q First Commonwealth of Missouri, Inc.

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1 The Guardian Life Insurance Company of America q The Guardian Life Insurance company of America underwrites group term ife, accidenta death and dismemberment, short term disabiity, ong term disabiity, critica iness, denta and vision coverages. q First Commonweath of Missouri, Inc. First Commonweath of Missouri, Inc. underwrites group pre-paid denta coverage Enroment/Change Form Page 1 of 8 Guardian Life, P.O. Box 14319, Lexington, KY Pease print ceary and mark carefuy. Empoyer Name: COLUMBIA COLLEGE Group Pan Number: Benefits Effective: PLEASE CHECK APPROPRIATE BOX q Initia Enroment q Re-Enroment q Add Empoyee/Dependents q Drop/Refuse Coverage q Information Change q Increase Amount q Famiy Status Change Cass: ALL OTHER ELIGIBLE EMPLOYEES Division: Subtota Code: (If appicabe, pease obtain this from your Empoyer) About You: First, MI, Last Name: Socia Security Number - - Address City State Zip Gender: q M q F Date of Birth(mm-dd-yy): - - Phone:( ) - Emai Address: Are you married or do you have a spouse? q Yes q No Date of marriage/union: - - Do you have chidren or other dependents? q Yes q No Pacement date of adopted chid: - - About Your Job: Hours worked per week: Job Tite: Work Status: q Active q Retired q Cobra/State Continuation Date of fu time hire: - - Annua Saary: $ About Your Famiy: Pease incude the names of the dependents you wish to enro for coverage. A dependent is a person that you, as a taxpayer, caim; who reies on you for financia support; and for whom you quaify for a dependency tax exception. Dependency tax exemptions are subject to IRS rues and reguations. Additiona information may be required for non-standard dependents such as a grandchid, a niece or a nephew. Spouse (First, MI, Last Name) Phone: ( ) - Chid/Dependent 1: Gender q M q F q Add q Drop Gender q M q F Socia Security Number - - Date of Birth (mm-dd-yyyy) - - Socia Security Number - - Status (check a that appy) q Student (post high schoo) q Disabed q Non standard dependent Phone: ( ) - Chid/Dependent 2: Phone: ( ) - q Add q Drop Gender q M q F Date of Birth (mm-dd-yyyy) - - Socia Security Number - - Date of Birth (mm-dd-yyyy) - - Status (check a that appy) q Student (post high schoo) q Disabed q Non standard dependent CEF2014-MO DETACH ENTIRE FORM AND RETURN TO YOUR EMPLOYER DATE FORM PUBLISHED: Nov 05,

2 Chid/Dependent 3: q Add q Drop Gender q M q F Socia Security Number - - Status (check a that appy) q Student (post high schoo) q Disabed q Non standard dependent Phone: ( ) - Chid/Dependent 4: Phone: ( ) - q Add q Drop Gender q M q F Date of Birth (mm-dd-yyyy) - - Socia Security Number - - Date of Birth (mm-dd-yyyy) - - Status (check a that appy) q Student (post high schoo) q Disabed q Non standard dependent Drop Coverage: q Drop Empoyee q Drop Dependents The date of withdrawa cannot be prior to the date this form is competed and signed. Last Day of Coverage: - - q Termination of Empoyment q Retirement Last Day Worked: - - q Other Event: Date of Event: - - Loss Of Other Coverage: I and/or my dependents were previousy covered under another insurance pan. Loss of coverage was due to: q Termination of Empoyment: - - q Divorce - - q Death of Spouse - - q Termination/Expiration of Coverage - - Coverage Lost q Denta q Vision Coverage Being Dropped: q Denta q Empoyee q Spouse q Chid(ren) q Vision q Empoyee q Spouse q Chid(ren) q Basic Life q Empoyee q Spouse q Chid(ren) q Vountary Life q Empoyee q Spouse q Chid(ren) q VAD&D q Empoyee q Spouse q Chid(ren) q Critica Iness q Empoyee q Spouse q Chid(ren) q Accident q Empoyee q Spouse q Chid(ren) q Cancer q Empoyee q Spouse q Chid(ren) q Muti-Coverage q Long Term Disabiity q Short Term Disabiity I have been offered the above coverage(s) and wish to drop enroment for the foowing reasons: q Covered under another insurance pan q Other (additiona information may be required) Denta Coverage: You must be enroed to cover your dependents. Check ony one box. Empoyee Ony EE, Spouse & Dependent/Chid(ren) PPO q q q I do not want this coverage. If you do not want this Denta Coverage, pease mark a that appy: q I am covered under another Denta pan q My spouse is covered under another Denta pan q My dependents are covered under another Denta pan Vision Coverage: You must be enroed to cover your dependents. Check ony one box. Your Semi-monthy Premium Empoyee Ony EE & Spouse EE & EE, Spouse & Dependent/Chid(ren) Dependent/Chid(ren) Fu Feature q $6.66 q $10.65 q $10.88 q $17.53 q I do not want this coverage. If you do not want this Vision Coverage, pease mark a that appy: q I am covered under another Vision pan q My spouse is covered under another Vision pan q My dependents are covered under another Vision pan 2 DETACH ENTIRE FORM AND RETURN TO YOUR EMPLOYER

3 Guardian Group Pan Number: Pease print empoyee name: Basic Life Coverage with Accidenta Death and Dismemberment (AD&D): Benefit reductions appy. Pease see pan administrator. Poicy Amount Empoyee Ony R 200% of your annua saary to a maximum of $250,000 q I do not want this coverage. Name your beneficiaries: (Primary beneficiary percentages must tota 100%) Primary Beneficiaries: Name: Socia Security Number: - - % Date of Birth (mm-dd-yy): - - Phone: ( ) - Reationship to Empoyee:_ Name: Socia Security Number: - - % Date of Birth (mm-dd-yy): - - Phone: ( ) - Reationship to Empoyee:_ Contingent Beneficiary: Socia Security Number: - - Date of Birth (mm-dd-yy): - - Phone: ( ) - Reationship to Empoyee:_ (In the event the primary beneficiaries are deceased, the contingent beneficiary wi receive the benefit. Empoyer maintains beneficiary information.) If this Basic Life poicy wi repace your existing ife insurance poicy under your current empoyer, provide the amount of the previous poicy $ Important Notes: Based on your pan benefits and age, you may be required to compete an evidence of insurabiity form for Basic Life. Vountary Term Life Coverage With Accidenta Death and Dismemberment (AD&D): reductions appy. Pease see pan administrator. Empoyee You must be enroed to cover your dependents. Benefit Poicy Amount Check one box ony q $20,000 q $30,000 q $40,000 q $50,000 q $60,000 q $70,000 q $80,000 q $90,000 q $100,000 q $110,000 q $120,000 q $130,000 q $140,000 q $150,000* q $160,000 q $170,000 q $180,000 q $190,000 q $200,000 q $210,000 q $220,000 q $230,000 q $240,000 q $250,000 q $260,000 q $270,000 q $280,000 q $290,000 q $300,000 q $310,000 q $320,000 q $330,000 q $340,000 q $350,000 q $360,000 q $370,000 q $380,000 q $390,000 q $400,000 q $410,000 q $420,000 q $430,000 q $440,000 q $450,000 q $460,000 q $470,000 q $480,000 q $490,000 q $500,000 *Guarantee Issue Amount q I do not want this coverage Add Vountary Life for Spouse Poicy Amount q $5,000 q $10,000 q $15,000 q $20,000 q $25,000 q $30,000 q $35,000 q $40,000 q $45,000 q $50,000* q $55,000 q $60,000 q $65,000 q $70,000 q $75,000 q $80,000 q $85,000 q $90,000 q $95,000 q $100,000 q $105,000 q $110,000 q $115,000 q $120,000 q $125,000 q $130,000 q $135,000 q $140,000 q $145,000 q $150,000 q $155,000 q $160,000 q $165,000 q $170,000 q $175,000 q $180,000 q $185,000 q $190,000 q $195,000 q $200,000 q $205,000 q $210,000 q $215,000 q $220,000 q $225,000 q $230,000 q $235,000 q $240,000 q $245,000 q $250,000 *Guarantee Issue Amount *The amount may not be more than 0% of the empoyee amount for Vountary Life. q I do not want this coverage 3 DETACH ENTIRE FORM AND RETURN TO YOUR EMPLOYER

4 LIFE INSURANCE continued Add Vountary Life for Dependent/Chid(ren) Poicy Amount q $1,000 q $5,000 q $10,000* *Guarantee Issue Amount *The amount may not be more than 10% of the empoyee amount for Vountary Life. q I do not want this coverage Have you used any form of tobacco in the past 6 months (e.g., pipe, chewing tobacco) and/or have you smoked cigarettes in the past 12 months? Empoyee Yes q No q Spouse Yes q No q Important Notes: Based on your pan benefits and age, you may be required to compete an evidence of insurabiity form for Vountary Life. Name your beneficiaries: (Primary beneficiary percentages must tota 100%) If eecting different beneficiaries that are not the same as those named for Basic Life, pease name beow. Primary Beneficiaries: Name: Socia Security Number: - - % Date of Birth (mm-dd-yy): - - Phone: ( ) - Reationship to Empoyee:_ Name: Socia Security Number: - - % Date of Birth (mm-dd-yy): - - Phone: ( ) - Reationship to Empoyee:_ Contingent Beneficiary: Date of Birth (mm-dd-yy): - - Phone: ( ) - Reationship to Empoyee:_ Socia Security Number: - - (In the event the primary beneficiaries are deceased, the contingent beneficiary wi receive the benefit. Empoyer maintains beneficiary information.) Short-Term Disabiity (STD) Coverage: Weeky Benefit q $ q $ q $ q $ q $ q $ q $ q $ q $1, q $1, This amount may not exceed 60% of your weeky saary. q I do not want this coverage. Long-Term Disabiity (LTD) Coverage: Weeky Benefit q $1, q $1, q $1, q $1, Monthy Benefit R 60% of saary to a maximum of $7,500 4

5 Guardian Group Pan Number: Pease print empoyee name: Critica Iness Coverage: You must be enroed to cover your dependents Benefit reductions appy. Pease see pan administrator. Empoyee Insurance Amount: q $5,000 q $10,000 q $15,000 q $20,000 q $25,000 q $30,000 q $35,000 q $40,000 q $45,000 q $50,000 q I do not want this coverage. Spouse Insurance Amount: Up to 50% of the empoyee's amount to a maximum of $12,500 q $2,500 q $5,000 q $7,500 q $10,000 q $12,500 q I do not want this coverage. Dependent/Chid(ren) Insurance Amount: q 25% of the empoyee's amount q I do not want this coverage. Have you used any form of tobacco in the past 6 months (e.g. pipe, chewing tobacco) and/or have you smoked cigarettes in the past 12 months? Empoyee q Yes q No Spouse q Yes q No If eecting Critica Iness Coverage, you must answer the foowing heath questions. 1. Has any proposed insured been diagnosed with or treated by a medica professiona for any of the foowing conditions: cancer, carcinoma in situ,maignant meanoma, tumor (benign or maignant), Barretts esophagus, Crohns disease, ucerative coitis, bood disorder (other than AIDS or HIV), any chronic or progressive disease of kidneys, iver (incuding hepatitis), ungs, incuding emphysema and COPD, pancreas or bone marrow? Or, been advised to have an organ transpant, incuding bone marrow or stem ce transpant? Empoyee q Yes q No Spouse q Yes q No 2. Has any proposed insured been diagnosed with or treated by a medica professiona for heart attack, heart disease or coronary artery disease, stroke or transient ischemic attack (TIA), or been advised to have bypass surgery, stent insertions or treatment for coronary arteries? Empoyee q Yes q No Spouse q Yes q No 3. Has any proposed insured been diagnosed with or treated by a medica professiona for uncontroed bood pressure (requiring a change in medication or dosage in the past 6 months or been diagnosed with or treated for diabetes (except if present ony in pregnancy)? Empoyee q Yes q No Spouse q Yes q No 4. Has any proposed insured been diagnosed with or treated by a medica professiona for AIDS (acquired immune deficiency syndrome), AIDS-Reated Compex or tested positive for HIV (human immunodeficiency virus)? Empoyee q Yes q No IMPORTANT NOTES: Spouse q Yes q No Based on your pan benefits and age, you may be required to compete an additiona evidence of insurabiity form for Critica Iness. Accident Coverage You must be enroed to cover your dependents. Your Semi-monthy premium Empoyee Ony EE & Spouse EE & Dependent/Chid(ren) EE, Spouse & Dependent/Chid(ren) q $8.10 q $11.58 q $15.45 q $18.93 q I do not want this coverage. 5 DETACH ENTIRE FORM AND RETURN TO YOUR EMPLOYER

6 Name your beneficiaries: (Primary beneficiary percentages must tota 100%) Primary Beneficiaries: Name: Socia Security Number: - - % Date of Birth (mm-dd-yy): - - Phone: ( ) - Reationship to Empoyee:_ Name: Socia Security Number: - - % Date of Birth (mm-dd-yy): - - Phone: ( ) - Reationship to Empoyee:_ Contingent Beneficiary: Date of Birth (mm-dd-yy): - - Phone: ( ) - Reationship to Empoyee:_ Socia Security Number: - - (In the event the primary beneficiaries are deceased, the contingent beneficiary wi receive the benefit. Empoyer maintains beneficiary information.) Signature An empoyee's decision to eect Vision or not eect Vision must be retained unti the next pan's Open Enroment period. If the empoyee eects not to enro in vision coverage, they are not eigibe to enro unti the pan's next Open Enroment period. I understand that ife insurance coverage for a dependent, other than a newborn chid, wi not take effect if that dependent is confined to a hospita or other heath care faciity, or is home confined, or is unabe to perform two or more Activities of Daiy Living (ADL's). I understand that my dependent(s) cannot be enroed for a coverage if I am not enroed for that coverage. I understand that the premium amounts shown above are estimations and are for iustrative purposes ony. Submission of this form does not guarantee coverage. Among other things, coverage is contingent upon underwriting approva and meeting the appicabe eigibiity requirements as set forth in the appicabe benefit booket. I understand that I must be activey at work or my eected coverage wi not take effect unti I have met the eigibiity requirements (as defined in the benefit booket.) This does not appy to eigibe retirees. If coverage is waived and you ater decide to enro, ate entrant penaties may appy. You may aso have to provide, at your own expense, proof of each person's insurabiity. Guardian or its designee has the right to reject your request. Pan design imitations and excusions may appy. For compete detais of coverage, pease refer to your benefit booket. State imitations may appy. Your coverage wi not be effective unti approved by a Guardian or its designated underwriter. I hereby appy for the group benefit(s) that I have chosen above. I understand that I must meet eigibiity requirements for a coverages that I have chosen above. I agree that my empoyer may deduct premiums from my pay if they are required for the coverage I have chosen above. I acknowedge and consent to receiving eectronic copies of appicabe insurance reated documents, in ieu of paper copies, to the extent permitted by appicabe aw. I may change this eection ony by providing thirty (30) day prior written notice. I attest that the information provided above is true and correct to the best of my knowedge. Any person who with intent to defraud any insurance company or other person fies an appication for insurance or statements of caim containing any knowingy, fase information, or conceas for purpose of miseading information concerning any fact materia hereto, commits a frauduent insurance act, which is a crime, and may aso be subject to civi penaties, or denia of insurance benefits. The state in which you reside may have a specific state fraud warning. Pease refer to the attached Fraud Warning Statements page. The aws of New York require the foowing statement appear: Any person who knowingy and with intent to defraud any insurance company or other person fies an appication for insurance or statement of caim containing any materiay fase information, or conceas for the purpose of miseading, information concerning any fact materia thereto, commits a frauduent insurance act, which is a crime, and sha aso be subject to a civi penaty not to exceed five thousand doars and the stated vaue of the caim for each such vioation. (Does not appy to Life Insurance.) SIGNATURE OF EMPLOYEE X DATE Enroment Kit , 0001, EN 6

7 Guardian Group Pan Number: Pease print empoyee name: Fraud Warning Statements The aws of severa states require the foowing statements to appear on the enroment form: Aabama: Any person who knowingy presents a fase or frauduent caim for payment of a oss or benefit or who knowingy presents fase information in an appication for insurance is guity of a crime and may be subject to restitution fines or confinement in prison, or any combination thereof. Arizona: For your protection Arizona aw requires the foowing statement to appear on this form. Any person who knowingy presents a fase or frauduent caim for payment of a oss is subject to crimina and civi penaties. Caifornia: For your protection Caifornia aw requires the foowing to appear on this form: Any person who knowingy presents fase or frauduent caim for the payment of a oss is guity of a crime and may be subject to fines and confinement in state prison. Coorado: It is unawfu to knowingy provide fase, incompete, or miseading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penaties may incude imprisonment, fines, denia of insurance, and civi damages. Any insurance company or agent of an insurance company who knowingy provides fase, incompete, or miseading facts or information to a poicy hoder or caimant for the purpose of defrauding or attempting to defraud the poicy hoder or caimant with regard to a settement or award payabe from insurance proceeds sha be reported to the Coorado Division of Insurance within the Department of Reguatory Agencies. Connecticut, Iowa, Kansas, Nebraska, Oregon, and Vermont: Any person who knowingy, and with intent to defraud any insurance company or other person, fies an appication of insurance or statement of caim containing any materiay fase information or conceas, for the purpose of miseading, information concerning any fact materia thereto, may be guity of a frauduent insurance act, which may be a crime, and may aso be subject to civi penaties. Deaware, Indiana and Okahoma: WARNING: Any person who knowingy, and with intent to injure, defraud or deceive any insurer, makes any caim for the proceeds of an insurance poicy containing any fase, incompete or miseading information is guity of a feony. District of Coumbia: WARNING: It is a crime to provide fase or miseading information to an insurer for the purpose of defrauding the insurer or any other person. Penaties incude imprisonment and/or fines. In addition, an insurer may deny insurance benefits, if fase information materiay reated to a caim was provided by the appicant. Forida: Any person who knowingy and with intent to injure, defraud, or deceive any insurer fies a statement of caim or an appication containing any fase, incompete, or miseading information is guity of a feony of the third degree. Kentucky: Any person who knowingy and with intent to defraud any insurance company or other person fies a statement of caim containing any materiay fase information or conceas, for the purpose of miseading, information concerning any fact materia thereto commits a frauduent insurance act, which is a crime. Louisiana and Texas: Any person who knowingy presents a fase or frauduent caim for payment of a oss or benefit is guity of a crime and may be subject to fines and confinements in state prison. Maine, Tennessee, Virginia and Washington: It is a crime to knowingy provide fase, incompete or miseading information to an insurance company for the purpose of defrauding the company. Penaties may incude imprisonment, fines or a denia of insurance benefits. Maryand and Rhode Isand: Any person who knowingy and wifuy presents a fase or frauduent caim for payment of a oss or benefit or knowingy and wifuy presents fase information in an appication for insurance is guity of a crime and may be subject to fines and confinement in prison. Minnesota: A person who fies a caim with intent to defraud or heps commit a fraud against an insurer is guity of a crime. New Hampshire: Any person who, with a purpose to injure, defraud or deceive any insurance company, fies a statement of caim containing any fase, incompete or miseading 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 knowingy fies a statement of caim containing any fase or miseading information is subject to crimina and civi penaties. New Mexico: Any person who knowingy presents a fase or frauduent caim for payment or a oss or benefit or knowingy presents fase information in an appication for insurance is guity of a crime and may be subject to civi fines and crimina penaties or denia of insurance benefits. Ohio: Any person who with intent to defraud or knowing that he/she is faciitating a fraud against an insurer, submits an appication or fies a caim containing a fase or deceptive statement is guity of insurance fraud. Pennsyvania: Any person who knowingy and with intent to defraud any insurance company or other person fies an appication for insurance or statement of caim containing any materiay fase information or conceas for the purpose of miseading, information concerning any fact materia thereto commits a frauduent insurance act, which is a crime and subjects such person to crimina and civi penaties. 7 DETACH ENTIRE FORM AND RETURN TO YOUR EMPLOYER

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