Mexico School District # 59. All Eligible

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1 key* E V8.6 Mexico School District # 59 All Eligible Benefits Plan Here is your new coverage. Make sure you return the completed form, if applicable, to your plan administrator. If you miss the deadline, the coverage may be delayed or you may not be eligible for enrollment this year and proof of insurability may be required. HIGHLIGHTS: n Protect your family s future, with life coverage n Comprehensive dental care for all your needs n High-quality vision care coverage Questions? Concerns? Helpline (888) Call weekdays, 7:00AM to 8:30PM, EST. And refer to your plan number: Learn more about Guardian at

2 We re ready to get working for you If you re like most employees, finding enough time in the day to accomplish your lengthy to-do list can often be no easy task. As your Guardian coverage begins, we want you to know that we re here for you every step of the way and are committed to providing you with the resources to obtain fast, accurate answers to your benefits-related questions. One way in which we do this is through our online member resource, Guardian Anytime sm, which allows you to manage your benefits when it works best for you day or night. Plus, it offers helpful resources to ensure you get access to the quality care you need. We encourage you to take a couple minutes to check out and register for Guardian Anytime sm at We promise it will be time well spent. Welcome to Guardian!

3 Life Plans Basic Life Your employer provides $10,000 Basic Term Life coverage for all full time employees. Your Basic Life coverage includes Accidental Death and Dismemberment coverage equal to one times the employee s life benefits. Your spouse is eligible for coverage in the amount of $2,000. Your dependent children ages 14 days to 23 (25 if full time student) are eligible for coverage in the amount of $1,000**. See enrollment form for details. You may elect Voluntary Term coverage. Premiums will be deducted from your monthly payroll check. YOUR GUARDIAN PLAN OFFERS: Low group rates Family coverage for spouse and children Reliable claims payments Plan coverage begins July 01, 2012 COVERAGE OPTIONS VOLUNTARY TERM LIFE Employee Benefit Choice of 6 employer-specified amounts, from $25,000 to $150,000. See Cost Illustration page for details. Spouse benefit You may elect one of the following benefit options: $10,000. See Cost Illustration page for details. Child benefit children age 14 days to 23 years (25 if full time student) You may elect one of the following benefit options: $10,000. Subject to state limits. See Cost Illustration page for details. Subject to coverage limits Spouse coverage is based on employee age and terminates at age 70. Premiums for Voluntary Life increase in five-year increments. See enrollment form for details. Did you know? According to the National Safety Council, someone dies in an accident every six minutes. 1

4 PLAN DETAILS BASIC LIFE VOLUNTARY TERM LIFE Guarantee Issue Premiums Portability Underwriting may be required, depending on amount and/or age Covered by your company if you meet eligibility requirements Yes, with age and other restrictions, including evidence of insurability We Guarantee Issue coverage up to $150,000 per employee, $10,000 for a spouse and $10,000 for dependent children Increase on plan anniversary after you enter next 5 year age group Yes, with age and other restrictions Conversion Yes, with restrictions; see certificate of benefits Yes, with restrictions; see certificate of benefits Accelerated Life Benefit No Yes Waiver of Premiums For employees disabled prior to age 60, with premiums waived until age 65, if conditions are met For employees disabled prior to age 60, with premiums waived until age 65, if conditions met Benefit Reductions 35% at age 65, 50% at age 70 35% at age 65, 60% at age 70, 75% at age 75, 85% at age 80 EXCLUSIONS AND LIMITATIONS A SUMMARY OF PLAN LIMITATIONS AND EXCLUSIONS For Basic Life: You must be working full-time on the effective date of your coverage; otherwise, your coverage becomes effective after you have completed a specific waiting period. 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 one year; or (b) in an area under travel warning by the US Department of State. Subject to state specific variations. Dependent life insurance will not take effect if a dependent, other than a newborn, is confined to the hospital or other health care facility or is unable to perform the normal activities of someone of like age and sex. Evidence of Insurability is required on all late enrollees. This coverage will not be effective until approved by a Guardian underwriter. This proposal is hedged subject to satisfactory financial evaluation. Please refer to certificate of coverage for full plan description. A SUMMARY OF PLAN LIMITATIONS AND EXCLUSIONS for Voluntary Term Life: You must be working full-time on the effective date of your coverage; otherwise, your coverage becomes effective after you have completed a specific waiting period. 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 one year; or (b) in an area under travel warning by the US Department of State. Subject to state specific variations. We pay no benefits if the insured s death is due to suicide within two years from the insured s original effective date. This two year limitation also applies to any increase in benefit. This exclusion may vary according to state law Dependent coverage will not take effect if a dependent, other than a newborn is confined to a hospital or other health care facility, or is unable to perform the normal activities of someone of like age and sex (may vary by state). Accelerated Life Benefit is not paid to an employee under the following circumstances: one who is required by law to use the benefit to pay creditors; is required by court order to pay the benefit to another person; is required by a government agency to use the payment to receive a government benefit; or loses his or her group coverage before an accelerated benefit is paid. GP-1-R-EOPT-96. Guarantee Issue/Conditional Issue amount applies for ages less than 65. Ages maximum issue underwriting amounts $10,000 for employee and $5,000 spouse. Ages 70 and older must be individually underwritten for all amounts. Late entrants and benefit increases require underwriting approval. A SUMMARY OF PLAN LIMITATIONS AND EXCLUSIONS for AD&D: We pay no Accidental Death and Dismemberment (AD&D) benefits for an insured where death or dismemberment occurs: As the result of a disease or a bodily infirmity; By declared or undeclared war or act of war or armed aggression, or while a member of any armed force. May vary by state; Through intentional self-injury; While driving without a valid driver's license; While legally intoxicated; While participating in civil disorder or committing a felony; Traveling on any type of aircraft while having any duties on that aircraft; While voluntarily using a non-prescription controlled substance; GP-1-R-ADCL1-00 et al. Questions? Call the Guardian Helpline (888) Enrollment Kit , 0001, EN 2

5 Life Cost Illustration Voluntary Life Cost Illustration Monthly premiums displayed. Policy Election Amount Policy Election Cost Per Age Bracket Employee < $25,000 $1.25 $1.25 $1.75 $2.50 $4.00 $6.25 $9.25 $14.25 $23.75 $40.00 $50,000 $2.50 $2.50 $3.50 $5.00 $8.00 $12.50 $18.50 $28.50 $47.50 $80.00 $75,000 $3.75 $3.75 $5.25 $7.50 $12.00 $18.75 $27.75 $42.75 $71.25 $ $100,000 $5.00 $5.00 $7.00 $10.00 $16.00 $25.00 $37.00 $57.00 $95.00 $ $125,000 $6.25 $6.25 $8.75 $12.50 $20.00 $31.25 $46.25 $71.25 $ $ $150,000 $7.50 $7.50 $10.50 $15.00 $24.00 $37.50 $55.50 $85.50 $ $ Policy Election Amount Spouse $10,000 $.50 $.50 $.70 $1.00 $1.60 $2.50 $3.70 $5.70 $9.50 $16.00 Policy Election Amount Child(ren) $10,000 $1.90 $1.90 $1.90 $1.90 $1.90 $1.90 $1.90 $1.90 $1.90 $1.90 Guarantee Issue Amount: Employee $150,000; Spouse $10,000; Child $10,000 Estimated premiums; refer to your first paycheck deduction for final rates. Your company has selected Guardian to provide life coverage to eligible employees 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. For more details see enrollment form. Subject to coverage limits Premiums for Voluntary Life Increase in 5 year increments Spouse coverage is based on employee age and terminates at age 70. Benefit reductions apply. See plan details 3

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7 Tips for buying Life Insurance Life insurance helps provide financial protection for your family and loved ones. If something were to ever happen to you, life insurance would provide money so that your family and loved ones can continue to manage expenses if you were no longer around. Sample expenses include mortgage payments, legal or medical expenses, childcare, college education and outstanding debts. If someone depends on you, whether or not you work, chances are you need life insurance. Here are some things to keep in mind when you buy life insurance: Know how much Life insurance you need A very broad rule of thumb is that your life insurance coverage should be 7 to 10 times your income. However, every person s life insurance needs are different. For example, you ll need more insurance if you have four children compared to two or if you have credit card debt versus none. How do you stack up? For a personal estimate on how much life insurance you need, go to the Life and Health Insurance Foundation for Education s website at The online life insurance needs calculator is easy to use and takes just minutes. A good place to start is at your workplace Think about supplementing your workplace benefit If your employer offers a life insurance benefit, think about enrolling in it. A workplace benefit is generally affordable (just a few dollars a month in many cases) and easy to buy. You don t typically need a medical exam to enroll and your employer has done the legwork of finding a quality plan to offer its employees. Your workplace benefit is a good place to start but may not meet the needs of all people. Know how much your workplace benefit covers. If it s not enough based on your personal estimate, it might make sense for you to supplement it. Consider talking to a financial advisor. Know that, unlike a workplace benefit, when you buy life insurance outside of work a medical exam is usually required. As things change in your life, your life insurance needs will too. Review your life insurance policy every year. If you ve experienced a life milestone like getting married, having a baby or buying a home in the last year, you ll want to make sure your family and loved ones continue to be adequately protected. 5

8 Dental Plans Option 1 or 3: With your Base Plan or Buy Up Plan plan, you can visit any dentist; but you pay less out-of-pocket when you choose a PPO dentist. Option 2: With your PPO In-Network Only plan, you save money by visiting a PPO dentist. Out-of network visits are not covered. COMPARE THE PLANS Option 1: Base Plan Option 2: PPO In-Network Option 3: Buy Up Plan Network DentalGuard Preferred DentalGuard Preferred DentalGuard Preferred Your Monthly premium $26.48 $37.54 $37.54 You and spouse $50.33 $72.77 $72.77 You and child(ren) $55.44 $79.73 $79.73 You, spouse and child(ren) $79.29 $ $ Calendar year deductible In-Network Out-Network In-Network Out-Network In-Network Out-Network Individual $50 $50 $0 N/A $50 $50 Family limit 3 per family 3 per family 3 per family Waived for Preventive Preventive Not applicable Not applicable Preventive Preventive Charges covered for you (co-insurance) In-Network Out-Network In-Network Out-Network In-Network Out-Network Preventive Care (e.g. cleanings) 100% 100% 100% Not Covered 100% 100% Basic Care (e.g. fillings) 50% 50% 100% Not Covered 80% 80% Major Care (e.g. crowns, dentures) 25% 25% 60% Not Covered 50% 50% Orthodontia Not Covered Not Covered Not Covered Annual Maximum Benefit $1000 $1000 $1000 N/A $1000 $1000 Maximum Rollover Yes No Yes Rollover Threshold $500 $500 Rollover Amount $250 $250 Rollover In-network Amount $350 $350 Rollover Account Limit $1000 $1000 YOUR GUARDIAN PLAN OFFERS: No charge for preventive care (subject to plan limits) Maximum rollover If a member submits at least one claim and stays under the claims threshold, a part of the unused maximum will be rolled over for use in future years. National PPO network of more than 70,000 dentist locations Reliable claims payment four days on average Plan coverage begins July 01, 2012 Find out if your dentist is in Guardian s network at Lifetime Orthodontia Maximum Not Applicable Not Applicable Not Applicable Not Applicable Dependent Age Limits Let Guardian put its 30-plus years of dental benefits experience to work for you and your family. 6

9 CATEGORY PLAN DETAILS Option 1: Base Plan Option 2: PPO In-Network Option 3: Buy Up Plan Plan pays (on average) Plan pays (on average) Plan pays (on average) In-network Out-of-network In-network Out-of-network In-network Out-of-network Preventive Care Cleaning (prophylaxis) 100% 100% 100% Not Covered 100% 100% Frequency: Once Every 6 Months Once Every 6 Months Once Every 6 Months Fluoride Treatments 100% 100% 100% Not Covered 100% 100% Limits: No Age Limits No Age Limits No Age Limits Oral Exams 100% 100% 100% Not Covered 100% 100% Sealants (per tooth) 100% 100% 100% Not Covered 100% 100% X-rays 100% 100% 100% Not Covered 100% 100% Basic Care Anesthesia* 50% 50% 100% Not Covered 80% 80% Fillings 50% 50% 100% Not Covered 80% 80% Periodontal Maintenance 50% 50% 100% Not Covered 80% 80% Frequency: Once Every 6 Months Once Every 6 Months Once Every 6 Months (Standard) (Standard) (Standard) Scaling & Root Planing (per quadrant) 50% 50% 100% Not Covered 80% 80% Simple Extractions 50% 50% 100% Not Covered 80% 80% Major Care Bridges and Dentures 25% 25% 60% Not Covered 50% 50% Inlays, Onlays, Veneers** 25% 25% 60% Not Covered 50% 50% Perio Surgery 25% 25% 60% Not Covered 50% 50% Repair & Maintenance of Crowns, Bridges & Dentures 25% 25% 60% Not Covered 50% 50% Root Canal 25% 25% 60% Not Covered 50% 50% Single Crowns 25% 25% 60% Not Covered 50% 50% Surgical Extractions 25% 25% 60% Not Covered 50% 50% This is only a partial list of dental services. Your certificate of benefits will show exactly what is covered and excluded. **Crowns, Inlays, Onlays and Labial Veneers are covered only when needed because of decay or injury and only 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 of 19; 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. Fillings restrictions may apply to composite fillings. Please note: The plan details listed here are some of the most common services related to dental coverage. The coinsurance percentages for the PPO plan options correspond to the coverage categories of Preventive, Basic, Major and Orthodontia listed in the table above. Some services may be paid under a different category than listed. The actual co-insurance shown reflects your plan's coverage. 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 preventive, restorative, n 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. 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 7

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11 Maximum Rollover Save Your Dental Annual Maximum Dollars For a Time When You Need Them Most! With Maximum Rollover, Guardian will roll over a portion of your unused annual maximum into your personal Maximum Rollover Account (MRA). The MRA can be used in further years, if you reach the plan s annual maximum. To qualify, you must submit a claim for covered services for which a benefit payment is issued, in excess of any deductible or co-pay, and you must not exceed the paid claims threshold during the benefit year. You and your insured dependents maintain separate MRAs based on your own claim activity. Each MRA may not exceed the MRA limit. You can view your annual MRA statement detailing your account and those of your dependents on PLAN ANNUAL MAXIMUM ** THRESHOLD MAXIMUM ROLLOVER AMOUNT IN-NETWORK ONLY MAXIMUM ROLLOVER AMOUNT MAXIMUM ROLLOVER ACCOUNT LIMIT $1000 $500 $250 $350 $1000 ** If a plan has a different annual maximum for PPO benefits vs. non-ppo benefits, ($1500 PPO/$1000 non-ppo for example) the non-ppo maximum determines the Maximum Rollover plan. NOTES: Cases on either a calendar year or policy year accumulation basis qualify for the Maximum Rollover feature. For calendar year cases with an effective date in October, November or December, the Maximum Rollover feature starts as of the first full benefit year. For example, if a plan starts in November of 2009, the claim activity in 2010 will be used and applied to MRAs for use in Under either benefit year set up (calendar year or policy year), Maximum Rollover for new entrants joining with 3 months or less remaining in the benefit year, will not begin until the start of the next full benefit year. Maximum Rollover is deferred for members who have coverage of Major services deferred. For these members, Maximum Rollover starts when coverage of Major services starts, or the start of the next benefit year if 3 months or less remain until the next benefit year. 9

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13 Finding a dentist or vision care provider is easy Go online it just takes minutes! The best way to save money through your dental or vision plan is by seeing a provider in your plan s network. Guardian s Find a Provider site makes it easy for you to search for a dental or vision provider meets your needs. Guardian s Find a Provider site is available to you 24 hours a day, 7 days a week. Here are just a few things you can do online: Customize your search by specialty, languages spoken and more Get side-by-side comparisons of provider information (ie. office status, distance) Create a quick-list of favorite providers for easy reference online Get maps and directions to a providers office location View your results online or have them faxed or ed to you Save your search criteria for easy access when you revisit the site Create a customized provider directory Nominate a dentist to be included in a network Just go to Under Contact Us, click on Find a Provider. 11

14 Prepared for Mexico School District # 59 Guardian Group Plan Number Vision Plans YOUR GUARDIAN PLAN OFFERS: Visit any doctor with your Full Feature plan, but save by visiting any of the 34,000 locations in the nation's largest vision network. UNDERSTAND YOUR PLAN Network Full Feature Your Monthly premium $ Copay You and spouse $ You and child(ren) $ You, spouse and child(ren) $ Exams Copay $ 10 Materials Copay (waived for elective contact lenses) Service Frequencies Exams Lenses (for glasses or contact lenses) Frames Network discounts (cosmetic extras, glasses and contact lens professional service) VSP Network Signature Plan $ 25 Dependent Age Limits 25 Every 12 months Every 12 months Every 24 months Limitless within 12 months of exam. 1 Benefit includes coverage for glasses or contact lenses, not both. Reduced prices An average 15% to 30% discount off an extensive list of "cosmetic extras", including special lenses and scratch-resistant coatings. No claims submission for in-network services and supplies. Did you know? "Two-thirds of employees would rather trade a vacation day for eyecare benefits." Bests Review, 2006 Questions? Call the Guardian Helpline (888) Enrollment Kit , 0001, EN 12

15 PLAN DETAILS FULL FEATURE You pay (after copay if applicable): In-network Out-of-network Eye Exams $0 Amount over $46 Single Vision Lenses $0 Amount over $47 Lined Bifocal Lenses $0 Amount over $66 Lined Trifocal Lenses $0 Amount over $85 Lenticular Lenses $0 Amount over $125 Frames 80% of amount over $120 Amount over $47 Contact Lenses (Elective) Amount over $105 Amount over $105 Contact Lenses (Medically Necessary) $0 Amount over $210 Contact Lenses (Evaluation and fitting) 15% off UCR No discounts Cosmetic Extras Avg. 30% off retail price No discounts Glasses (Additional pair of frames and lenses) 20% off retail price^ No discounts Laser Correction Surgery Discount Up to 15% off the usual charge or 5% off promotional price No discounts 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. In addition Full-Feature plans offer 30% off additional prescription glasses and nonprescription sunglasses, including lens options, if purchased on the same day as the eye exam from the same VSP doctor who provided the exam. 13

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17 Please print clearly to ensure accurate processing Employer: Mexico School District # S Jefferson St Attn: Anthony Chance Mexico, MO Guardian Group Plan Number: The Guardian Life Insurance Company of America EMPLOYER USE ONLY q New Application q Add Dependent(s) q Drop Dependent(s) q Change Address q Change Name q Drop Coverage as of: / / Class All Eligible Hours Worked Division Benefits Effective / / Keep a copy for your records and return form to: Midwest Regional Office, P.O. Box 8012, Appleton, WI ABOUT YOURSELF Print clearly in black or blue ink. First, Middle Initial, Last Name q Add q Change q Drop Sex Date of Birth (mm/dd/yyyy) Social Security Number q M q F / / - - Address City State Zip Preferred Day Phone Eve Phone The best way to reach you: q q Day Phone q Eve Phone Job Title Work Status Date work status began q Full-Time q Part-Time q Retired q COBRA/State Continuation / / Annual Salary/Earnings $ Are you married? q Yes q No Do you have children or other dependents? q Yes q No ABOUT YOUR DEPENDENTS q A sheet with information about additional dependents is attached. Spouse First, Middle Initial, Last Name q Add q Change q Drop Sex q M q F Date of Birth (mm/dd/yyyy) Social Security Number / / - - Marriage Date (mm/dd/yyyy) / / Child 1 q Add q Change q Drop Sex Child 2 q Add q Change q Drop Sex q M q F q M q F Date of Birth (mm/dd/yyyy) q Full-time student, at / / (school): Date of Birth (mm/dd/yyyy) / / q Full-time student, at (school): City/State: Attending Since / / City/State: Attending Since / / Child 3 q Add q Change q Drop Sex q M q F Date of Birth (mm/dd/yyyy) q Full-time student, at / / (school): City/State: Attending Since / / Child 4 q Add q Change q Drop Sex q M q F Date of Birth (mm/dd/yyyy) q Full-time student, at / / (school): City/State: Attending Since To drop coverage for yourself or your dependents, check the box(es) to the right of the name(s) and select the coverage(s) to drop below. Attach a separate sheet if you wish to drop more than one dependent from different coverages. q Basic Life q Voluntary Life q Dental q Vision / / CEF2005 Questions? Call the Guardian Helpline (888) Enrollment Kit , 0001, EN 1 DETACH ENTIRE FORM AND RETURN TO YOUR EMPLOYER DATE FORM PUBLISHED: Mar 12, 2012

18 YOUR BASIC LIFE COVERAGE WITH ACCIDENTAL DEATH AND DISMEMBERMENT (AD&D) Policy Amount You must be enrolled to cover your dependents. Employee R $10,000 Basic Life for Spouse R $2,000 The amount may not be more than 50% of the employee amount. Basic Life for Child(ren) R $1,000 The amount may not be more than 10% of the employee amount. If this Basic Life policy will replace your existing life insurance policy under your current employer, provide the amount of the previous policy $ Name your beneficiaries Primary beneficiaries must total 100%. Primary Beneficiary 1 First, Middle Initial, Last Name Relationship to Employee Percent % Primary Beneficiary 2 % Contingent Beneficiary % In the event the designated primary beneficiaries are deceased, the contingent beneficiary will receive the benefit. CHOOSE YOUR VOLUNTARY TERM LIFE COVERAGE Check one box only Employee Policy Amount You must be enrolled to cover your dependents. q $25,000 q $50,000 q $75,000 q $100,000 q $125,000 q $150,000* q I waive this coverage *Guarantee Issue Amount Add Voluntary Life for Spouse Check one box only q $10,000* *Guarantee Issue Amount q I waive this coverage The amount may not be more than 50% of the employee amount for Voluntary Life. Add Voluntary Life for Child(ren) Check one box only q $10,000* *Guarantee Issue Amount q I waive this coverage The amount may not be more than 10% of the employee amount for Voluntary Life. q A separate sheet for Voluntary Term Life beneficiaries is attached if they are not the same as those named for Basic Life. For Voluntary Life, an Evidence of Insurability form must be completed for any amount above the Guarantee Issue. IMPORTANT NOTES n If you waive life or disability coverage and later decide to enroll, you will have to provide, at your own expense, proof of each person's insurability. Guardian reserves the right to reject your request. n Children will not be covered until they reach 14 days. n Based on your plan benefits and your age, you may be required to complete an additional evidence of insurability form for Voluntary Life and/or Guardian Universal Life. 2 DETACH ENTIRE FORM AND RETURN TO YOUR EMPLOYER

19 Guardian Group Plan Number: Please print employee name: CHOOSE YOUR DENTAL COVERAGE Check one box only Your monthly premium Option 1: Base Plan Option 2: PPO In-Network Only Option 3: Buy Up Plan Employee alone q $26.48 q $37.54 q $37.54 q I waive this coverage Employee and Spouse q $50.33 q $72.77 q $72.77 q I waive this coverage Employee and Child(ren) q $55.44 q $79.73 q $79.73 q I waive this coverage Entire family q $79.29 q $ q $ q I waive this coverage If you or your family have lost dental coverage, please explain below. Late entry penalties may apply. Reason for Loss of coverage: q Termination of Employment q Divorce q Death of Spouse q Termination or Expiration of coverage Date of coverage loss If you are waiving coverage, are you covered under another dental plan? q Yes q No / / If you are waiving dependent coverage, are your dependents covered under another dental plan? q Yes q No IMPORTANT NOTES n Newborn Children: A newborn child will be covered for the first 31 days from the moment of his or her birth. To continue coverage beyond the first 31 days, you must notify Guardian within 31 days of the newborn child s date of birth. Guardian will then provide any necessary forms and instructions for enrollment. You must enroll the child and agree to make any additional required payments, within 10 days of receipt of the forms. If you fail to do this, the newborn child s coverage will cease at the end of the first 31 days. If you later enroll the child, he or she will be considered a late enrollee n Proof of insurability does not apply to dental, but if you waive dental coverage and later decide to enroll, you may be subject to a late entrant penalty and your dental benefits may be limited for a period of time. Guardian may waive late-entrant penalties if you lose dental coverage due to termination of the plan, loss of employment, death of spouse, divorce or where a court has ordered coverage be provided for an eligible spouse or eligible children, provided you apply within 30 days. CHOOSE YOUR VISION COVERAGE Check one box only Your monthly premium Full Feature Employee alone q $12.39 q I waive this coverage Employee and Spouse q $20.85 q I waive this coverage Employee and Child(ren) q $21.26 q I waive this coverage Entire family q $33.65 q I waive this coverage If you are waiving coverage, are you covered under another vision plan? q Yes q No If you are waiving dependent coverage, are your dependents covered under another vision plan? q Yes q No IMPORTANT NOTES n If I have waived the vision coverage, and elect coverage at a later date, enrollment delays may apply. n Your plan includes a One Year Lock-In/Lock-Out Provision - Your election to enroll in or waive vision coverage must remain in effect until your plan's next annual vision enrollment period. Questions? Call the Guardian Helpline (888) Enrollment Kit , 0001, EN DETACH ENTIRE FORM AND RETURN TO YOUR EMPLOYER 3

20 SIGNATURE n I hereby apply for the group benefit(s) that I have chosen above. n I understand that I must meet eligibility requirements for all coverages that I have chosen above. n I understand I must be actively at work until I have completed a waiting period (as defined in the group plan) of full time service for my life and/or disability coverage. This requirement does not apply to eligible retirees. n I understand that my dependent(s) cannot be enrolled for a coverage if I am not enrolled for that coverage. n I understand that life insurance coverage for a dependent, other than a newborn child, will not take effect if that dependent is confined to a hospital or other health care facility, or is home confined, or is unable to perform the normal activities of someone of like age and sex. n I agree that my employer may deduct premiums from my pay or add premiums to my dues; if they are required for the coverage I have chosen above. n I understand that the premium amounts shown above are estimations. If the premium amounts shown above and the deductions for premiums shown on my paycheck stub do not agree, my paycheck stub will prevail. I understand that the premium amounts may be amended. n I attest that the information provided above is true and correct to the best of my knowledge. n 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 be guilty of insurance fraud. SIGNATURE OF EMPLOYEE X DATE 4

21 Thank You If applicable, return your completed form to your plan administrator. Please remember to: q q q q q q Check the coverage you want Include your social security number (and those of your dependents, if applicable) Include dates of birth Indicate the best way to reach you Include your name on each page of the form Sign and date form You chose... Dental: q Option 1: Base Plan q Option 2: PPO In-Network Only q Option 3: Buy Up Plan Life: q Basic Life q Term Life Vision: q Full Feature Date form submitted:

22 Make the most of your Guardian benefits at Enrolled members and their dependents can access helpful, secure information about their Guardian benefit(s) instantly at Review your benefits Look up amounts and services covered in your plan Check the status of a claim Receive alerts when a response to your dental* claim is available online Print forms and plan materials...and much more To register, go to Mexico School District # 59 Benefits Plan 2005 The Guardian Life Insurance Company of America, 7 Hanover Square, New York *Not available to members with Guardian pre-paid Dental/DHMO plans (including FirstCommonwealth and Managed DentalGuard plans). 0001