Employee Enrollment Packet 2020

P.O. Box 21367 Billings, MT 59104-1367
Phone: 800.777.3575 or 406.245.3575
Website: www.ebms.com

Company Name: Group #: Cert#:

This Section Is To Be Completed By Employee

Last Name First Name M.I. Gender Marital Status
Single-S Married-M
Divorced-D Legally Separated
SSN: Date of Birth: Email Address:
Zip:
Current Mailing Address: City: State:
(ext)
Home Phone ( ) Work Phone ( )
Relationship
Life Insurance Beneficiary (if applicable): Relationship Contingent Life Beneficiary (if applicable)

Address: SSN: Address: SSN:

Please Indicate the Coverage Elected for Each Dependent:

List of Eligible Dependents Social Security # Date of Relationship to
Birth Employee
Full Name Required Gender Medical Dental Vision
SELF

Other Health Benefit Information

Are you or any of your dependents enrolled in another health benefit plan? Yes If yes, please indicate other insurance coverage below.

Are any of your dependent children eligible for other Employer Sponsored Coverage No Yes If yes, please indicate other insurance coverage (OIC) below.

If other insurance coverage (OIC) information is not indicated on this enrollment form, this will imply that no other insurance coverage (OIC) is in effect and/or
that no dependent children are eligible for other Employer Sponsored Coverage.

Last Name First Name Other Health Benefit Name, Policy Number and Phone Number: Medicare A Medicare B Medical Dental Vision

For the Other Insurance Coverage, please complete the following. For more than one insurance continue on the back of this form.

Other Policy Holder’s name: Other Policy Holder’s Date of Birth: / /

Type of Policy: Employer Sponsored Retiree COBRA Individual Medicaid/CHIP/Other State Program

Relationship of Policy Holder to those covered: Effective Date of Policy: / /

Application is made for benefits under Employer’s benefit plan for which I am eligible and authorization is granted to deduct from my salary or wages any premiums

required. By signing below I am indicating that, to the best of my knowledge, all information is true and accurate. I understand that if the information provided herein is

determined to be inaccurate, this will be considered an intentional misrepresentation and coverage could be terminated retroactively.

Accept: If you accept coverage please sign and date below. WAIVER OF PARTICIPATION: By my signature below, I acknowledge

(This form is valid only if signed and dated.) that coverage has been offered to me and I elect not to participate at

this time.

Signature Date / / Signature Date / /
This Section Is To Be Completed By Employer PPO Date of Hire _1_1_/_0_4_/_2_0_1_9_____________________

Division Name: Division #:

Effective Date: _1_2_/_0_1_/_2_0_1_9______________ Plan: _______________________________ Employment Status: Full-Time Part-Time

Occupation: __________________________ Earnings: $___________________ Life Insurance (if applicable) $ ______________________________

Initially Eligible Open Enrollment Late Enrollment Reinstatement – Date / / Newborn Deletion Marriage Name/Address

EBMS_EnrollmentForm_09/2012

Health and Rehab Solutions

2020 Premium Comparison at 75% Contribution

2020 Balance 1000, 80/20 $35 Co-pay Monthly Cost

Coverage Employee Monthly Employee Per Period

Premium Premium

Employee $125.44 $62.72

Employee/Spouse $627.20 $313.60

Employee/Child(ren) $677.38 $338.69

Family $1,179.16 $589.58

2020 HSA 3000 Plan Monthly Cost

Coverage Employee Monthly Employee Per Period
Premium Premium
$49.26
Employee $98.52 $246.31
$266.02
Employee/Spouse $492.62 $463.07

Employee/Child(ren) $532.03

Family $926.13

Employer Contribution Total Premium Annual Employee
$376.33 Contribution
$376.33 $501.77 $1,505.28
$376.33 $1003.53 $7,526.40
$376.33 $1,053.71 $8,128.56
$1,555.49 $14,149.92
Employer Contribution
$295.58 Total Premium Annual Employee
$295.58 Contribution
$295.58 $394.10 $1,182.24
$295.58 $788.20 $5,911.44
827.61 $6,384.36
$1,221.71 $11,113.56

The Guardian Life Insurance Company of America Enrollment Form
And its Affiliates and Subsidiaries Page 1 of 4

Guardian Life, P.O. Box 14319, Please print clearly and mark carefully.
Lexington, KY 40512

Employer Name: Health and Rehab Solutions Group Plan Number: 00537850 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:___________________ Division:_________________ Subtotal Code:____________________ (Please obtain this from your Employer)

About You: Social Security Number

First, MI, Last Name: ___ ___ ___ - ___ ___ - ___ ___ ___ ___

Address City State Zip

Gender: q M q F Date of Birth (mm-dd-yy): ____ - ____ - ____ Phone: ( ) -
Email 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: Date of full time hire: ____ - ____ - ____
q Active q Retired q Cobra/State Continuation

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 dependent tax exemption. Dependent
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) Gender Social Security Number

q M q F _____ - _____ - _____

Address/City/State/Zip:

Date of Birth (mm-dd-yyyy)

Phone: ( ) - ____ - ____ - ____

Child/Dependent 1: q Add q Drop Gender Social Security Number Status (check all that apply)
Address/City/State/Zip: q M q F _____ - _____ - _____ q Student (post high school) q Disabled
q Non standard dependent

Phone: ( ) - Date of Birth (mm-dd-yyyy)
Child/Dependent 2: ____ - ____ - ____

q Add q Drop Gender Social Security Number Status (check all that apply)
q M q F _____ - _____ - _____ q Student (post high school) q Disabled
q Non standard dependent

Address/City/State/Zip: Date of Birth (mm-dd-yyyy)
Phone: ( ) - ____ - ____ - ____

CEF2015-R www.guardianlife.com 1
Questions? Call the Guardian Helpline (888) 600-1600

DETACH ENTIRE FORM AND RETURN TO YOUR EMPLOYER

Child/Dependent 3: q Add q Drop Gender Social Security Number Status (check all that apply)
Address/City/State/Zip: q M q F _____ - _____ - _____ q Student (post high school) q Disabled
q Non standard dependent
Phone: ( ) -
Child/Dependent 4: Date of Birth (mm-dd-yyyy)
Address/City/State/Zip: ____ - ____ - ____

Phone: ( ) - q Add q Drop Gender Social Security Number Status (check all that apply)
q M q F _____ - _____ - _____ q Student (post high school) q Disabled
q Non standard dependent

Date of Birth (mm-dd-yyyy)
____ - ____ - ____

Dental Coverage: You must be enrolled to cover your dependents. Check only one box.

Your Bi-weekly Premium Employee Only EE & Spouse EE & EE, Spouse &

Dependent/Child(ren) Dependent/Child(ren)

Option 1: PPO q $16.10 q $32.93 q $38.86 q $59.29

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.

Your Bi-weekly Premium Employee Only EE & Spouse EE & EE, Spouse &
Full Feature q $6.60 q $11.10
Dependent/Child(ren) Dependent/Child(ren)

q $11.32 q $17.91

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

Signature

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.

l I understand that my dependent(s) cannot be enrolled for a coverage if I am not enrolled for that coverage.

l I understand that the premium amounts shown above are estimations and are for illustrative purposes only.

l 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.

l 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.

l Plan design limitations and exclusions may apply. For complete details of coverage, please refer to your benefit booklet. State limitations may apply.

l I hereby apply for the group benefit(s) that I have chosen above.

l I understand that I must meet eligibility requirements for all coverages that I have chosen above.

l I agree that my employer may deduct premiums from my pay if they are required for the coverage I have chosen above.

l 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.

l I attest 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.

2
DETACH ENTIRE FORM AND RETURN TO YOUR EMPLOYER

Guardian Group Plan Number: 00537850 Please print employee name:

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 00537850, 0001, 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.

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.

Questions? Call the Guardian Helpline (888) 600-1600 www.guardianlife.com 3

DETACH ENTIRE FORM AND RETURN TO YOUR EMPLOYER

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.

4

Health and Rehab Solutions Valid Until: July 1, 2019

Supplemental Employee Life

Employee Plan Summary Class 1
Feature
All Active Full Time Employees
Class Description $10,000 Increment
$100,000
Employee Benefit
Guaranteed Issue $10,000
Amount
Minimum $500,000
Benefit
Maximum Voluntary
Benefit Standard
Employee Contribution

Employee Continuity of Coverage

Supplemental Life Age Rate per $1,000
Smoker/Non Smoker
Supplemental Life - Band 0.05
Employee <25 0.041
25-29 0.046
Rate Guarantee: 3 years 30-34 0.068
35-39 0.103
40-44 0.17
45-49 0.273
50-54 0.397
55-59 0.512
60-64 0.741
65-69 1.295
70-74 3.725
75+

July 1, 2019

5

Benefits Enrollment Form for Health and Rehab Solutions

Hartford Life and Accident Insurance Company

One Hartford Plaza, Hartford, Connecticut 06155 (A stock insurance company)

The Hartford® is The Hartford Financial Services Group, Inc., and its subsidiaries.

Instructions: 1) Please print clearly with blue or black ink and provide complete information. (Missing information causes delays.) 2) Please review the

applicable benefit highlight/summary information for each product prior to electing coverage. You (employee) and your dependent(s) (if applicable) are only
eligible for coverage as allowed by the applicable group policy. 3) For each coverage, please check the appropriate box(es) to elect or decline coverage
and enter amounts where necessary. 4) Please sign and date the form. 5) Submit the form as instructed by your benefits administrator by the enrollment

deadline. (Do not submit or send the form directly to The Hartford.)

EMPLOYEE INFORMATION Employee Social Security Date of Birth (MM/DD/YYYY)
Name (FIRST MI LAST) Number

Gender Married/Partnered Email Address State Zip Code
 M  F  Yes  No City

treet Address

Date of Hire (MM/DD/YYYY) Hours Position/Job Title/Physician Specialty Salary/Earnings
Class Worked/Week Division/Department

Location

DisabilityFLEX® (VOLUNTARY SHORT TERM DISABILITY INSURANCE)

Benefit Commencement Period/Benefit Pay Period Premium Amount
(Cost per Pay Period –Monthly)
Duration – Select One Option Benefit Amount – Select One Option
$_______________
 Benefits Begin: 8th day  $100 each week $_______________
Duration: 13 weeks  $700 each week $_______________
 $1300 each week $_______________
 Benefits Begin: 8th day  $2,000 each week (Max) $_______________
Duration: 26 weeks  $_______________ each week $_______________
 $200 each week $_______________
 Decline Coverage  $700 each week $_______________
 $1,300each week $_______________
 $2,000 each week (Max) $_______________
 $_______________ each week
N/A N/A

Additional Information:
• The benefit amount you elect cannot exceed 60% of your current weekly earnings.
• Your premium amount is based on your age; therefore, your premium amount will change as you grow older.

Form PA-9676 PAGE 1 OF 4 CREATION DATE: 06/01/2018
EMPLOYEE NAME: ________________________________ HEALTH AND REHAB SOLUTIONS

VOLUNTARY LONG TERM DISABILITY INSURANCE

Benefit Amount

60%

Coverage for Elimination Period Pay Period Premium Amount Elect Coverage Decline
Employee Only (Cost per Pay Period – Monthly) Coverage
90 Days

Benefit Duration

SSNRA

Employee 60% of earnings, up to $5,000 $_________  
each month

• *If you were previously eligible for coverage and are enrolling for the first time, you must complete and submit an evidence of insurability (EOI)
form/health application. The form is available from your employer.

VOLUNTARY TERM LIFE INSURANCE

Coverage for Employee Only Benefit Amount – Select One Option Pay Period Premium Amount
(Cost per Pay Period – Monthly)

 $10,000 $_______________

 $50,000 $_______________

Employee  $100,000 $_______________
 $250,000 $_______________

 $_______________ $_______________

 Decline Employee Coverage N/A

Additional Information:

• Guarantee Issue $100,000 without EOI, anything over $100,000 requires medical underwriting. GI only applies when enrolling timely, within 31 days of

your date of eligibility, full EOI applies if enrolling outside of this period.

Form PA-9676 PAGE 2 OF 4 CREATION DATE: 06/01/2018
EMPLOYEE NAME: ________________________________ HEALTH AND REHAB SOLUTIONS

BENEFICIARY DESIGNATION (PLEASE ENSURE YOUR BENEFICIARY DESIGNATION IS CLEAR SO THERE IS NO QUESTION OF YOUR INTENT)

This designation is for all group insurance coverage issued by The Hartford for which benefits are payable to a beneficiary or survivor (as indicated by each
specific policy) in the event of your death, unless otherwise requested by you in writing. This designation may be changed upon written request. All
information requested is required, per beneficiary. If more than one beneficiary is named, the beneficiaries shall share benefits equally unless percentages
are stated below. The percentages must total 100% for all Primary Beneficiaries and 100% for all Contingent Beneficiaries. If you need to designate
more beneficiaries than space will allow, please include the additional information on a separate paper and attach it to/submit it with this form, clearly
stating your name. Please consult your benefits administrator or legal advisor for assistance or additional information.

Primary Beneficiary(ies) (PRIMARY BENEFICIARIES ARE FIRST IN LINE TO RECEIVE BENEFITS IF LIVING AT THE TIME OF YOUR DEATH)

1) Name (FIRST MI LAST) Date of SSN Relationship to You Percent
%
Birth

Address (STREET, CITY, STATE & ZIP) Phone Number

2) Name (FIRST MI LAST) Date of SSN Relationship to You Percent
Birth %

Address (STREET, CITY, STATE & ZIP) Phone Number

Contingent Beneficiary(ies) (CONTINGENT(S) WILL RECEIVE BENEFITS IF NO PRIMARY BENEFICIARY IS ALIVE AT THE TIME OF YOUR DEATH)

1) Name (FIRST MI LAST) Date of SSN Relationship to You Percent

Birth %

Address (STREET, CITY, STATE & ZIP) Phone Number

2) Name (FIRST MI LAST) Date of SSN Relationship to You Percent
Birth %

Address (STREET, CITY, STATE & ZIP) Phone Number

CONFIRMATION & SIGNATURE

By signing below:

• I acknowledge that I have been given the opportunity to enroll in the insurance coverage offered by my employer.

• I understand and agree that: 1) If I decline coverage now, but later decide to enroll, I may be required to provide evidence of insurability that is
satisfactory to The Hartford and be approved for such coverage before it becomes effective; 2) My request for coverage may be denied by The Hartford;
3) Insurance will go into effect and remain in effect only in accordance with the provisions, terms and conditions of the insurance policy; 4) Only the
insurance policy(ies) issued to my employer can fully describe the provisions, terms, conditions, limitations and exclusions of my insurance coverage; 5)
In the event of any difference between the enrollment form and the insurance policy, I agree to be bound by the insurance policy; 6) No insurance will be
valid or in force if I am not eligible in accordance with the terms of the group policy(ies) as issued to my employer; and 7) If group participation
requirements are required and are not met, the policy(ies) may not be implemented and the coverage I have elected may not be in force.

• I authorize payroll deductions from my wages to cover my cost of coverage where applicable. I understand that any premium amounts indicated on this
form are estimates, which are subject to change based on the final terms of the applicable policy, and may be subject to ongoing change based on my
age and/or earnings. I also understand that rates and benefits may be changed by the insurer.

• I have read and understand the “Important Notice – Fraud Warning Statements” that applies to my state of residence.

Employee Signature Date of Signature

END OF FORM – PLEASE REVIEW THE “IMPORTANT NOTICE – FRAUD WARNING STATEMENTS” ON THE FOLLOWING PAGE

Form PA-9676 PAGE 3 OF 4 CREATION DATE: 06/01/2018
EMPLOYEE NAME: ________________________________ HEALTH AND REHAB SOLUTIONS

Benefits Enrollment Form

Important Notice – Fraud Warning Statements

Hartford Life and Accident Insurance Company

One Hartford Plaza, Hartford, Connecticut 06155 (A stock insurance company)

The Hartford® is The Hartford Financial Services Group, Inc., and its subsidiaries.

Please read the statement that applies to your state of residence prior to signing the enrollment form.

For residents of all states EXCEPT Arizona, California, Colorado, Florida, Kentucky, Maine, Maryland, New Jersey, New Mexico, New York,
North Carolina, Ohio, Oregon, Pennsylvania, Puerto Rico, Tennessee, Virginia and Washington: 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.

For Residents of 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.

For Residents of California: The falsity of any statement in the application for any policy covered by this chapter 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.

For residents of 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 policyholder or
claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement award payable from insurance
proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies.

For residents of 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.

For residents of Kentucky: Any person who knowingly and with intent to defraud any insurance company or other person files a statement of claim or 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.

For residents of 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 and denial of insurance benefits.

For residents of Maryland: 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.

For residents of New Jersey: Any person who knowingly files a statement of claim containing any false or misleading information is subject to criminal
and civil penalties. Any person who includes any false or misleading information on an application for insurance is subject to criminal and civil penalties.

For residents of New Mexico and North Carolina: 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 civil fines and criminal penalties.

For residents of New York (not applicable to Life Insurance): 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.

For residents of Ohio: Any person who, with intent to defraud or knowing that he 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.

For residents of Oregon: 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 is
subject to a denial and/or reduction in insurance benefits and may be subject to any civil penalties available.

For residents of 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 hereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties.

For residents of Puerto Rico: 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.

For residents of Virginia: Any person who, with the intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application or
files a claim containing a false or deceptive statement may have violated the state law.

Form PA-9676 PAGE 4 OF 4 CREATION DATE: 06/01/2018
EMPLOYEE NAME: ________________________________ HEALTH AND REHAB SOLUTIONS

PS - Health and Rehab Solutions

DisabilityFLExsm

Class Description(s):
All Full-time Active Employees Excluding Employees who work in CA, HI, NJ, RI or PR and Physicians
Full Time Eligibility: 30 hours per week

Emolovee Benefit Ootions
Employees may elect a flat weekly benefit amount from $100 to $2000 in increments of $100. The employee may not elect an
incremental benefit amount that exceeds 60% of their weekly earnings.

Employees may elect from the following Benefit Durations and Benefit Commencements Periods:

Benefit Duration Day Injury/Day Sickness Benefit Commences
13 Weeks 8th/8th

Attained A!!e PS - Health and Rehab Solutions
UNDER35
DisabilityFLEX Rates
35 - 49
50 - 59 Monthly Rates Per $100 Weekly Benefit

60+ 13 Weeks Benefit Duration
Benefit Commencement Period IDay Injury/Day Sickness)

8/8
$11.79
$6.669
$10.746
$14.49

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