easiest sign up when first eligible. If you enroll at any other time or for more than the guaranteed coverage amount, you will need to provide evidence of good health satisfactory to rudential. Can I drop this life insurance coverage at any time? Yes, subject to your employer s administrative policies. "What is the difference between a primary and contingent beneficiary?" you designate to receive your life Your primary beneficiary is the person insurance benefit when you die. You can name more than one primary beneficiary and assign a different percentage of your benefit to each, if you like. If you name a contingent beneficiary, that person will receive the life insurance benefit when you die only if all primary beneficiaries are not living at the time of your death. You can name more than one contingent beneficiary and assign different percentages to them, too. "Whatif I want to change my beneficiary?" Beneficiary Change orms and relatedinformation may be obtained by contacting your Human esources Department or Benefits Administrator. "When is a medical exam required and who pays for it?" A medical exam may be required if you elect more coverage than the guaranteed amount. We will pay the cost of any required medical exam when medical exams are conducted by an examiner who is chosen by rudential. coverage go into effect?" "When will 10

12 coverage to become effective, you must be actively at work during or your theenrollment period and on the effective date of your coverage. Ifyou apply for an amount that requires evidence of good health, you must be actively at work on the date of approval for the amount requiring evidence of good health. If your dependents are confined for medical treatment at home or elsewhere, their coverage will begin when confinement ends. efer to the Booklet-Certificate for details. "Can I increase my coverage in the future?" Yes, you can increase your coverage up to your plan s maximum coverage amount. However, evidence of good health satisfactory to rudential will be required as previously noted. How to enroll How can I enroll?" To enroll, simply complete the Enrollment orm with Beneficiary Designations. Then, return it as instructed. After the date your group insurance becomes effective, you will receive a Booklet-Certificate that details your plan provisions. Implementation of the insurance plan(s) will depend upon having a specific percentage of all eligible employees enrolling in the plan(s). In the event the minimum participation level is not met, rudential retains the right to re-evaluate rate guarantee period, or terminate the rates, require a re-enrollment, reduce the coverage. eceipt of accelerated death benefits may affect eligibility for public assistance programs and may be taxable. There is no administrative fee to accelerate death benefits. The accelerated amount is not discounted. Accelerated Death Benefit option is a feature that is made available to group life insurance participants. It is not a health, nursing home, or long-term care insurance benefit and is not designed to eliminate the need for those types of insurance amount of the accelerated death coverage. The death benefit is reduced bythe benefit paid. There is no administrative fee to accelerate benefits. eceipt of accelerated death benefits may affect eligibility for public assistance and may be federal income tax treatment of payments made under this rider taxable.the depends upon whether the insured is the recipient of the benefits and is considered terminally ill. You may wish to seek professional tax advice before exercising this option. All benefit features may not be available in all states. 11 Group Term Life, Accidental Death and Dismemberment and Disability coverages are issued by The rudential Insurance Company of America, a rudential inancial Company, 751 Broad Street, Newark, NJ Life Claims: and Disability Support: This brochure is intended to be a summary of provisions, exclusions and limitations. your benefits and does not include all plan lease refer to the Booklet-Certificate,which is made a part of the Group Contract, for all plan details, including any exclusions, limitations and restrictions which may apply.ifthere is a discrepancy between this document and the IS-A Ed ECEd Exp

13 Booklet-Certificate/Group Contract issued by The rudential Insurance Company of America, the terms of the Group Contract will govern. Contract provisions may vary by state. Contract Series: California CA #1179 NAIC # rudential inancial, Inc., and its related entities. rudential, the rudential logo, and the ock symbol are service marks of rudential inancial, Inc. and its related entities, registered in many jurisdictions worldwide. IS-A Ed ECEd Exp

14 IMTANT NTICE A record of your beneficiary is required for Basic Term Life Insurance Term Life Insurance, Basic AD&D Insurance, and ptional 13

15 Enrollment orm - UNIVESITY SUTHEN INDIANA age 1 of 3 The rudential Insurance Company of America 751 Broad Street, Newark, New Jersey General Information (Employee) Effective Date of Coverage (for office use only) / / Last Name irst Name Middle Initial hone Address City State Zip Code Social Security No. - - Single Divorced Marital Status Married Widowed Date of Birth Month Day Year / / Date Employed Your Annual Earnings Spouse Date of Birth (or rudential Use nly) Month Day Year Month Day Year / / $ / / Control # ptional Term Life Coverage amount chosen: $ ayroll deduction: $ No coverage chosen. ptional Dependen t Life You must be enrolled for ptional Term Life to elect coverage for your dependents. Spouse coverage cannot exceed 50% of your ptional Term Life coverage amount. Child(ren) coverage cannot exceed 50% of your ptional Term Life coverage amount. Spouse/ Domestic artner Children Coverage amount chosen: $ Coverage amount chosen: $ ayroll deduction: $ ayroll deduction: $ No coverage chosen. No coverage chosen. Group Term Life and Disability coverages are issued by The rudential Insurance Company of America, a rudential inancial company, 751 Broad Street, Newark, NJ Life Claims: , Disability Support: This brochure is intended to be a summary of your benefits and does not include all plan provisions, exclusions and limitations. lease refer to the Booklet-Certificate, which is made a part of the Group Contract, for all plan details, including any exclusions, limitations and restrictions which may apply. If there is a discrepancy between this document and the Booklet-Certificate/Group Contract issued by The rudential Insurance Company of America, the Group Contract will govern. Contract provisions may vary by state. Contract Series: California CA # 1179 NAIC # rudential inancial, Inc., and its related entities. rudential, the rudential logo, and the ock symbol are service marks of rudential inancial, Inc. and its related entities, registered in many jurisdictions worldwide. GL

16 Enrollment orm - UNIVESITY SUTHEN INDIANA age 2 of 3 Employee General Information Last Name irst Name Middle Initial Social Security No. - - Acceptance or Waiver of Coverage I am enrolling for coverage and I authorize UNIVESITY SUTHEN INDIANA to deduct from my earnings until further notice my contributions for insurance under a contract issued by The rudential Insurance Company of America. I understand that if I desire to increase the amount of my insurance or add dependent coverage hereafter, I may be required to furnish evidence of insurability for myself and/or my dependents. To the best of my knowledge and belief, I declare the statement above is true and understand it is the basis for determining the monthly contribution for coverage. I also understand that for coverage to become effective, I must be actively at work during the enrollment period and on the effective date of the plan. If I apply for an amount that requires evidence of insurability satisfactory to The rudential Insurance Company of America, I must be actively at work on the date of approval for the amount requiring satisfactory evidence of insurability. I do not wish to enroll for any of the above optional coverages. I certify that I have been given the opportunity by my above named employer to enroll for coverage. I understand that if I desire to enroll hereafter, I may be required to furnish satisfactory evidence of insurability to The rudential Insurance Company of America for myself and/or my dependents. ESIDENTS ALL STATES EXCET ALABAMA, DISTICT CLUMBIA, LIDA, KENTUCKY, MAYLAND, NEW JESEY, NEW YK, ENNSYLVANIA, UET IC, HDE ISLAND, UTAH, VEMNT, VIGINIA AND WASHINGTN; WANING: Any person who knowingly and with intent to injure, defraud, or deceive any insurance company or other person, or knowing that he is facilitating commission of a fraud, submits incomplete, false, fraudulent, deceptive or misleading facts or information when filing an insurance application or a statement of claim for payment of a loss or benefit commits a fraudulent insurance act, is/may be guilty of a crime and may be prosecuted and punished under state law. enalties may include fines, civil damages and criminal penalties, including confinement in prison. In addition, an insurer may deny insurance benefits if false information materially related to a claim was provided by the applicant or if the applicant conceals, for the purpose of misleading, information concerning any fact material thereto. ALABAMA ESIDENTS - 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. DISTICT CLUMBIA and HDE ISLAND ESIDENTS--Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. KENTUCKY ESIDENTS--Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance 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. MAYLAND ESIDENTS - Any person who knowingly or willfully presents a false or fraudulent claim for payment of a loss or benefit or who 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. NEW J ESEY ESIDENTS--Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and civil penalties. ENNSYLVANIA AND UTAH ESIDENTS--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 material fact thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties. UET IC ESIDENTS - Any person who knowingly and with the intention of defrauding presents false information in an insurance application, or presents, helps, or causes the presentation of a fraudulent claim for the payment of a loss or any other benefit, or presents more than one claim for the same damage or loss, shall incur a felony and, upon conviction, shall be sanctioned for each violation by a fine of not less than five thousand dollars ($5,000) and not more than ten thousand dollars ($10,000), or a fixed term of imprisonment for three (3) years, or both penalties. Should aggravating circumstances [be] present, the penalty thus established may be increased to a maximum of five (5) years, if extenuating circumstances are present, it may be reduced to a minimum of two (2) years. VEMNT ESIDENTS--Any person who knowingly presents a false or fraudulent claim for payment of a loss or knowingly makes a false statement in an application for insurance may be guilty of a criminal offense under state law. GL

17 Enrollment orm - UNIVESITY SUTHEN INDIANA age 3 of 3 Employee General Information Last Name irst Name Middle Initial Social Security No. - - VIGINIA ES IDENTS--Any person who knowingly and with intent to injure, defraud, or deceive any insurance company or other person, or knowing that he is facilitating commission of a fraud, submits incomplete, false, fraudulent, deceptive or misleading facts or information when filing a statement of claim for payment of a loss or benefit may have violated state law, is guilty of a crime and may be prosecuted and punished under state law. enalties may include fines, civil damages and criminal penalties, including confinement in prison. In addition, an insurer may deny insurance benefits if false information materially related to a claim was provided by the applicant or if the applicant conceals, for the purpose of misleading, information concerning any fact material thereto. WASHINGTN ESIDENTS--Any person who knowingly provides false, incomplete, or misleading information to an insurance company for the purpose of defrauding the company commits a crime. enalties include imprisonment, fines, and denial of insurance benefits. LIDA ES IDENTS--Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing false, incomplete, or misleading information is guilty of a felony of the third degree. NEW YK ESIDENTS--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. This warning NLY applies to accident and disability coverage. Employee Signature Date (Month/Day/Year) / / Michigan and Minnesota esidents only Dependent Consent for Coverage: If you wish to enroll your spouse and/or dependent child(ren) 18 years of age or older for dependent life or accidental death and dismemberment insurance coverage, your spouse and each child must acknowledge consent for coverage. Spouse or Domestic artner Signature Date (Month/Day/Year) / / Child Signature Date (Month/Day/Year) / / Child Signature Date (Month/Day/Year) / / You must also complete a separate beneficiary designation form. GL

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