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Published by , 2018-12-07 10:42:06

benefits Packet Spreads Final

benefits Packet Spreads Final

HEALTH

SAVINGS

DENTAL
BENEFITVCISSAIROEN

INSURANCE DISCOUNTS

BENEFIT PACKET

HELLO

BENEFITS

INTRODUCTION
WELCOMEHAPPY LIVESCYHOANUGING
TO HAVE INFORMATION
L4LWELCOME ABOARD

WELCOME

WELCOME EMPLOYEE BENEFIT INFORMATION AND ACKNOWLEDGEMENT SHEET

Employee Benefit Information
& Acknowledgment Sheet

Charter Name:

Name: SSN:
City, State, Zip Code:
Address: Cell Phone

Home Phone:

Marital Status: (Check One)

Welcome aboard! Single Married Widowed Divorced Domestic Partnership
Date of Birth:
We are so happy to have you with us. Enclosed are your Benefit Summaries for all benefits offered to Gender: Male Female
you as a full-time employee. We believe that our employees are our finest asset so we strive to ensure
that the benefits we provide are carefully selected to meet the needs of our employees. Our Employee Status: Full Time Personal Email Address:
visionaries make every effort to ensure that our benefits remain both competitive and affordable.
I have been informed that the above information will be used to create a username and password for my
We understand that your time is valuable so we no longer require you to complete countless benefit PlanSource benefit enrollment profile. I hereby acknowledge that I have received the Health Benefits Enrollment
enrollment forms. Instead, we have implemented online benefit enrollment. During the presentation packet. I understand that I am entitled to full benefits effective the 1st of the month following my 1 month
you will be provided with detailed information on how to use the online Benefit Administration eligibility waiting period. I also understand and accept full responsibility in completing my Health Benefits
System. Our online system will allow you to access your benefit information and options 24 hours a day, seven Enrollment on PlanSource once I have been instructed to do so. I furthermore accept any (and/or) all deduction
days a week, in the comfort of your home or while on the go. premium(s) I may have incurred and understand that the premium(s) will be deducted from my payroll check
each pay period in accordance with my elections.
If you should have an immediate question, you may contact the Employee Benefits Department at
(661) 272-1225 or send an email to [email protected]. Employee Signature: Date:
Benefit Representative Signature: Date:
Thank you,

Your Employee Benefits Department

DISCOUNTSFUN SPECIALS ATTRACTIONS

DEALS S$$A$V$E$

LOCAL & NATIONAL

EMPLOYEE DISCOUNTS
SAVINGS

PERKS

ABENITY EMPLOYEE DISCOUNT PROGRAM

“LET THE $AVINGS BEGIN” Good News!

Learn4Life Employee Discount Program!! You are eligible for an employee discount. As an employee you can receive discounts on your personal
Verizon wireless account. You can be eligible for the following discounts:
LET THE $AVINGS BEGINLearn4Life is excited to announce the addition of an Employee Discount Program. • Up to 15% off the monthly access fee on qualifying voice plans of $34.99 or higher.
sAabveinngitLsy,eEwmiatphrloancyce4eesDlsiitfsoceothuonEutsmParnodgpsraolmof looyfcfaeelrasenedmDnpaloitisyoenceasol oduvisecnro$ut4n,t5Po0rf0foeinrsg, ram! • Up to 25% off of accessories.

Learnc4aslihfebaisckecxocmitpeadristoonasnhonpopuinngc, eantdheexcaldusdivietiomnemobf earn-oEnlmy ppelrokys.ee discount Program.

ThoTuhsaonudssaonfddsisocofudnitsscionculnudtsinign:cluding: STEP 1: STEP 2:
· Ho·tHelos,teRless,tRaeusratanutsra&nMtso&viMe TohveieatTehrseaters
Follow this link and you will be directed to the You will receive this message and will have to wait
· Po·pPuolapruRleatraRileertsa,ilFelorsri,sFtslo&risLtosca&l LMoecarclhManetrschants following Verizon wireless page. for an email to be delivered to your company email
· The·mTheePmareksP,aNraktsi,oNnaaltiAotntraalcAtiottnrasc&tioConnsc&erCtsoncerts address.
https://www.verizonwireless.com/discount-program/
Savings from vendors including:
· CoSstacov,iSnpgrisntf,rFoirmestvoenen,dDoirrescTiVn,cluding:

T·-MCoosbticleo,&SpDreinllt, Firestone, DirecTV, T-Mobile & Dell
· TaBr·rgT&oeattPhr.gcheoeirlmstip.,c,&soOCmPvohe, nOrilssiptvuoesmcrCkseot.rocnoEcsmklue.mc,cotBermroron,EoiBlckersscotoroksniBcrsothers,
Over 150 National Attractions:
· WaOlt Dviesnre1y 5W0orlNd/aDtisionenyaLalnAdtRtersaocrtt,ions:
Univ·eWrsaalltSDtuidsnioesy, SWeaoWrldo/rDldi,s&neCyirLqaunedduReSsooleritl,

Universal Studios, Sea World, & Cirque du Soleil

Once you have been pre-registered, you will have full access to the
discounts available to you as an employee. You will receive a Welcome
email that will include your username and log in inforOmnacetioyonu. Rheamveebmebeenrpre-registered, you will
to log in often because new discounts are added and uphdaavteefdulrleagcucelasrslyt.o the discounts available to
We want you to be a good steward of your hard-earnedymouonaseyananemd pglioveyee. You will receive a
you a reason to Celebrate Your Savings.
Welcome email that will include your

username and log in information. Remember

to log in often because new discounts are

added and updated regularly. We want you to

be a good steward of your hard-earned money

and give you a reason to Celebrate Your Savings.

Abenity Employee Discount Program offers

employees over $4,500 in savings, with

access to thousands of local and national

discount offers, cash back comparison

shopping, and exclusive member-only

perks.

EMPLOYEE DISCOUNT PROGRAM EMPLOYEE ASSISTANCE PROGRAM

STEP 3: EMPLOYEE IDENTITY ABILITY BENEFICIARY ESTATE LIFE
TRAVEL PROTECTION ASSIST ASSIST GUIDANCE CONVERSATIONS
You will receive an email delivered to your company email that will look like the screen shot below. Click
on the link Register Your Line and follow the instructions. When completed your line should be registered ASSISTANCE SUPPORT
for the company discount. PROGRAM SERVICE

• A vailable if • Toll-free 24 hours • Counseling • E motional • Online Will • Counseling
Services or Grief
traveling 100 a day professional Counseling preparation regarding life
• F inancial
miles or more from fraud recovery Planning • S tress, insurance elections
Assistance Anxiety and
your home for 90 assistance Depression • Online assistance
• L egal
days or less Consultations • R elationship with licensed • Estate Planning
or Marital
conflict attorneys

• P re-Trip • L egal, emotional
Information
• Also offers and financial

additional counseling

• E megency estate planning
Medical Assistance
service for

additional

• E mergency • S ubstance purchase
Personal Services Abuse

Already a Verizon Wireless Customer?

Register your line and complete enrollment to have your employee
discount applied to your qualifying line. Register Your Line

Act now! Link will expire in 72 hours.

PLEASE NOTE: In order to be eligible for the Verizon discount the account must be
in your name and not your spouses. If your Verizon account is in your spouse’s name
and you would like to utilize the discount, you will have to call Verizon customer service
and fill out paperwork to transfer responsibility from your spouse’s name to your name,
once this is completed you will qualify for the discount.

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place" of variable text and the header.
Template: Additional_Services

Additional Services

Benefit Highlights

Does my life insurance Your life coverage comes with value added services that help with challenges that come
coverage include any before and after a claim.
additional services? • Funeral Planning and Concierge Services 1 provides a suite of online tools to guide

you through key decisions before a loss, including help comparing funeral-related
costs. After a loss, this service includes family advocacy and professional negotiation
of funeral prices with local providers—often resulting in significant financial savings.
For more information on Funeral Planning and Concierge Services
Call 1-866-854-5429
Or visit www.everestfuneral.com/hartford Use Code: HFEVLC
• EstateGuidance ® 2 Will Services helps you protect your family’s future by creating a
will online—backed by online support from licensed attorneys. Your will is customized
and legally binding.
For more information on EstateGuidance® Will Services
Visit www.estateguidance.com/wills Use Code: WILLHLF
• Beneficiary Assist ® 2 Counseling Services offers compassionate expertise to help
you or your beneficiaries (those you name in your policy) cope with emotional,
financial and legal issues that arise after a loss. Includes unlimited phone contact with
a counselor, attorney or financial planner for up to a year, and five face-to-face
sessions.
For more information on Beneficiary Assist ® Counseling Services
Call 1-800-411-7239
• Travel Assistance Services with ID Theft Protection and Assistance 3 includes
pre-trip information to help you feel more secure while traveling. It can also help you
access medical professionals across the globe for medical assistance when traveling
100+ miles away from home for 90 days or less when unexpected detours arise. The
ID theft services are available to you and your family at home or when you travel.
For more information on Travel Assistance Services or ID Theft Services
Call 1-800-243-6108
Collect from other locations: 202-828-5885
Fax: 202-331-1528
Or email [email protected]
Travel Assistance Identification Number: GLD-09012
You’ll be asked to provide your employer’s name, a phone number where you can be
reached, nature of the problem, Travel Assistance Identification Number, and your
company policy number which can be obtained through your Human
Resources/Personnel department.
If you have a serious medical emergency, please obtain emergency medical services
first, and then contact Europ Assistance USA for follow-up.

The Hartford® is The Hartford Financial Services Group, Inc. and its subsidiaries including issuing companies Hartford
Life Insurance Company, Hartford Life and Accident Insurance Company and Hartford Fire Insurance Company. Home
Office is Hartford, CT.

00079815
Creation Date: 1/17/2018

Page 1 of 3
4208 NS 02/12

Does my accidental Your AD&D coverage comes with value added services that help with challenges that Important Details
death and come before and after a claim. 1 Funeral Planning and Concierge Services are offered through Everest Funeral Package, LLC (Everest). Everest is not
affiliated with The Hartford and is not a provider of insurance services. Everest and its affiliates have no affiliation with Everest
dismemberment For more information on Beneficiary Assist ® Counseling Services ReGroup, Ltd., Everest Reinsurance Company or any of their affiliates.
coverage include any Call 1-800-411-7239 2 EstateGuidance® and Beneficiary Assist® services are provided through The Hartford by ComPsych®. ComPsych is not
• Travel Assistance Services with ID Theft Protection and Assistance 3 includes affiliated with The Hartford and is not a provider of insurance services. A simple will does not cover credit shelter trust, printing
additional services? pre-trip information to help you feel more secure while traveling. It can also help you or certain other features. These features are available at an additional cost to you.
access medical professionals across the globe for medical assistance when traveling 3 Travel Assistance and ID Theft Protection and Assistance are provided by Europ Assistance USA. Europ Assistance is not
100+ miles away from home for 90 days or less when unexpected detours arise. The affiliated with The Hartford and is not a provider of insurance services.
ID theft services are available to you and your family at home or when you travel. 4 Ability Assist® is offered through The Hartford by ComPsych®. ComPsych is not affiliated with The Hartford and is not a
For more information on Travel Assistance Services or ID Theft Services provider of insurance services.
Call 1-800-243-6108
Collect from other locations: 202-828-5885 This benefit highlights sheet is an overview of the non-insurance services being offered and is provided for illustrative purposes
Fax: 202-331-1528 only and is not a contract. It in no way changes or affects the services as actually provided. Only the service provider can fully
Or email [email protected] describe all of the provisions, terms, conditions, limitations and exclusions of your non-insurance service coverage.
Travel Assistance Identification Number: GLD-09012
You’ll be asked to provide your employer’s name, a phone number where you can be
reached, nature of the problem, Travel Assistance Identification Number, and your
company policy number which can be obtained through your Human
Resources/Personnel department.
If you have a serious medical emergency, please obtain emergency medical services
first, and then contact Europ Assistance USA for follow-up.

Does my disability Your disability coverage comes with value added services that help with challenges that
coverage include any come before and after a claim.
• Ability Assist ® 4 Counseling Services provides access to Master’s- and PhD-
additional services?
degreed clinicians for 24/7 assistance if you’re enrolled in our long-term disability plan.
This includes 3 face-to-face visits per occurrence per year for emotional concerns and
unlimited phone consultations for financial, legal, and work-life concerns.
For more information on Ability Assist® Counseling Services
Call 1-800-964-3577
Or visit www.guidanceresources.com
Company name: Abili Company ID: HLF902
• Travel Assistance Services with ID Theft Protection and Assistance 3 includes
pre-trip information to help you feel more secure while traveling. It can also help you
access medical professionals across the globe for medical assistance when traveling
100+ miles away from home for 90 days or less when unexpected detours arise. The
ID theft services are available to you and your family at home or when you travel.
For more information on Travel Assistance Services or ID Theft Services
Call 1-800-243-6108
Collect from other locations: 202-828-5885
Fax: 202-331-1528
Or email [email protected]
Travel Assistance Identification Number: GLD-09012
You’ll be asked to provide your employer’s name, a phone number where you can be
reached, nature of the problem, Travel Assistance Identification Number, and your
company policy number which can be obtained through your Human
Resources/Personnel department.
If you have a serious medical emergency, please obtain emergency medical services
first, and then contact Europ Assistance USA for follow-up.

00079815 00079815
Creation Date: 1/17/2018 Creation Date: 1/17/2018

Page 2 of 3 Page 3 of 3
4208 NS 02/12 4208 NS 02/12

TRAVEL24/7 HELP ESMEERRVGIECNECSY
ASSISTANCEIDENTITY THEFT PROTECTION
PREPAREINFORMATION PROTECT
GOOD TO GO

PRE-TRIP

TRAVEL ASSISTANCE

TRAVEL ASSISTANCE AND ID THEFT PROTECTION SERVICES

TRAVEL ASSISTANCE AND ID THEFT PROTECTION
SERVICES.

EVEN THE BEST PLANNED TRIPS As long as you contact Europ Assistance USA
CAN BE FULL OF SURPRISES. at the time of need, you could be approved for
up to $1 million in covered services.4
The best laid travel plans can go awry, leaving
you vulnerable and, possibly, unable to SERVICES FROM HERE TO THERE.
communicate your needs. When the unexpected
happens far from home, it’s important to know Travel Assistance begins even before you embark,
whom to call for assistance. with pre-trip information, and continues throughout
your trip. See the list of services in the chart on
If you are covered under a Hartford Group the back of this page.
Policy, you and your family have access to
Travel Assistance Services provided by Europ IDENTITY THEFT ASSISTANCE, TOO.
Assistance USA.1
Identity theft, America’s fast growing crime,
With a local presence in 200 countries and victimizes almost 10 million American consumers
territories around the world, and numerous 24/7 each year.5 Europ Assistance USA helps protect
assistance centers, they are available to help you you and your family from its consequences 24/7,2
anytime, anywhere. at home and when you travel.

GOOD TO GO: MULTILINGUAL In addition to prevention education, this service
ASSISTANCE 24/7. provides advice and help with administrative
tasks resulting from identity theft.
Whether you’re traveling for business or pleasure,
Travel Assistance services are available when
you’re more than 100 miles from home for 90
days or less.2,3

continued

TRAVEL ASSISTANCE AND ID THEFT PROTECTION SERVICES

EMERGENCY MEDICAL PRE-TRIP INFORMATION EMERGENCY PERSONAL IDENTITY THEFT ASSISTANCE
ASSISTANCE6 SERVICES7

đ
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ƫ ! % 0%+*ƫ * ƫ!5!#( // đ ƫ .!2!*0%+*ƫ !.2% !/
đ
ƫ ! % (ƫ)+*%0+.%*# requirements prescription assistance - Education
đ ƫ
! % (ƫ!2 1 0%+* - Identity Theft Resolution Kit
đ ƫ !, 0.% 0%+* đ ƫ*+ 1( 0%+*ƫ * đ ƫ )!.#!* 5ƫ0. 2!(
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đ ƫ !,!* !*0ƫ $%( .!*ƫ //%/0 * ! requirements ƫƫƫƫƫƫġƫƫ ƫ . 1 ƫ (!.0ƫ0+ƫ0$.!!ƫ .! %0ƫ
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đ ƫ +.!%#*ƫ!4 $ *#!ƫ. 0!/ đ ƫ + 0%*#ƫ(+/0ƫ%0!)/ bureaus
friend đ ƫ ) //5ƫ * ƫ +*/1( . đ ƫ %(ƫ 2 * !)!*0 đ ƫ !/+(10%+*ƫ 1% * !ƫ *
đ ƫ )!.#!* 5ƫ)! % (ƫ, 5)!*0/
đ ƫ !01.*ƫ+"ƫ)+.0 (ƫ.!) %*/ referrals Assistance
- Credit information review

ƫƫƫƫƫƫġƫƫ ƫ ƫ $!"0ƫ þ 2%0ƫ
Assistance

- Card replacement
đ ƫ !./+* (ƫ !.2% !/

- Translation
- Emergency cash advance*

* Cash advance available when theft occurs 100 miles or more from your primary residence. Must be secured by a valid credit card.

CASE ILLUSTRATION: HELP A WORLD AWAY.8

As a Human Resource Professional, Tammy had always been on the coordinating end of travel
services helping her company’s employees; but when her daughter was hurt while traveling with
her school group in Italy, she suddenly found herself in a different position.

Using the travel assistance medical referral, medical monitoring, and repatriation services from
Europ Assistance USA, Tammy’s daughter was able to receive immediate medical treatment
and was evacuated within 48 hours. The Europ Assistance USA Case Manager helped Tammy
through some of the most stressful days she’s experienced as a mother and provided care for her
daughter when she couldn’t.

What to have ready: Your employer’s name, a phone number where you can be reached, nature of the
problem, Travel Assistance Identification Number and your company policy number, which can be
obtained through your #FOFGJUT %epartment. 1PMJDZ


Have a serious medical emergency? Please obtain emergency medical services first
(contact the local “911”), and then contact Europ Assistance USA to alert them to your situation.
Call: 1-800-243-6108 Collect from other locations: 202-828-5885 Fax: 202-331-1528
Travel Assistance Identification Number: GLD-09012

Prepare. Protect. Prevail.®

Visit us at THEHARTFORD.COM/EMPLOYEEBENEFITS

The Hartford® is The Hartford Financial Services Group, Inc. and its subsidiaries including issuing companies Hartford Life Insurance Company and Hartford Life and Accident Insurance Company.
Home office is Hartford, CT.
1 Travel Assistance and Identity Theft services are provided by Europ Assistance USA Europ Assistance USA is not affiliated with The Hartford and is not a provider of insurance services. Europ Assistance USA may
modify or terminate all or any part of the service at any time without prior notice. None of the benefits provided to you by Europ Assistance USA as a part of the Travel Assistance and Identity Theft service are
insurance. This brochure, the Travel Assistance and Identity Theft service Terms and Conditions of Use, and the Identity Theft Resolution Kit constitute your benefit materials and contain the terms, conditions, and
limitations relating to your benefits. These services may not be used for business or commercial purposes or by any person other than the individual insured under The Hartford’s group insurance policy . The
Hartford is not responsible and assumes no liability for the goods and services described in these materials.
2 Coverage includes spouse (or domestic partner) and dependent children under age 26.
3 Services are available in every country of the world. Depending on the current political situation in the country to which you are traveling, EA may experience difficulties providing assistance, which may result in
delays or even the inability to render certain services. It is your responsibility to inquire, prior to departure, whether assistance service is available in the countries where you are traveling.
4 The Combined Single Limit (CSL), or amount of money available to the insured under a Hartford Group policy the Travel Assistance Program, is $1 million. One service or a combination of the services may exceed the
CSL. The insured is responsible for payment of any expenses that exceed the CSL. Note: Certain Accidental Death and Dismemberment programs may offer different CSLs. Please consult with your Human Resources
Manager for more details.
5 www.transunion.com/personal-credit/identity-theft-and-fraud/identity-theft-facts.page, viewed on 6/25/15.
6 In a medical emergency, Europ Assistance USA pays for assistance as described herein, but you are personally responsible for paying your medical/hospital expenses.
7 Europ Assistance USA provides the described personal services to you in an emergency, but you are personally responsible for the cost of air fare not approved as medically necessary by the attending physician;
food, hotel and car expenses; and attorney fees. Emergency cash advances and bail advancement require your personal satisfactory guarantee of reimbursement provided through a valid credit card.
8 This case illustration is fictitious and for illustrative purposes only.
9 Emergency cash is charged as a cash advance, and emergency airline tickets are charged as a purchase to your credit card account and are all subject to that account’s finance rates.
DISCLAIMER: Service Exclusions and Limitations: Europ Assistance USA (EA) services are eligible for payment or reimbursement by EA only if EA was contacted at the time of the services and arranged
and/or preapproved the services. Certain terms, conditions and exclusions apply; for further information refer to the Web site listed or call EA at the number provided.
4213 06/15 Printed in the U.S.A. © 2015 The Hartford Financial Services Group, Inc. All rights reserved.

ABILITY ASSIST®

COUNSELINGINFORMATION
COMPASSIONATE

SUPPORTEMOTLIOENGALALPARDOVTICEECT
ASSISTANCEADVICEPROFESSIONAL ABILITY ASSIST® COUNSELING SERVICES

RESOURCES For employees covered under The Hartford’s approach takes the complexity out of benefits
Disability insurance, Critical Illness insurance when life throws you a curve.
or Leave Management Services.
COMPASSIONATE SOLUTIONS
GETTING SUPPORT SHOULD FOR COMMON CHALLENGES.
BE EASY.
From the everyday issues like job pressures,
Life presents complex challenges. If the relationships, retirement planning or personal
unexpected happens, you want to know impact of grief, loss, or a disability, Ability
that you and your family have simple Assist can be your resource for professional
solutions to help you cope with the stress support.
and life changes that may result. That’s why
the Hartford’s Ability Assist Counseling You and your family, including spouse and
Services, offered by ComPsych®,1 can play dependents, can access Ability Assist, at
such an important role. Our straightforward any time, as long as you are covered under
The Hartford’s Disability insurance,
ABILITY ASSIST Critical Illness insurance or Leave
Management Services.

ABILITY ASSIST COUNSELING SERVICES

Emotional Helps address stress, relationship or other personal issues you or your family members
or Work-Life may face. It’s staffed by GuidanceExperts� – highly trained master’s and doctoral level
Counseling clinicians – who listen to concerns and quickly make referrals to in-person counseling or
other valuable resources. Situations may include:

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Financial Provides support for the complicated financial decisions you or your family members may
Information face. Speak by phone with a Certified Public Accountant and Certified Financial Planner ™
and Resources Professionals on a wide range of financial issues. Topics may include:

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=

continued

ABILITY ASSIST®

ABILITY ASSIST COUNSELING SERVICES con’t.

Legal Support Offers assistance if legal uncertainties arise. Talk to an attorney by phone about the
and Resources issues that are important to you or your family members. If you require representation,
you’ll be referred to a qualified attorney in your area with a 25% reduction in customary
legal fees thereafter. Topics may include:
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Health A service that supports you through all aspects of your health care issues by helping to
ChampionSM !*/1.!Ƴ0$ 0Ƴ5+1Ě.!Ƴ"1((5Ƴ/1,,+.0! Ƴ3%0$Ƴ!),(+5!!Ƴ //%/0 * !Ƴ,.+#. )/Ƴ * Ɣ+.Ƴ3+.'ġ(%"!Ƴ
services. HealthChampion is staffed by both administrative and clinical experts who
understand the nuances of any given health care concern. Situations may include:

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đ !!Ɣ, 5)!*0Ƴ,( *Ƴ*!#+0% 0%+*

= Online: The point is simplicity.
You’ll also have 24/7 access to
A CASE IN POINT.3 GuidanceResources® Online (offered by
ComPsych).1 This resource provides trusted
“The initial counselor I spoke with was so information, resources, referrals and answers
comforting and easy to communicate to everyday questions right from your desktop
with. She put me right at ease and or the privacy of your home. It includes:
empowered me to follow through with
the program. She was wonderful.” ĕ # /ſ. ..$*).ſ2$/#ſ+-*! ..$*) 'ſ(* - /*-.ď
– Hartford Customer, Ability Assist User
ĕ ſ ..ſ/*ſ#0) - .ſ*!ſ+ -.*) 'ſ# '/#ſ/*+$ .
SERVICE FEATURES. and resources for child care, elder care,
attorneys or financial planners.

The service includes up to three face-to-face Visit WWW.GUIDANCERESOURCES.COM
emotional or work-life counseling sessions per to create your own personal username and
occurrence per year. This means you and your password. If you’re a first-time user, you’ll
family members won’t have to share visits. be asked to provide the following information on
Each individual can get counseling help for the profile page:
his/her own unique needs. Legal and financial
counseling are also available by telephone 1. In the Company/Organization field, use:
during business hours. HealthChampion� HLF902
offers unlimited access to services.2
2. Then, create your own confidential user
GETTING IN TOUCH IS EASY. name and password.

On the phone: Just one simple call. 3. Finally, in the Company Name field at the
For access over the phone, simply call toll-free bottom of personalization page, use: ABILI
1-800-96-HELPS (1-800-964-3577).

Prepare. Protect. Prevail.®

Visit us at THEHARTFORD.COM/EMPLOYEEBENEFITS

The Hartford® is The Hartford Financial Services Group, Inc. and its subsidiaries including issuing companies Hartford Life Insurance Company and Hartford Life and Accident Insurance Company.
Home Office is Hartford, CT.
1 Ability Assist®, The GuidanceResources® Program, and HealthChampionSM services are offered through The Hartford by ComPsych®. ComPsych is not affiliated with The Hartford and is not a provider

of insurance services. The Hartford is not responsible and assumes no liability for the goods and services provided by ComPsych. ComPsych and GuidanceResources are registered trademarks and
HealthChampion is a service mark of ComPsych Corporation.
2 HealthChampionSM specialists are only available during business hours. Inquiries outside of this time frame can either request a call-back the next day or schedule an appointment.
3 This case illustration is fictitious and for illustrative purposes only.
4264 06/15 Printed in U.S.A. © 2015 The Hartford Financial Services Group, Inc. All rights reserved.

BENEFICIARY ASSIST® COUNSELING SERVICES

BENEFICIARY24/7 HELP

SUPPORTAPRSOSFEISSSTIOANANLCHEELP
COMPASSIONREEXSPOEURRTCISEES

COUNSELING GETTING THROUGH A LOSS IS HARD. GETTING
SUPPORT TO COPE IS EASY.

INFORMATION FINANCIAL The loss of a loved one can leave you ĕ ſ +ſ/*ſñ1 ſ! Ħ/*Ħ! ſ. ..$*).ſ*-
feeling overwhelmed. In addition to grief, equivalent professional time for one
BENEFICIARY ASSIST you may have financial and legal worries. service or a combination.
Questions you can’t easily answer alone.
And maybe some unresolved issues. HANDLING A SPECTRUM OF
If you’re covered under The Hartford’s NEEDS WITH COMPASSION
Group Life or Accident insurance AND EXPERTISE.
policy, you have access to Beneficiary
Assist® counseling services provided Because Beneficiary Assist covers a
byComPsych.1 spectrum of concerns, you and your
beneficiaries will have a convenient,
PROFESSIONAL HELP AFTER A single source for the following needs.
LOSS OR TERMINAL ILLNESS. Emotional or grief counseling. ComPsych
GuidanceExperts� are master’s and
Beneficiary Assist provides you, your doctoral level clinicians who’ll listen to
eligible beneficiaries and immediate family your concerns with compassion and refer
members with unlimited 24/7 phone access you to the right resources for:
to help related to the death of yourself or a
loved one. That includes: ĕ -$ !ſ ) ſ'*..ď

ĕ ſ " 'ſ 1$ Đſñ) ) $ 'ſ+' ))$)"ſ ) ĕ /- ..Đſ )3$ /4ſ ) ſ +- ..$*)ď
emotional counseling for up to one year
from the date the claim is filed. ĕ ' /$*).#$+ĭ( -$/ 'ſ *)ô$ /ď

ĕ -* ' (.ſ2$/#ſ #$' - )ď

ĕ
* ſ+- ..0- .ď

ĕ 0 ./ ) ſ 0. ď

continued

BENEFICIARY ASSIST® COUNSELING SERVICES

CASE ILLUSTRATION: FINANCIAL INFORMATION
SOLID FOOTING.2 AND RESOURCES.

Greg’s sudden death at the age of With loss often come tough financial
42 came as an enormous blow to $.$*).ďſ # - ſ4*0-ſ *) -).ſ2$/#ſ -/$ñ ſ
his wife, Sharon. Besides the shock public accountants and certified financial
and grief, Sharon had to struggle planners for assistance with:
with debt and claims to Greg’s
estate by children from a former ĕ
) "$)"ſ ſ 0 " /ď
marriage. She went back and forth
between anger and depression. ĕ ./ / ſ '*.0- ď

Through Beneficiary Assist, she ĕ /$- ( )/ſ$(+ /.ď
was able to link up with counselors
who listened compassionately and ĕ 3ſ,0 ./$*).ď
referred her to a grief expert. She
also used the legal and financial ĕ //$)"ſ*0/ſ*!ſ /ď
counseling resources to get solid
answers to complex questions. LEGAL SUPPORT AND RESOURCES.

When legal uncertainties arise, get the help
you need. Attorneys are available for private
consultations for the following:

ĕ ./ / ſ ) ſ+-* / ď

ĕ /ſ ) ſ )&-0+/ 4ď

ĕ 'ſ ./ / ſ/- ). /$*).ď

ĕ ($'4ſ' 2ď

If additional legal representation is needed
4*) ſ/# ſ! Ħ/*Ħ! ſ1$.$/.Đſ4*0ſ )ſ ſ
referred to a qualified attorney in your area.
You may qualify for a 25 percent reduction
in the attorney’s customary fees by using the
*( .4 #ſ /2*-&ď

REACH OUT.

$) ſ*0/ſ(*- ſ *0/ſ ) ñ $ -4ſ ..$./ſ
counseling services by calling 1-800-411-7239.
It’s a service you’ll be glad to have when you
need it.

Prepare. Protect. Prevail.®

Visit us at THEHARTFORD.COM/EMPLOYEEBENEFITS

The Hartford® is The Hartford Financial Services Group, Inc. and its subsidiaries including issuing companies Hartford Life Insurance Company and Hartford Life and Accident Insurance Company.
Home office is Hartford, CT.
1 Beneficiary Assist® is offered through The Hartford by ComPsych®. ComPsych is not affiliated with The Hartford and is not a provider of insurance services. The Hartford is not responsible and assumes no
liability for the goods and services provided by ComPsych and reserves the right to discontinue any of these services at any time.
2 This case illustration is fictitious and for illustrative purposes only.
4211 06/15 Printed in the U.S.A. © 2015 The Hartford Financial Services Group, Inc. All rights reserved.

ESTATEGUIDANCE® WILL SERVICES

CONVENIENT RESOURCES

ESTATEWILLSSEUPRPVOIRCTES
HELPSIMPLE QUICK

ESTATE GUIDANCE
GUIDANCE CREATE A SIMPLE WILL FROM THE CONVENIENCE
OF YOUR DESKTOP.
ASSISTANCE
Whether your assets are few or many, ĕ ſ $/$*) 'ſ ./ / ſ+' ))$)"ſ. -1$ .ſ -
it’s important to have a will. It’s the only also available for purchase, including
way to ensure that your intentions will the creation of living wills and trusts,
be honored in the event of your death. guidance about divorce proceedings,
A will states your wishes about who and durable power of attorney.
will inherit your property, who will be
the guardian of your children, and who QUICK ANSWERS TO KEY
will manage your estate. Without a will, QUESTIONS.
those decisions may be left to others.
Where there’s a will, there are bound to
AN EASY AND EMPOWERING be questions. Here are answers to four
SOLUTION. common ones.

As a covered employee under a Hartford “ Isn’t will preparation complicated?”
Group Life insurance policy, you have Not with EstateGuidance®. You’ll be asked
access to EstateGuidance® Will Services a series of questions online that are used
provided by ComPsych®.1 It helps you to compose your will. In many states, you
create a simple, legally binding will quickly need only add your signature to make the
and conveniently online, saving you will valid.
the time and expense of a private legal
consultation. Other advantages include: “ What if I have questions as I’m
creating my will?”ſ # ſ*)'$) ſ 0 /$*)ſ
ĕ ſ )'$) ſ ..$./ ) ſ!-*(ſ'$ ). ſ //*-) 4. center provides answers regarding family
should you have questions. law. You can also access fully licensed
attorneys who’ll respond to you online.
ĕ ſ # ſ $'$/4ſ/*ſ. 1 ſ - !/.ſ!*-ſ0+ſ/*ſ.$3
months. During this period, you can “ What about my privacy?” All
revise your will at no cost, as long as you information is kept secure and
haven’t already printed or downloaded it. confidential with the latest encryption
technology.2

continued

ESTATEGUIDANCE® WILL SERVICES

CASE ILLUSTRATION: “ So, what happens if I don’t create a will?”
THE FINAL WORD.3 # ſ./ / Đſ)*/ſ4*0Đſ2*0' ſ $ ſ#*2ſ4*0-ſ
property is distributed. In most states, all of
Laura was the single parent of a your community and joint property would
six-year-old daughter, Amy. She pass to your spouse if you have one. Separate
worried that if she were to die, her property is passed according to a complex
modest but hard-earned assets order of distribution, regardless of your
would not be available to her loved ones’ wishes. By drafting a will, you
daughter. can spare them a potentially awkward and
contentious situation.
The cost of a legal will seemed
beyond her means until she GOOD INTENTIONS AREN’T ENOUGH.
discovered EstateGuidance®
through her group life insurance You might have the best of intentions,
provider. With it, she was able but without a will, they aren’t legally
to appoint her older sister as $) $)"ďſ & ſ/#$.ſ*++*-/0)$/4ſ/*ſ+0/ſ
executor of her will and name her your intentions into action.
brother and sister-in-law as Amy’s
legal guardians. She felt better Visit
knowing that she would have WWW.ESTATEGUIDANCE.COM/WILLS
the final word in protecting her today. Use this code: WILLHLFďſ # )ſ
daughter’s best interests. follow the easy steps below:

Ćď ſ ..ſ # ſ -/!*- ğ.ſ ./ / 0$ ) ŀ
Will Services online.

2. Sign in to the secure site by entering the
access code.

3. Follow the instructions and create your will.

4. Download the final will to your computer
and print.

5. Obtain signatures and determine if your
will should be notarized.

Prepare. Protect. Prevail.®

Visit us at THEHARTFORD.COM/EMPLOYEEBENEFITS

The Hartford® is The Hartford Financial Services Group, Inc. and its subsidiaries including issuing companies Hartford Life Insurance Company and Hartford Life and Accident Insurance Company.
Home office is Hartford, CT.
1 EstateGuidance® is offered through The Hartford by ComPsych® Corporation. ComPsych is not affiliated with The Hartford and is not a provider of insurance services. The Hartford is not responsible and
assumes no liability for the goods and services provided by ComPsych and reserves the right to discontinue any of these services at any time. A simple will does not cover credit shelter trust, printing or
certain other features. These features are available at an additional cost to you.
2 The EstateGuidance® website is secured with a GoDaddy.com Web Server Certificate. Transactions on the site are protected with up to 256-bit Secure Sockets Layer encryption.
3 This case illustration is fictitious and for illustrative purposes only.
Services may not be available in all states.
4212 06/15 Printed in the U.S.A. © 2015 The Hartford Financial Services Group, Inc. All rights reserved.

FUNERAL PLANNING AND CONCIERGE SERVICES

LCIFOENVERSATIONSPFUENAECRAELOPLFANMNIINNGD
COMPASSIONRDEESCOIUSRIOCNESS

TRUSTED ADVISOR
SUPPORTINFORMATION CONCIERGE ADDED PEACE OF MIND WHEN IT’S NEEDED THE MOST.

The death of a loved one is one of EVEREST SERVICES
life’s most stressful situations. Quick,
often costly decisions must be made 24/7 Advisor đ ƫ +1* ġ0$!ġ (+ 'Ƴ !//Ƴ0+
while emotions are at their peak. Assistance 2!.!/0Ƴ 2%/+./Ǝ
Yet, how many people know how
to plan a funeral? That’s why your đ ƫ //%/0 * !Ƴ3%0$Ƴ ((Ƴ"1*!. (
employer offers a funeral planning ,( **%*#Ƴ%//1!/Ǝ
and concierge service through The
LIFE CONVERSATIONS Hartford’s Group Life insurance PriceFinderSM đ ƫ $!Ƴ+*(5Ƴ* 0%+*3% !
program – provided by Everest,1 the Research 0 /!Ƴ+"Ƴ"1*!. (Ƴ$+)!
first to offer this service nationwide. Reports
,.% !/Ǝ
THE RESOURCES TO HELP YOU Online Planning
MAKE CONFIDENT, INFORMED Tools đ ƫ !0 %(! Ƴ(+ (Ƴ"1*!. (Ƴ$+)!
DECISIONS. ,.% !Ƴ +), .%/+*/Ǝ

Everest’s advisors help families đ ƫ *(%)%0! Ƴ !//Ƴ0+Ƴ.!,+.0/
understand all of their options and put 2 %( (!Ƴ+*Ƴ !) * Ƴ2% Ƴ0$!
them into action while staying within ! Ƴ/%0!Ǝ
their budget. Here are the services they
offer you, your spouse/partner and đ ƫ *(%)%0! Ƴ1/!Ƴ+"Ƴ 2!.!/0Ě/
children under the age of 26. +*(%*!Ƴ,( **%*#ƏƳ.!/! . $Ə
* Ƴ'*+3(! #!Ƴ0++(/Ǝ

đ ƫ .! 0!Ƴ/%),(!Ƴ+.Ƴ !0 %(!
"1*!. (Ƴ,( */Ƴ1/%*#Ƴ2 .%+1/
.!"!.!* !Ƴ) 0!.% (/Ə
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!2!.5+*!Ƴ/$+1( Ƴ) '!Ǝ

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1, 0! ƏƳ.!0.%!2! Ƴ *
,.%*0! Ƴ+*Ƴ !) * Ǝ

continued

FUNERAL PLANNING AND CONCIERGE SERVICES

EVEREST SERVICES con't

At-Need Family đ ƫ +* %!.#!Ƴ/!.2% !/Ƴ 0Ƴ+.Ƴ*! .
Support 0$!Ƴ0%)!Ƴ+"Ƴ ! 0$Ƴ,.+2% !
5Ƴ 2!.!/0Ě/Ƴ(% !*/! Ƴ"1*!. (
CASE ILLUSTRATION: A %.! 0+./ƏƳ3$+Ƴ+û!.Ƴ /Ƴ)1 $Ƴ+.
SHOULDER TO LEAN ON.2 /Ƴ(%00(!Ƴ //%/0 * !Ƴ /Ƴ0$!Ƴ" )%(5
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!.Ƴ 2!.!/0Ƴ 2%/+.Ƴ //%/0! Ƴ 3%0$Ƴ0$!Ƴ"1*!. (Ƴ$+)!ƏƳ+"0!*
3%0$Ƴ!2!.5Ƴ /,! 0Ƴ+"Ƴ0$!Ƴ"1*!. (Ƴ .!/1(0%*#Ƴ%*Ƴ/%#*%ü *0Ƴü* * % (
,( **%*#Ƴ,.+ !//ƏƳ#%2%*#Ƴ ,.%(Ƴ / 2%*#/Ǝ
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0%)!ƎƳ * Ƴ/$!Ƴ.! !%2! Ƴ *Ƴ Express Claim đ ƫ * (1 !/Ƴ 4,.!//Ƴ 5ƏƳ *
!4,! %0! Ƴ(%"!Ƴ%*/1. * !Ƴ, 5)!*0Ƴ Processing %**+2 0%2!Ƴ ( %)/Ƴ, 5)!*0
3%0$%*Ƴ Ƴ3!!'Ƴ+"Ƴ$!.Ƴ$1/ * Ě/Ƴ /!.2% !Ƴ0$ 0Ƴ *Ƴ !(%2!.Ƴ !*!ü0/
= %*Ƴ /Ƴ(%00(!Ƴ /ƳƈƌƳ$+1./Ǝ
! 0$ƏƳ3$% $Ƴ$!(,! Ƴ! /!Ƴ) *5Ƴ
+"Ƴ0$!Ƴ" )%(5Ě/Ƴü* * % (Ƴ,.!//1.!/ƎƳ đ ƫ ((+3/Ƴ5+1.Ƴ !*!ü % .5Ƴ0+Ƴ1/!
2!.!/0Ě/Ƴ/!.2% !/Ƴ.!(%!2! Ƴ ,.%(Ƴ+"Ƴ 0$!Ƴ%*/1. * !Ƴ,.+ !! /Ƴ0+Ƴ, 5
/+)!Ƴ+"Ƴ0$!Ƴ/0.!//Ƴ0$ 0Ƴ +)!/Ƴ3%0$Ƴ "+.Ƴ%))! % 0!Ƴ"1*!. (Ƴ!4,!*/!/Ǝ
(+//ƏƳ ((+3%*#Ƴ$!.Ƴ0+Ƴ"+ 1/Ƴ+*Ƴ$!.Ƴ
" )%(5Ǝ A TRUSTED ADVISOR DURING
THE WORST OF TIMES.

We can’t always predict, but we can prepare.
Find out more about The Hartford’s Funeral
and Concierge Services by calling
1-866-854-5429.

Or visit

WWW.EVERESTFUNERAL.COM/HARTFORD

and use this code: HFEVLC.

Prepare. Protect. Prevail.®

Visit us at THEHARTFORD.COM/EMPLOYEEBENEFITS

The Hartford® is The Hartford Financial Services Group, Inc. and its subsidiaries including issuing companies Hartford Life Insurance Company and Hartford Life and Accident Insurance Company.
Home office is Hartford, CT.
1 Funeral Concierge Services are offered through Everest Funeral Package, LLC (Everest). Everest and the Everest logo are service marks of Everest Funeral Package, LLC. PriceFinder is a service mark of Everest

Information Services, LLC. Everest is not affiliated with The Hartford and is not a provider of insurance services. Everest and its affiliates have no affiliation with Everest ReGroup, Ltd., Everest Reinsurance
Company or any of their affiliates. The Hartford is not responsible and assumes no liability for the services provided by Everest Funeral Package, LLC as described in these materials.
2 This case illustration is fictitious and for illustrative purposes only.
4210 06/15 Printed in the U.S.A. © 2015 The Hartford Financial Services Group, Inc. All rights reserved.

Voya Index Solution PortfoliosING Solution PortfoliosSM (Effective ?) SM ING SOLUTION

FINANCIALGOALS FUNDS An investment path designed to keep retirement goals on track. STABILITY O
LARGE CAP
SAVINGSSERVICES LARGE CAP
SMALL/MID
GLOBAL/INT

AGSRSOEWTTSH Your employer-sponsored retirement What’s an Index Solution PortfolioSM and how can it help
savings plan makes it easy for you guide you to retirement?
to save for your future. But when ING SOLUTION 2055 PORTFOLIO ING SOLUTIO
it comes to choosing a mix of
PORTFOLIO investments that suits your personal To build a diversified investment portfolio, you typically choose a handful of
timetable for retirement, it can get funds from different asset classes that you believe wilSlThAeBIlLpITYyoOuF PrReINaCcIPhALyFoUuNrDS
FUTURE complicated – especially if you lack financial goals for retirement. But a Voya Index SolutioLnARPGoE rCtAfoP lViAoLSUMEh(LeVl)ps you22% STABILITY
the interest or time to manage your eliminate the guesswork of picking multiple funds becLaAuRGsEeCyAoP uGRoOnWlTyHc(hLGo)ose22% LARGE CA
portfolio. That’s why your employer one fund based on the year you want to retire or yourSiMnAvLeL/sMtmID/eSPnEtCIgALoTaYl(SdMa)te.20% LARGE CA
offers you a simpler investment path Professional investment managers do all the work by yGineLvOaeBrAssLtu/iInNngTtEilRinNreAaTtiIOmreNimAxLeo(Gnf Ltf).u3An1nd%ds SMALL/MI
to save through the plan; it’s called in a variety of asset classes guided by the number of GLOBAL/IN
the Voya Index Solution PortfoliosSM.
This chart shows you how a Voya Index they automatically monitor and rebalance the portfolio and shift assets to more
Solution PortfolioSM adjusts over time. When conservative investments as the retirement date draws near.
you’re further away from your retirement
RETIREMENT INVESTING year, your portfolio has more time to take HpoorwtfoinlidoebxescoolmuteiosInNmGpSooOrLreUtfTocIOolNion2s0s5e5arPrvOeaRTatFidvOLejIuOsted over time as each ING SOLUTIO
advantage of market highs and recover from
market lows so it includes more aggressive ING SOLUTION 2035 PORTFOLIO
funds (orange). Over time, as you get closer
to retirement, assets in the portfolio gradually STABILITY OF PRINCIPAL FUNDS STABILITY OF PRINCIPAL FUNDS STABILITY O
shift to more conservative investments LARGE CAP
(yellow). LARGE CAP VALUE (LV) 22% LARGE CAP VALUE (LV) 21% LARGE CAP
SMALL/MID
LARGE CAP GROWTH (LG) 22% LARGE CAP GROWTH (LG) 21% GLOBAL/IN

SMALL/MID/SPECIALTY (SM) 20% SMALL/MID/SPECIALTY (SM) 23%

More Aggressive GLOBAL/INTERNATIONAL (GL) 31% GLOBAL/INTEMRoNrAeTICOoNnAsLer(GvaL)tiv2e0%

Initially the portfolio will Some money is gradually More is allocated to stability
include a mix of more shifted out of more aggressive of principal funds.
aggressive funds. funds and into more income-
oriented funds.
ING SOLUTION INCOME PORTFOLIO
ING SOLUTION 2035 PORTFOLIO
The pie charts displayed reflect the long-term, strategic asset
Asset Class key allocation composition (“STaTArgBeItLAITllYocOaFtioPnRsI”N)CaInPdALarFeUrNevDieSwed
STABILITY OF PRINCpIePrAioLdFicUaNllyD,Showever, changes to these target allocations may
403B RETIREMENT SAVINGS PLAN n Stability of principal funds Po(LcleVcau)sreorneafeqr u2toa1r%ttheerlyprboasspiseLLAAcotRRruGGassEEfowCCraAAmrPProarGVneAtReiOLndUfWobEryTm(HmLaVta(i)LorkGne).t condi8ti%ons.
n Income-oriented funds LARGE CAP VALUE
n Aggressive funds 7%

LARGE CAP GROWTH (LG) 21%
Important Information: There is noSMguAaLrLa/nMteIDe/tShPaEtCaInAyLTinYve(SsMtm)ent2o3p%tion will aScMhieAvLeL/iMtsIsDta/StPeEdCoIbAjLeTcYtiv(eS.MP)rincip9a%l
vaaplpureoxfliumcatuteatdeastaenwdhtehneraenisinnvoesgtuoarGrpLalOnatnBesAetLoo/IfsNvtaTarElutRewNiaAtthTdaInrOayNwtAiimnLge(,tGhinLec)irlu2md0oi%nngetyh. eWthaerGgnLetOthdeBaiArteLta/.IrTNgheTetERd“taNatAregTiesIOtrdeNaaAtceLh”e(Gids,Lt)thhee6y%
may have more or less than the original amount invested. For each target-date portfolio, until the day prior to its target
date, the portfolio will seek to provide total returns consistent with an asset allocation targeted for an investor who is
retiring in approximately each portfolio’s designated target year. On the target date, the portfolio will seek to provide a
combination of total return and stability of principal.

gStroecaktesraflreucmtuoarteiovnoslaintilveatlhuaenthbaoInNnGdpsoS,rtOafnoLdlUiopTsIoOwrtNiftohIlNiaoCshOwigMihtheEraPcOhoinRgcTheFenOrtcLraoIOtniocnenintrabtoionndso.fFsotorecikgsnasrteocmkosraenldikesmlyatoll experience
and midcap
stocks may be more volatile than large cap stocks. Investing in bonds also entails credit risk and interest rate risk.
Generally investors with longer timSeTAfraBmILeITsYcaOnFcPoRnIsNidCeIPrAaLssFuUmNinDgSmore risk in their investment portfolio. The Voya
IwnidthexoSr ochluatniognePtoorotftohleiorspSMoratrfeolaiocstiLovAevRelyrGmtEimaCneAa.PgReeVdfAearLnUtdoEtth(hLeeVap) srosespt eaclltoucs8af%toiornmaodrjeusintefodromvaetriotnimaeb.oTuhtethpeorstpfoelcioifiscmriasyksmoefrge
investing in the various asset classLeAsRiGncEluCdAePdGinRtOhWe VToHya(LIGnd) ex Sol7u%tion PortfoliosSM.

SMALL/MID/SPECIALTY (SM) 9%

GLOBAL/INTERNATIONAL (GL) 6%

How do you pick the index solution portfolio that works Learn4Life Concept Charter Schools 403(b) Plan
for you?
Model Portfolios
Voya Index Solution Portfolios include 10 funds, each spanning five-year
increments. Consider the year you plan to retire, or your investment goal year A model for your personal standards
when analyzing the portfolios that may work for you. For example, if you plan
to retire in 2042, you would likely consider the Voya Solution 2040 Portfolio. Special Report

Fund name Target retirement year What kind of assets does • Bonds (Conservative/ Moderate/
your model have? Aggressive)
Voya Index Solution Income Portfolio For those retiring soon Seeks income or growth of income,
Voya Index Solution 2020 Portfolio For those retiring 2018-2022 Model portfolios can help you work with less emphasis on capital
Voya Index Solution 2025 Portfolio For those retiring 2023-2027 toward your personal investment appreciation. May include aggressive:
Voya Index Solution 2030 Portfolio For those retiring 2028-2032 objectives by using “asset allocation below-investment grade bonds or
Voya Index Solution 2035 Portfolio For those retiring 2033-2037 strategies,” which consider the historic bonds of foreign issuers; moderate:
Voya Index Solution 2040 Portfolio For those retiring 2038-2042 rates of return of different asset investment-grade corporate bonds,
Voya Index Solution 2045 Portfolio For those retiring 2043-2047 classes over long periods of time. mortgages, government bonds and,
Voya Index Solution 2050 Portfolio For those retiring 2048-2052 An asset class is a broad group of to a lesser degree, preferred stock,
Voya Index Solution 2055 Portfolio For those retiring 2053-2057 individual securities or investments foreign or convertible bonds; or
Voya Index Solution 2060 Portfolio For those retiring 2058 or later that have similar characteristics, such conservative: Treasury Bills and other
as risk or market capitalizations. While highly-rated, short-term (e.g., 90-day)
Check with your employer for information about the specific target date funds using asset allocation as part of an securities.
offered by your plan. investment strategy neither assures
nor guarantees better performance • Large Cap Value (Moderate)
How can you learn more about Voya Index Solution PortfoliosSM? and cannot protect against loss Seeks long-term growth of capital or
in declining markets, it is a well- a combination of growth and income
Not FDIC/NCUA/NCUSIF Insured I Not a Deposit of a Bank/Credit Union I May Lose Value I Not Bank/Credit Union Guaranteed I Not Insured by Any Federal Government Agency A role model is someone recognized risk management strategy. by investing primarily in stocks of
Variable annuities and mutual funds under a retirement plan are long-term investments designed for retirement purposes. Early withdrawals prior to age 59½ will be subject to a we try to emulate; their larger, mature companies. Selected
10% premature distribution penalty tax, unless an exception applies. Money taken from the plan will be taxed as ordinary income in the year the money is distributed. Account values behavior sets the standard Model portfolios are typically for the potential price appreciation
fluctuate with market conditions, and when surrendered the principal may be worth more or less than its original amount invested. An annuity does not provide any additional tax for imitation or comparison. comprised of six different asset and for the value of the current
deferral benefit, as tax deferral is provided by the plan. Annuities may be subject to additional fees and expenses to which other tax-qualified funding vehicles may not be subject. In many ways, a model classes: income provided through dividends.
However, an annuity does provide other features and benefits, such as lifetime income payments and death benefits, which may be valuable to you. portfolio is no different. It’s Generally exhibit a lower level of
an investment strategy you • Stability of Principal (Conservative) price volatility, due to the types of
You should consider the investment objectives, risks, charges and expenses of the variable product and its underlying fund options; or decide to emulate based on Seeks to hold the principal value companies favored, such as those
mutual funds offered through a retirement plan, carefully before investing. Prospectuses/prospectus summaries/information booklets your goals, risk tolerance of an investment stable through able to pay dividends.
contain this and other information, which can be obtained by contacting your local representative. Please read the information carefully and timeframe. various market conditions. May credit
before investing. a stated rate of return or minimum • Large Cap Growth (Moderate/
This information is provided for your education periodic interest rate that may vary. Aggressive)
Any insurance products, annuities and funding agreements that you may have purchased are sold as securities and are issued by Voya Retirement Insurance and Annuity Company only by the Voya® family of companies. Dividend rates and income levels Seeks long-term growth of capital by
(“VRIAC”). Fixed annuities are issued by VRIAC. VRIAC is solely responsible for meeting its obligations. Plan administrative services provided by VRIAC or Voya Institutional Plan fluctuate with market conditions and investing primarily in stocks of larger
Services, LLC (“VIPS”). Neither VRIAC nor VIPS engage in the sale or solicitation of securities. If custodial or trust agreements are part of this arrangement, they may be provided by are not guaranteed. U.S. companies. Typically has higher
Voya Institutional Trust Company. All companies are members of the Voya family of companies. Securities distributed by Voya Financial Partners, LLC (member SIPC) or other price/earnings ratios and makes little
broker-dealers with which it has a selling agreement. All products or services may not be available in all states. or no dividend payments. Tends to be
157545 3015763.X.P-6 © 2017 Voya Services Company. All rights reserved. CN0427-33916-0519D more established, with lower relative
volatility, than more aggressive small
Voya.com and mid-cap stocks.

5039288

• Small/Mid/Specialty (Aggressive) • Global/International (Aggressive)

Seeks capital appreciation by Seeks capital appreciation by

investing primarily in stocks of small- investing in foreign stock: stocks of Investor Profiles
and medium-sized companies; also companies outside the United States;

invests in “specialty” or “sector” world stock: stocks of companies Aggressive Portfolio Moderate Portfolio Conservative Portfolio
companies, which include those in a in the United States and developed (Investor Profile Score: 28-32) (Investor Profile Score: 18-22) (Investor Profile Score: 8-12)
particular industry. Generally, strives to countries outside the United States;

develop new products or markets and and emerging markets: stocks of Primarily invested in equities or similar An intermediate risk and return Primarily invested in stability of
has above-average earnings growth developing countries. May provide higher risk investments, weighted portfolio that provides a blend principal and income-oriented
potential, but with higher risk and greater diversification benefits toward aggressive growth and of equities and income-oriented investments, and equities to provide
volatility. than domestic securities alone, but international investments. investments. growth potential.
involves additional risks.
Model Investment Portfolios/Allocation MeCnotonrsider this portfolio if you: Consider this portfolio if you: Consider this portfolio if you:
• Have high return expectations for • Have moderate return expectations • Need income to supplement your

Self-Assessment Quiz and Model Portfolios Model InvestmenAAGstsGePRt oECSlraStsIsfVoElPioORsT/FAOlLlIoO caAtliloocnatioMn e•nCytooarunr investments degrees of for your investments cash flow
tolerate higher • Want some current income return on • Are unwilling or unable to accept risk/
gsTcheoinsreesr,earllefi-vdaiesesaweostfshmheoemwnotydqoeuulizpcoowruitllfldohluieoslpethydaoitfufceodrerernteetsrpamsoisnnedetsyctoloausrysoreiussrktoitnovbleeusrialtdonrcaepw.roeOfilnll-Medc.eoivEdeyaeorclsuhIinfi’vmeveedoscdptameolclerutgnAAfloGstiaBGSLLLBsvGleaaamPooltieoRrrrtnneogggaboECddsleeealSd.lss/ralMCCCS/tsIynIaaaisfVydtpppooe/EoSVVGrulnpPaairuaeoOolluutcwariReesoiatTnh/ltFaAyOl lLlIoOcaAtliloocna22222ti655533o1M%%%%%%%n e•nAiflitnnourvertcehtasuetaoyvtoraioulaunnnegd(soehafrayroriopsrku,asrtmhainokoverretre-stetemrxmpeenvtrosielantcileityd)
specific<<<<<M<<<<<<ino22712125222vd36%1350%163e%e%%%%%%%%sltMMPmoooeddrnteeftoll olIIinnopvvsteeiossnttmmsPSPAMASeeoccooggnnoMAAAAAMMMAAAAMAAMoofrrggGGGdsssssssssfttttOOOOOOrrLLLBSLBLBSSLSLBSSGGSSLSGLGLSBSGSBBBGSGLLLLLsssssssssrreffeeGGGeeeeeeeeeeaaaaaaaaaaaaaaaDDDDDDeettttttmmmmmmmmooPPoooooooolllllllaaaaaa::oooooooRRRrrrrrrrrrrrrrrrrtttttttttrnnnnnnnnEEEEEEssllgggggggggggggggaaaaaaaabbbbbbbbbbbbbaoo22eEEECCCCCCCCCiiddddddddRRRRRRsslllllllleeeeeeeeeeeeeeeiiiiiiooaaaaaaallllllllSSSllllltlllllllllssss38ssss////////iiiiiiAAAAAArriiaaaaaaaaadlllllllttttttMMMMMMMMeCCCCCCCCCCCCCCCSSS///////vvyyyyyy--ttsssssssssTTTTTTIIIIIIInnnnIIInnnaaaaaaaaalaaaaaa23iiiiiiiieesssssssssffEEEEEEVVVddddddddooooooytttttttpppppppppppppppboo27LLLLLeeeeeee////////ffffffEEEPPSSSSSSSSYYYYYVGVGGGVGVVVGGVGrrrrrrrPPPPPPllyOOnnnnnnnppppppppPPPaaaaaaaiirrrrrrrrrrrrrAAAAAaaaaaaaeeeeeeeeiiiiiiooOOOooooooooRRlllllllnnnnnnuuuuuuuGGGGGtttttttccccccccwwwwwwwwTTiiiiiiiccccccRRReeeeeeessoooooooiiiiiiiiGGGGGaaaaaaaaiiiiiiFFttttttttTTTppppppnnnnnnnhhhhhhhh//llllllllRRRRROOttttFFFttttaaaaaaaaaaaaaAAyyyyyyyyEEEEEOOOllllllllllLLlll SSSSSIIllLLLOOSSSSSllIIIooOOOIIIIIVVVVVccEEEEEaaPPPPPAAAAAAAAAOOOOOttllllllllliilllllllllRRRRRooooooooooocccccccccTTTTTnnaaaaaaaaaFFFFF222222222222222222211212222ttttttttt12221111111OOOOO005iiiiiiiii46666555555700333006666333333333777771ooooooooo1111111MM%%%%%%LLLLL%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%nnnnnnnnnIIIIIOOOOOee••MhPC•g(onnIinrrrwHHiDogttnoioiooemvneaaihvdwlrrenslvvseeaetstinieesrrdherrtieetaolr,edm1myiet5wrsrreidoieekntPnholhdntyvvtiriurlinheteoeesAsrmversfinspagaettoslmmtoeelgsesrttrderooehlSmteyfnnaicyoosnehettoeslfsniiyefeoraig.etvexqrsfhreisrc:fuiofne2eobyPimtgex3ocieoepd-uuifry2nsoets:oifc7rncoeoeuo)tfldrlarmiaysototoiieoimnou-nnilsar your investments volatility
• Are willing and able to accept a • Are a cautious investor
• Are more concerned about current
moderate level of risk and return
• Are primarily a growth investor but income than outpacing inflation

After reviewing the model portfolios, you can choose from want greater diversification • Have five or fewer years before
your Plan in each asset class. SCORE • Are concerned about inflation you will need the money from your
• Have five or more years before investments
Self-Assessment Quiz
< 10% SCMMSPPccoooMAMAMAooAAAMMMoorrnsssddsssOOOttOOOrrsssSSSBLBLGLGLSLGSLBGLSBLGSSLLGGSSSSSLBBLLLssssffeeeeeeeDDDeeeaaaaaaaaaaDDDaaaattttttmmmmmoommooooeoolllllllaaaaaa::tttooooooorrrrrrrrrrtttrrrrrrnnnnEEEEEEnnllggggggggggaaaaabbbaabbbrggggCCCbbbbbbbaa11CCCiiddddRRRRRRddvllllllleeeeeeeeeeiiiiiioo38eeeeaaaaaaalllllllllllllllttlllssss/////aaa//iiiAAAiiissaaaAAAallllllltttMMMMMtttMMee--CCCCCCCCCC///////sssCCCCyyyyyysssTTTIIIII1II2TTTtsssnnnnnnnaaaaaaaalaaiiiiiiisss7EEEaaaaidddddddooooooyEEE2ttttttpppppppptppvppppeeeeeee/////fff//fffLLLPPPSSSSSSSeGVVVVGGGVGrrrrrrrYYYPPPPPPOOOVVGGnnnnnnnpppppppaaaaarrrrrrrrrraaaaaaaaaeeeeeeeiiiiiiCCCoooooRRRrrlllllnnnnnnuuuuutttttoottllcccccccwwwwwTTTiiiiiiiOOOuucccccceeeeeoooooooiiiiiiiwwaaaaaaaiiiFFFiiitttteetppppppnnnnnnnNNNhhhhhlllllllttOOOtttttttaaaaaaaaaaaaahhyyyyySSSyyllllllllLLLlllll EEEIIIOOORRRVVVAAATTTIIIAAAAAAVVVlllllllllEEElllooooooccccccPPPaaaaaa2222OOO2244ttt111222211111111ttt11112211111111iii000555533333iii4444777706ooo00036695592281111RRRooo11%%%%%%%%%%%%%%%%%%%%%%%%%nnn%%%%%%%%%%%%nnnTTTFFFOOO••••LLLafDmCHwiaAIIInOOOocnraeaivorlehdlnvsedainieeasvreteretonvor1emeail0lnepteadteugreoxtonraitplltnrygihttetesemyeronoremtinofumeaioartantyrpeoleroctrankryheeuceeleedtroeyutainpenrdrifgnnsroqvoosfl-esuwbtmaesstietnhtirtyibfmmytoaouioitnlnreirgtuenvnyarsetyoissnoftsuor you will need the money from your
Scoring: 4 Strongly Agree 3 Agree 2 Disagree 1 Strongly Disagree < 25% investments
< 21%
Financial Goals < 14% Moderately Conservative Portfolio
1. Investments: I have long-term financial goals of 10 years or longer. < 17% (Investor Profile Score: 13-17)
2. Large expenses: I do not need short-term investment results to cover < 13%
Invested in growth, growth and
financial obligations or planned expenditures. < 10% income, income-oriented, and stability
3. Inflation: Despite the risks, growth of capital is most important to me. < 45% of principal investments.
Risk Tolerance < 16%
4. Volatility: I am more focused on growth of capital than on receiving < 9% Consider this portfolio if you:
< 12% • Need more current income from your
regular income. < 8%
5. Risk vs. reward: When pursuing my financial goals, I can handle < 15% investments
< 60% • Are willing and able to accept some
short-term losses on my investments. < 10%
6. Decline in value: I am willing to accept additional investment risk when this < 7% risk/volatility
• Are a cautious or first-time investor
risk increases the probability of reaching my financial goals. • Want some potential hedge against
7. Equity investing: I understand the potential consequences of not reaching
inflation
my financial goals. • Have five or fewer years before
8. Knowledge of risk: I consider myself to be a sophisticated investor.
you will need the money from your
What type of investor are you? investments

MAACssOOssGBLNeeDaoltotSrEngCbCERdealRlasaAlV/sCsITsnAsaEtTpeLIrYVVnEaaCtlPiOuoOenNRaSlTEFROVLAIOTIAAVllllEooccPaaO4tt1iio56o8Rn%%n%TFOLIO
ConservativeSSLtataarbbgiielliittyCy aoopff PPGrriirnnoccwiipptaahll 11509%%%
MOBSBDomonEnadRdlls/sAMTidE/LSYpeCcOiaNltSy ERVATIVE PO641052R%%%TFOLIO
SPcoortrfeo: l8io-12ACAssOsLLsGSLLNeeaaaatlatorrtSrrggbggCbCEeeieeallRlaialtCCV/sCCysIsaanAsaaopptTppefIVGrPVVGnarEaaiorlnuotlwPiuceowitOepnhtRaahllTFOLIOAAllllooccaatt111ii0o0697o8n%%%%n%
< 5% SSBStmomanbaadlillll/is/tMMy iioddf//SSPpprieenccciiiaaplltatyyl 4115525%%%
Risk Tolerance Score < 3% CACsOOBLBLSGGsGGSLLSNNeaataaoomllmllaoooorrtSSrrnnggbaggbbabbCEEddeelilaaeeaallRRllss/ia/lllltMCCM//VV//CyCsIIIInnaannAAsiiaaoddttppttTTeeppeef//SIISVGrrrrPVVVGnnnnpparrEEaaaaieorelnuttottlcwcPPiiiicueooooiwiiatOOeapnnnnhltltaaaRRaahtyylllllTTFFOOLLIIOO 610368%%% All investments carry a degree of risk and past performance is not a guarantee of future results. Generally, the
Aggressive 28-32 Total Score ASSET CLASS KEY Alloca6t111i0053927o85%%%%%%%n%% greater an investment’s possible reward over time, the greater its level of price volatility, or risk. Investments are
Moderately Aggressive 23-27 not guaranteed and are subject to investment risk including the possible loss of principal. The investment return
Moderate 18-22 < STABILITY OF PRINCIPAL AsLseartgCelaCsasp Value Allocat1i0o%n and principal value of the security will fluctuate so that when redeemed, may be worth more or less than the
Moderately Conservative original investment.
Conservative 13-17 < BONDS LSatargbeilitCyaopf GPrrionwcitphal 157%%
8-12 < LARGE CAP VALUE Stocks are more volatile than bonds, and portfolios with a higher concentration of stocks are more likely to
< LARGE CAP GROWTH COBSNomSnaEdlRls/MVAidT/ISVpEecPiOalRtyTFOLIO 605%% experience greater fluctuations in value than portfolios with a higher concentration in bonds. Foreign stocks and
< SMALL/MID/SPECIALTY small- and mid-cap stocks may be more volatile than large-cap stocks. Investing in bonds also entails credit risk
The Models are provided solely for informational purposes and do not constitute investment advice. The Models were AsLGsealortgbCealalC/sInastpeVrnaalutieonal Allocat1i03o%%n and interest rate risk. Generally investors with longer timeframes can consider assuming more risk in their
constructed as of February 2017 based on available asset classes, benchmarks, constraints, capital market expectations and
market conditions at that time, and are not tailored to any individual customer’s circumstances. The Models are generally SLatargbeilitCyaopf GPrionwcitphal 157%
updated periodically, typically on an annual basis.
BSomnadlls/Mid/Specialty 605%%
< GLOBAL/INTERNATIONAL LGalorgbealC/InatpeVrnaalutieonal
103%

Large Cap Growth 7%

Small/Mid/Specialty 5% investment portfolio.

Global/International 3%

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BENEFITSMEDOMICVAELE/DDERINCTVAALI/LEVISVWIOISNCIOARNEDENTAL

EMPLOYEE BENEFITS OVERVIEW
HEALTH

OVERVIEW OF EMPLOYEE BENEFITS

MEDICAL DENTAL VISION
COVERAGE COVERAGE PLAN
LONG TERM
LIFE INSURANCE 403B SAVINGS CARE
STD & LTD PLAN INSURANCE

SUPPLEMENTAL
INSURANCE

Anthem HMO Not Covered Not Covered Not Covered Not Covered $100/trip Anthem Blue Cross
Out-of-Network Benefits Not Covered Not Covered Your Plan: Custom Premier PPO 150/10/10
Not Covered Your Network: Prudent Buyer PPO

$100/trip This summary of benefits is a brief outline of coverage, designed to help you with the selection process. This summary does not reflect each and
every benefit, exclusion and limitation which may apply to the coverage. For more details, important limitations and exclusions, please review
$10 copay per visit $100 Copay per Test the formal Certificate of Insurance or Evidence of Coverage (EOC). If there is a difference between this summary and the Certificate of
Yes Insurance or Evidence of Coverage (EOC), the Certificate of Insurance or Evidence of Coverage (EOC), will prevail.
No
Plan Details Yes No Copay $100/trip Covered Medical Benefits Cost if you use an Cost if you use a
No Copay $100 Copay In-Network Non-Network
Anthem PPO $100/trip Provider Provider
In-Network Benefits Out-of-Network Benefits HMO Benefits $150 single /
Overall Deductible $150 single / $450 family
General Plan Information See notes section to understand how your deductible works. Your plan may also have $450 family
a separate Prescription Drug Deductible. See Prescription Drug Coverage section. $6,000 single /
30% after deductible 30% after deductible 30% after deductible 10% after deductible/30% In-Network Providers and Non-Network Providers deductibles are combined. $12,000 family
Non emergency Satisfying one helps satisfy the other. 30% coinsurance
Outpatient Services Emergency Services
No No Out-of-Pocket Limit $2,000 single / 30% coinsurance
30% after deductible Yes When you meet your out-of-pocket limit, you will no longer have to pay cost-shares $4,000 family 30% coinsurance
No during the remainder of your benefit period. See notes section for additional 30% coinsurance
$100 copay and 10% after information regarding your out of pocket maximum.
deductible 30% coinsurance
Preventive care/screening/immunization No charge 30% coinsurance
Ambulance

10% after deductible/30%
Non emergency

In-network preventive care is not subject to deductible, if your plan has a deductible.

10% after deductible $10 copay 10% after deductible Yes 10% after deductible 10% after deductible Doctor Home and Office Services
10% after deductible (subject to utilization No
$100 copay and 10% Primary care visit to treat an injury or illness $10 copay per visit
review) after deductible Deductible does not apply to In-Network providers.

Specialist care visit $10 copay per visit
Deductible does not apply to In-Network providers.

Plan Name Copay/Deductible Waived if Prenatal and Post-natal Care $10 copay per visit
Primary Care Physician Admitted Deductible does not apply to In-Network providers.
Election Required Pre-Authorization of
Outpatient Facility Charge Specialist Visit Advanced Imaging Services Required Ground Other practitioner visits: $10 copay per visit
Diagnostic X-Ray and Lab Emergency Room Retail health clinic $10 copay per visit
Tests Deductible does not apply to In-Network providers.
Air On-line Visit
Deductible does not apply to In-Network providers.

Page 1 of 6

Covered Medical Benefits Cost if you use an Cost if you use a Covered Medical Benefits Cost if you use an Cost if you use a
In-Network Non-Network In-Network Non-Network
Chiropractor services Provider Provider Emergency and Urgent Care Provider Provider
Coverage for In-Network Provider and Non-Network Provider combined is $10 copay per visit 30% coinsurance Emergency room facility services $100 copay per
limited to 30 visit limit per benefit period. Deductible does not apply to Copay waived if admitted. admission and then Covered as In-Network
In-Network providers. $10 copay per visit 30% coinsurance 10% coinsurance Covered as In-Network
Acupuncture Emergency room doctor and other services 10% coinsurance Covered as In-Network
Coverage for In-Network Provider and Non-Network Provider combined is 30% coinsurance Ambulance (air and ground) 10% coinsurance
limited to 20 visit limit per benefit period. Deductible does not apply to 30% coinsurance Urgent Care (office setting) $10 copay per visit 30% coinsurance
In-Network providers. 30% coinsurance Deductible does not apply to In-Network providers.
30% coinsurance Outpatient Mental/Behavioral Health and Substance Abuse $10 copay per visit; 30% after deductible
Other services in an office: 10% coinsurance Doctor office visit deductible does not is met
Allergy testing 10% coinsurance 30% coinsurance apply
Chemo/radiation therapy 10% coinsurance 30% coinsurance Facility visit: 10% coinsurance 30% after deductible
Hemodialysis 10% coinsurance 30% coinsurance Facility fees after deductible is is met
Prescription drugs met
For the drugs itself dispensed in the office thru infusion/injection 30% coinsurance Outpatient Surgery 30% coinsurance
30% coinsurance Facility fees: 10% coinsurance 30% coinsurance
Diagnostic Services 10% coinsurance 30% coinsurance Hospital 10% coinsurance 30% coinsurance
Lab: 10% coinsurance Freestanding Surgical Center 10% coinsurance
Office 10% coinsurance 30% coinsurance Doctor and other services 30% coinsurance
Freestanding Lab 30% coinsurance 10% coinsurance
Outpatient Hospital 30% coinsurance Hospital Stay (all inpatient stays including maternity, mental / 30% coinsurance
behavioral health, and substance abuse) 10% coinsurance
X-ray: 10% coinsurance
Office 10% coinsurance Facility fees (for example, room & board)
Freestanding Radiology Center 10% coinsurance Co-pay $250 if you do not receive preauthorization. Apply to Out-of-Network
Outpatient Hospital Provider. Failure to obtain preauthorization may result in non-coverage or
reduced coverage. Apply to non-emergency admission.
Advanced diagnostic imaging (for example, MRI/PET/CAT scans): 10% coinsurance Doctor and other services
Office 10% coinsurance
Freestanding Radiology Center
Coverage for Out-of-Network Provider is limited to $800 maximum per test. 10% coinsurance
Outpatient Hospital
Coverage for Out-of-Network Provider is limited to $800 maximum per test.

Page 2 of 6 Page 3 of 6

Covered Medical Benefits Cost if you use an Cost if you use a Notes:
In-Network Non-Network  This Summary of Benefits has been updated to comply with federal and state requirements, including
Recovery & Rehabilitation Provider Provider applicable provisions of the recently enacted federal health care reform laws. As we receive additional guidance
Home health care and clarification on the new health care reform laws from the U.S. Department of Health and Human Services,
Coverage for In-Network Provider and Non-Network Provider combined is 10% coinsurance 30% coinsurance Department of Labor and Internal Revenue Service, we may be required to make additional changes to this
limited to 100 visit limit per benefit period. Summary of Benefits. This Summary of Benefits, as updated, is subject to the approval of the California
10% coinsurance 30% coinsurance Department of Insurance and the California Department of Managed Health Care (as applicable).
Rehabilitation services (for example,  In addition to the benefits described in this summary, coverage may include additional benefits, depending
physical/speech/occupational therapy): 10% coinsurance 30% coinsurance upon the member's home state. The benefits provided in this summary are subject to federal and California
10% coinsurance 30% coinsurance laws. There are some states that require more generous benefits be provided to their residents, even if the
Office master policy was not issued in their state. If the member's state has such requirements, we will adjust the
Costs may vary by site of service. benefits to meet the requirements.
Outpatient hospital  The family deductible and out-of-pocket maximum are embedded meaning the cost shares of one family
Habilitation services member will be applied to the individual deductible and individual out-of-pocket maximum; in addition,
amounts for all family members apply to the family deductible and family out-of-pocket maximum. No one
Cardiac rehabilitation 10% coinsurance 30% coinsurance member will pay more than the individual deductible and individual out-of-pocket maximum.
Office 10% coinsurance 30% coinsurance  All medical services subject to a coinsurance are also subject to the annual medical deductible.
Outpatient hospital 10% coinsurance 30% coinsurance  Annual Out-of-Pocket Maximums includes deductible, copays, coinsurance and prescription drug.
 In network and out of network out of pocket maximum are exclusive of each other.
Skilled nursing care (in a facility) No charge 30% coinsurance  For plans with an office visit copay, the copay applies to the actual office visit and additional cost shares may
Coverage for In-Network Provider and Non-Network Provider combined is limited apply for any other service performed in the office (i.e., X-ray, lab, surgery), after any applicable deductible.
to 100 day limit per benefit period. 10% coinsurance 30% coinsurance  Preventive Care Services includes physical exam, preventive screenings (including screenings for cancer, HPV,
10% coinsurance 30% coinsurance diabetes, cholesterol, blood pressure, hearing and vision, immunization, health education, intervention services,
Hospice HIV testing) and additional preventive care for women provided for in the guidance supported by Health
Deductible does not apply to In-Network providers. Resources and Service Administration.
 For Medical Emergency care rendered by a Non-Participating Provider or Non-Contracting Hospital,
Durable Medical Equipment reimbursement is based on the reasonable and customary value. Members may be responsible for any amount
in excess of the reasonable and customary value.
Prosthetic Devices  If your plan includes an emergency room facility copay and you are directly admitted to a hospital, your
emergency room facility copay is waived.
Page 4 of 6  If your plan includes out of network benefit and you use a non-network provider, you are responsible for any
difference between the covered expense and the actual non-participating providers charge.
 Non-emergency, out-of-network air ambulance services are limited to Anthem maximum payment of $50,000
per trip.
 Certain services are subject to the utilization review program. Before scheduling services, the member must
make sure utilization review is obtained. If utilization review is not obtained, benefits may be reduced or not
paid, according to the plan.
 Certain types of physicians may not be represented in the PPO network in the state where the member
receives services. If such physician is not available in the service area, the member's copay is the same as for
PPO (with and without pre-notification, if applicable). Member is responsible for applicable copays,
deductibles and charges which exceed covered expense.

Anthem Blue Cross is the trade name of Blue Cross of California. Anthem Blue Cross and Anthem Blue Cross Life and Health Insurance Company are independent licensees of
the Blue Cross Association. ® ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross name and symbol are registered marks of the Blue
Cross Association.

Questions:(855) 333-5730 or visit us at www.anthem.com/ca
CA/L/F/PPO/ C- LP2037/01-18/Printed 12-17

Page 5 of 6

 Additional visits maybe authorized if medically necessary. Pre-service review must be obtained prior to Anthem Blue Cross
receiving the additional services. Your Plan: Modified Premier HMO 10/100%
Your Network: California Care HMO
 If your plan includes out of network benefits, all services with calendar/plan year limits are combined both in
and out of network. This summary of benefits is a brief outline of coverage, designed to help you with the selection process. This summary does not reflect each and
every benefit, exclusion and limitation which may apply to the coverage. For more details, important limitations and exclusions, please review
 Transplants covered only when performed at Centers of Medical Excellence or Blue Distinction Centers. the formal Evidence of Coverage (EOC). If there is a difference between this summary and the Evidence of Coverage (EOC), the Evidence
 Bariatric Surgery covered only when performed at Blue Distinction Center for Specialty Care for Bariatric of Coverage (EOC), will prevail.

Surgery. Anthem Blue Cross HMO benefits are covered only when services are provided or coordinated by the primary care physician and authorized
 Skilled Nursing Facility day limit does not apply to mental health and substance abuse. by the participating medical group or independent practice association (IPA); except OB/GYN services received within the member's
 Respite Care limited to 5 consecutive days per admission. medical group/IPA, and services for mental and nervous disorders and substance abuse. Benefits are subject to all terms, conditions,
 Freestanding Lab and Radiology Center is defined as services received in a non-hospital based facility. limitations, and exclusions of the EOC.
 Coordination of Benefits: The benefits of this plan may be reduced if the member has any other group health
Covered Medical Benefits Cost if you use an Cost if you use a
or dental coverage so that the services received from all group coverage do not exceed 100% of the covered In-Network Non-Network
expense Provider Provider
 For additional information on limitations and exclusions and other disclosure items that apply to this plan, go $0
to https://le.anthem.com/pdf?x=CA_LG_PPO Overall Deductible $0
 For additional information on this plan, please visit sbc.anthem.com to obtain a Summary of Benefit Coverage. See notes section to understand how your deductible works. Your plan may also have $0 single /
a separate Prescription Drug Deductible. See Prescription Drug Coverage section. $0 family
Anthem Blue Cross is the trade name of Blue Cross of California. Anthem Blue Cross and Anthem Blue Cross Life and Health Insurance Company are independent licensees of
the Blue Cross Association. ® ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross name and symbol are registered marks of the Blue Out-of-Pocket Limit $1,500 single / Not covered
Cross Association. When you meet your out-of-pocket limit, you will no longer have to pay cost-shares $3,000 family
during the remainder of your benefit period. See notes section for additional Not covered
Questions:(855) 333-5730 or visit us at www.anthem.com/ca information regarding your out of pocket maximum. Not covered
CA/L/F/PPO/ C- LP2037/01-18/Printed 12-17 Not covered
Preventive care/screening/immunization No charge Not covered
Page 6 of 6 In-network preventive care is not subject to deductible, if your plan has a deductible. Not covered

Doctor Home and Office Services

Primary care visit to treat an injury or illness $10 copay per visit

Specialist care visit $10 copay per visit

Prenatal and Post-natal Care $10 copay per visit

Other practitioner visits: Not covered
Retail health clinic $10 copay per visit
On-line Visit

Page 1 of 5

Covered Medical Benefits Cost if you use an Cost if you use a Covered Medical Benefits Cost if you use an Cost if you use a
In-Network Non-Network In-Network Non-Network
Chiropractor services Provider Provider Emergency and Urgent Care Provider Provider
Coverage for In-Network Provider is limited to 60 day limit per benefit $10 copay per visit Not covered Emergency room facility services
period for Physical, Occupational and Speech Therapy combined. This is for the hospital/facility charge only. The ER physician charge may be
Chiropractor visits count towards your physical and occupational therapy separate. Copay waived if admitted. $100 copay per visit Covered as In-Network
limit. Emergency room doctor and other services
Acupuncture $10 copay per visit Not covered No charge Covered as In-Network
Ambulance (air and ground) $100 copay per trip Covered as In-Network
Other services in an office: $10 copay per visit Not covered for ground and air
Allergy testing $10 copay per visit Not covered Urgent Care (office setting) $10 copay per visit Covered as In-Network
Chemo/radiation therapy $10 copay per visit Not covered Copay waived if admitted. Costs may vary by site of service.
Hemodialysis 20% coinsurance up Not covered
Prescription drugs to $150 per visit Outpatient Mental/Behavioral Health and Substance Abuse
For the drugs itself dispensed in the office thru infusion/injection Doctor office visit $10 copay for Not covered

Diagnostic Services Facility visit: non-preventive visit
Lab: Facility fees
Office No charge Not covered No charge Not covered
Freestanding Lab No charge Not covered Outpatient Surgery
Outpatient Hospital No charge Not covered Facility fees:
Hospital
X-ray: No charge Not covered Freestanding Surgical Center No charge Not covered
Office No charge Not covered Doctor and other services No charge Not covered
Freestanding Radiology Center No charge Not covered No charge Not covered
Outpatient Hospital Hospital Stay (all inpatient stays including maternity, mental /
behavioral health, and substance abuse)
Advanced diagnostic imaging (for example, MRI/PET/CAT scans): $100 copay per test Not covered No charge Not covered
Office $100 copay per test Not covered Facility fees (for example, room & board) No charge Not covered
Costs may vary by site of service. $100 copay per test Not covered Doctor and other services
Freestanding Radiology Center $10 copay per visit Not covered
Costs may vary by site of service. Recovery & Rehabilitation
Outpatient Hospital Home health care
Costs may vary by site of service. Coverage for In-Network Provider is limited to 100 visit limit per benefit
period.

Page 2 of 5 Page 3 of 5

Covered Medical Benefits Cost if you use an Cost if you use a Notes:
In-Network Non-Network  This Summary of Benefits has been updated to comply with federal and state requirements, including
Provider Provider applicable provisions of the recently enacted federal health care reform laws. As we receive additional guidance
and clarification on the new health care reform laws from the U.S. Department of Health and Human Services,
Rehabilitation services (for example, $10 copay per visit Not covered Department of Labor and Internal Revenue Service, we may be required to make additional changes to this
physical/speech/occupational therapy): $10 copay per visit Summary of Benefits. This Summary of Benefits, as updated, is subject to the approval of the California
$10 copay per visit Not covered Department of Insurance and the California Department of Managed Health Care (as applicable).
Office  In addition to the benefits described in this summary, coverage may include additional benefits, depending
Coverage for In-Network Provider is limited to 60 day limit per benefit Not covered upon the member's home state. The benefits provided in this summary are subject to federal and California
period for Physical, Occupational and Speech Therapy combined. Costs may laws. There are some states that require more generous benefits be provided to their residents, even if the
vary by site of service. Chiropractor visits count towards your physical and Not covered master policy was not issued in their state. If the member's state has such requirements, we will adjust the
occupational therapy limit. Not covered benefits to meet the requirements.
Outpatient hospital Not covered  Your plan requires a selection of a Primary Care Physician. Your plan requires a referral from your Primary
Coverage for In-Network Provider is limited to 60 day limit per benefit Not covered Care Physician for select covered services.
period for Physical, Occupational and Speech Therapy combined. Costs may Not covered  Preventive Care Services includes physical exam, preventive screenings (including screenings for cancer, HPV,
vary by site of service. Not covered diabetes, cholesterol, blood pressure, hearing and vision, immunization, health education, intervention services,
Habilitation services HIV testing) and additional preventive care for women provided for in the guidance supported by Health
Habilitation and Rehabilitation visits count towards your Rehabilitation Resources and Service Administration.
limit.  For Medical Emergency care rendered by a Non-Participating Provider or Non-Contracting Hospital,
reimbursement is based on the reasonable and customary value. Members may be responsible for any amount
Cardiac rehabilitation $10 copay per visit in excess of the reasonable and customary value.
Office $10 copay per visit  If your plan includes an emergency room facility copay and you are directly admitted to a hospital, your
Outpatient hospital emergency room facility copay is waived.
 Certain services are subject to the utilization review program. Before scheduling services, the member must
Skilled nursing care (in a facility) No charge make sure utilization review is obtained. If utilization review is not obtained, benefits may be reduced or not
Coverage for In-Network Provider is limited to 100 day limit per benefit period. paid, according to the plan.
 Additional visits maybe authorized if medically necessary. Pre-service review must be obtained prior to
Hospice No charge receiving the additional services.
 Skilled Nursing Facility day limit does not apply to mental health and substance abuse.
Durable Medical Equipment 20% coinsurance  Respite Care limited to 5 consecutive days per admission.
 Freestanding Lab and Radiology Center is defined as services received in a non-hospital based facility.
Prosthetic Devices No charge  Infertility services are not included in the out of pocket amount.
 Coordination of Benefits: The benefits of this plan may be reduced if the member has any other group health
or dental coverage so that the services received from all group coverage do not exceed 100% of the covered
expense
 For additional information on limitations and exclusions and other disclosure items that apply to this plan, go
to https://le.anthem.com/pdf?x=CA_LG_HMO
 For additional information on this plan, please visit sbc.anthem.com to obtain a Summary of Benefit Coverage.

Page 4 of 5 Anthem Blue Cross is the trade name of Blue Cross of California. Independent licensee of the Blue Cross Association. ® ANTHEM is a registered trademark of Anthem
Insurance Companies, Inc. The Blue Cross name and symbol are registered marks of the Blue Cross Association.

Questions:(855) 333-5730 or visit us at www.anthem.com/ca
CA/L/F/HMO/ D – LH2047/01-18/Printed 12-17

Page 5 of 5

Cash-back Rewards From PayForward

Frequently asked questions

Get paid to shop. Really! Who is PayForward? Is there an app?

You’re invited to join this unique rewards program that gives PayForward is an Anthem partner. They’ve developed a Yes, you can download the PayForward
Anthem members up to 15% cash back on purchases. unique rewards program where Anthem members can earn app from the iTunes® store for Apple
up to 15% cash back on purchases at more than 60,000 devices, or from Google PlayTM for
Here’s why this is no ordinary rewards program: participating retailers. Android devices.
} You get serious cash back from PayForward – we’re talking up to 15% instant1 cash back when you shop at more
than 60,000 participating retailers — online and in stores like Home Depot, The Gap and Target.com.2 Why is Anthem partnering with PayForward? How do I earn cash back?
} You can link your own eligilble3 debit or credit card – so it’s amazingly easy! And if you already have rewards on your current
card, that’s great — you get them, plus PayForward’s. At Anthem, our goal is to focus on the whole health of our There are three ways to earn cash back from PayForward
members. This program offers a simple way to earn cash participating retailers:
Easy, right? It gets even better. back on everyday purchases you already make, which can
Once you’ve earned the cash, you decide how to use it! help to relieve stress and improve emotional well-being. If 1. Shop online — through the PayForward app or online
you wish, you can also use rewards to help pay for health at payforward.com. Select “Shop now”
Spend it Save it Share it care expenses, which we know can be a challenge for below the name of the store and it will forward you to
many people. the store’s website. Pay using any of your linked credit
however you like on in your PayForward account or with friends or family, or donate or decit card(s) to make sure you get your cash
whatever you want. transfer it to your bank account. it to charity — with no fees. Does it cost anything to enroll or earn cash back? back rewards.

You can even use rewards toward health care expenses! No, you can enroll, earn cash back, and donate funds with 2. Swipe your card — use your linked credit or debit
no fees. card(s) at your participating local store. Just remember
Sock away reward dollars in the Anthem Health Wallet that comes with your PayForward account. to select the “credit” option if you’re using a debit card.
Use it to help pay for things like copays, coinsurance and deductibles! How do I sign up?
3. Use mobile pay — when you’re in a store that uses
The easiest way is to enroll through the PayForward app. You mobile pay, just click the notification or open the
can also register online at payforward.com, just click “Sign PayForward app to pay in seconds.
up” in the upper right corner of your screen to
get started. Where can I shop to earn cash back?

You’ll need a few things to verify that you’re an Anthem PayForward has 60,000 participating retailers, and the list
member, like your zip code and date of birth. You’ll also is growing. This includes retailers like Home Depot, The
need the information to link any eligible1 debit or credit Gap and Target.com and more.2 For local merchants, enter
card(s) you already have. It only takes a few minutes, and your zip code or city in the app or online, and it will show
then you can start earning rewards. you the participating retailers in the area.

The best part? This program is absolutely free to join — Here’s how to sign up: How much can I earn?
and you won’t find it with any other health plan. For more
details, check out our video at payforward.com 1. Register through the PayForward app or online at You can earn up to 15% cash back on purchases at
payforward.com PayForward’s participating stores. There is no maximum on
how much cash back you can earn!
2. Link up your existing eligible3 debit or credit cards.
3. Shop away and watch rewards roll in.

1 Cash back is awarded at the time a transaction posts to PayForward, not when the purchase is made. Please see legal disclosures at payforward.com for details. 67324CAMENABC VPOD Rev. 09/17
2 Examples of brands currently undergoing approval process.
3 Most types of Visa or MasterCards and signature-based transactions at participating merchants are eligible for the PayForward cash back program. Please see legal disclosures at payforward.com for details.
Anthem Blue Cross is the trade name of Blue Cross of California. Anthem Blue Cross and Anthem Blue Cross Life and Health Insurance Company are independent licensees of the Blue Cross Association. ANTHEM is a registered trademark of Anthem Insurance Companies, Inc.

65925CAMENABC VPOD Rev 09/17

How can I use my cash back? How do I send money to a friend or family member? Overview of Benefits: Date Prepared: 01-12-2018
The Preferred Dentist Program was designed to help you get the dental care you need and help lower your costs.
You can use it three different ways: Log into your account online at payforward.com. Click the
magnifying glass in the upper right corner, then enter a You get benefits for a wide range of covered services — both in and out of the network. The goal is to deliver
1. Spend it — If you use mobile pay, you can use your friend or family member’s name in the search box. Click on
rewards to cover part or all of your purchase. their name, then “Send Money.” They must be a PayForward affordable protection for a healthier smile and a healthier you.
member.
2. Save it — Link a bank account, then transfer funds back Coverage Type In-Network: Out-of-Network:
and forth anytime. You can also save funds to your If they are an Anthem member but haven’t joined % of Negotiated Fee % of R&C Fee1
Anthem Health Wallet. You can have some or PayForward yet, select “Invite/Suggest” to establish a Type A
all of your rewards transferred there and use it to connection. Once you are connected, you can send money Type B 100% 100%
help pay for health care costs such as copays, through the app or website.
deductibles, medications, and more. 80% 80%
How can I check my rewards balance?
3. Share it — You can transfer funds to a friend or You can check your balance on the PayForward app or Type C 50% 50%
family member who is also a PayForward member, or online at payforward.com.
donate it to charity. Orthodontia 50% 50%
Can I keep earning rewards if I switch plans? $50 (Type B & C) $50 (Type B & C)
Do I need a special credit or debit card? Deductible:
Yes, you can continue earning rewards from PayForward Individual/Family* $2000 $1500
No, you can use any eligible1 credit or debit card you as long as you are an Anthem member in an eligible plan. Annual Maximum
already have. However, no other health care carrier offers this program, Benefit: Per Individual $1500 $1500
so if you switch to another insurer, you will no longer be Orthodontia Lifetime
Can I link a credit or debit card that has other rewards, able to earn rewards. But any rewards you’ve already earned Maximum: Per Ortho applies to Adult and Child (Up to dependent age limit)
like miles or cash back? are yours to keep. Individual

Yes! You can continue earning any rewards your card Is it available for all Anthem members? Understanding Your Dental Benefits Plan
already offers AND PayForward’s at the same time.
PayForward is available to Anthem members who have a With the MetLife Preferred Dentist Program you can visit the dentist of your
How soon after I shop do I earn my rewards? large or small group medical plan. Members who have an
Individual/Family, Medicare, Medicaid, or Specialty choice – an “in-network” dentist (a participating MetLife dentist) or an “out-of-
Most of the time, it will be posted to your account within standalone plan are not eligible at this time.
seconds of making your purchase. But it can sometimes take network” dentist.
longer, depending on when the retailer lets PayForward know How does the Anthem Health Wallet work?
you’ve made the purchase. Occasionally the merchant has  Plan benefits for in-network services are based on the percentage of the
some kind of delay in processing your transaction. But as When you sign up, you’ll automatically have an Anthem Health Negotiated fee –the fee that in-network dentists have agreed to accept as
soon as they post it to PayForward, the rewards are yours! Wallet set up in your account. A certain percentage of cash payment in full for covered services, subject to any co-payments,
back rewards will be automatically saved in your Anthem deductibles, cost sharing and benefit maximums. Negotiated fees are
How do I donate rewards to charity? Health Wallet. You can increase or decrease this percentage subject to change.
anytime, or move funds into or out of the wallet whenever you
You’ll find a list of charities on the PayForward app and like. Find yourself needing extra money to cover health care  Plan benefits for out-of-network services are based on a percentage of
online at payforward.com You can also set up a private or expenses? Just transfer the money you have saved in your the Reasonable and Customary (R&C) charge. If you choose a dentist
public cause to help with fundraising efforts — log into your wallet into your linked bank account. It’s that simple. who does not participate in the network, your out-of-pocket expenses may
account online, select “Causes,” then “Create Cause.” If you want be more, since you will be responsible for paying any difference between
to create a cause for a nonprofit or charitable organization, What if I need help or have more questions? the dentist's fee and your plan's payment for the approved service. Please
please email [email protected] or refer to the Selected Covered Services and Frequency Limitations page of
[email protected]. You can find more questions and answers online at support. this document for details regarding how R&C charges are defined under
payforward.com or contact PayForward Member Services this plan.
by email at [email protected] or by phone toll-free
at 844-944-9273. Certain plan benefits are based on a percentage of the negotiated fee. This is the amount that participating dentists
have agreed to accept as payment in full. If your plan benefits are based on a percentage of the Reasonable and
Customary (R&C) charges, your out-of-pocket expenses may be more, since you will be responsible for paying any
difference between the dentist's fee and your plan's payment for the approved service.

* If you are enrolled for dependent coverage, a maximum family deductible may apply.

Savings from enrolling in a dental benefits plan will depend on various factors, including the cost of the plan, how often participants visit the dentist
and the cost of services rendered.

1 Most types of Visa or MasterCards and signature-based transactions at participating merchants are eligible for the PayForward cash back program. Please see legal disclosures at payforward.com for details. © 2016 METLIFE, INC Page 1 of 7 Metropolitan Life Insurance Company, New York, NY
2 Examples of brands currently undergoing approval process. PEANUTS 2016 © United Feature Syndicate, Inc. L0717497231[exp0418][All States]
Anthem Blue Cross is the trade name of Blue Cross of California. Anthem Blue Cross and Anthem Blue Cross Life and Health Insurance Company are independent licensees of the Blue Cross Association. ANTHEM is a registered trademark of Anthem Insurance Companies, Inc.
2018-01-12_5576163_9999_9999 _Dental_19

Selected Covered Services and Frequency Limitations* payments may vary from the pretreatment estimate depending upon annual maximums, plan frequency limits, deductibles and
other limits applicable at time of payment.
Type A 1 in 6 months.
 Oral Examinations 1 in 6 months. 1. The Reasonable and Customary charge is based on the lowest of the: "Actual Charge" (the dentist’s actual charge); or "Usual Charge" (the
 Cleanings Children to age 14 / 1 in 12 months. dentist’s usual charge for the same or similar services); or "Customary Charge" (the 90th percentile charge of most dentists in the same geographic
 Fluoride Adult - 1 in 1 period / Children - 2 in 1 period separated by six area for the same or similar services as determined by MetLife).
months.
 Bitewing X-rays 1 in 60 months.
4 in 1 year less the number of teeth cleanings.
 Full Mouth X-rays
 Periodontal Maintenance 1 per tooth in 14 years of a dependent child up to 14th birthday.
 Space Maintainers
 Sealants (1st & 2nd permanent molars)
Type B
 Emergency Palliative Treatment

 Periodontal Root Planing & Scaling 1 per quadrant in any 24 months period.

 Periodontal Surgery 1 in 36 months.
 Amalgam & Composite Fillings No Limit. Composites covered on all teeth.
 Simple Extractions

 Root Canal

 Surgical Extractions

 Repairs (Crowns)

Type C 1 in 36 months.
 Crowns 1 in 10 years.
 Dentures 1 in 10 years.
 Bridges

 Implants 1 in 60 months.

Orthodontia
 Dependent children are covered up to their 26th birthday.

 All dental procedures performed in connection with orthodontic treatment are payable as Orthodontia.

 Payments are on a repetitive basis.

 20% of the Orthodontia Lifetime Maximum will be considered at initial placement of the appliance and paid based
on the plan benefit’s coinsurance level for Orthodontia as defined in the Plan Summary.

 Orthodontic benefits end at cancellation of coverage.

The service categories and plan limitations shown in this document represent an overview of your plan benefits, but
are not a complete description of the plan. Before making any purchase or enrollment decision you should review the
certificate of insurance which is available through MetLife or your employer. In the event of a conflict between this
overview and your certificate of insurance, your certificate of insurance governs. Like most group dental insurance
policies, MetLife group policies contain certain exclusions, limitations and waiting periods and terms for keeping them
in force. The certificate of insurance sets forth all plan terms and provisions, including all exclusions and limitations.

*Alternate Benefits: Your dental plan provides that if there are two or more professionally acceptable dental treatment alternatives
for a dental condition, your plan bases reimbursement, and the associated procedure charge, on the least costly treatment
alternative. If you and your dentist have agreed on a treatment that is more costly than the treatment upon which the plan benefit is
based, you will be responsible for any additional payment responsibility. To avoid any misunderstandings, we suggest you discuss
treatment options with your dentist before services are rendered, and obtain a pretreatment estimate of benefits prior to receiving
certain high cost services such as crowns, bridges or dentures. You and your dentist will each receive an Explanation of Benefits
(EOB) outlining the services provided, your plan’s reimbursement for those services, and your out-of-pocket expense. Actual

© 2016 METLIFE, INC Page 2 of 7 Metropolitan Life Insurance Company, New York, NY © 2016 METLIFE, INC Page 3 of 7 Metropolitan Life Insurance Company, New York, NY
PEANUTS 2016 © United Feature Syndicate, Inc. L0717497231[exp0418][All States] PEANUTS 2016 © United Feature Syndicate, Inc. L0717497231[exp0418][All States]

2018-01-12_5576163_9999_9999 _Dental_19 2018-01-12_5576163_9999_9999 _Dental_19

Exclusions

We will not pay Dental Insurance benefits for charges incurred for:
1. Services which are not Dentally Necessary, those which do not meet generally accepted standards of care for

treating the particular dental condition, or which We deem experimental in nature.
2. Services for which You would not be required to pay in the absence of Dental Insurance.
3. Services or supplies received by You or Your Dependent before the Dental Insurance starts for that person.
4. Services which are primarily cosmetic (For residents of Texas, see notice page section in your certificate).
5. Services which are neither performed nor prescribed by a Dentist except for those services of a licensed dental

hygienist which are supervised and billed by a Dentist and which are for:
 scaling and polishing of teeth; or
 fluoride treatments.
6. Services or appliances which restore or alter occlusion or vertical dimension.
7. Restoration of tooth structure damaged by attrition, abrasion or erosion.
8. Restorations or appliances used for the purpose of periodontal splinting.
9. Counseling or instruction about oral hygiene, plaque control, nutrition and tobacco.
10. Personal supplies or devices including, but not limited to: water piks, toothbrushes, or dental floss.
11. Decoration, personalization or inscription of any tooth, device, appliance, crown or other dental work.
12. Missed appointments.
13. Services:
 covered under any workers’ compensation or occupational disease law;
 covered under any employer liability law;
 for which the employer of the person receiving such services is not required to pay; or
 received at a facility maintained by the Employer, labor union, mutual benefit association, or VA hospital.
14. Services covered under other coverage provided by the Employer.
15. Temporary or provisional restorations.
16. Temporary or provisional appliances.
17. Prescription drugs.
18. Services for which the submitted documentation indicates a poor prognosis.
19. The following when charged by the Dentist on a separate basis:
 claim form completion;
 infection control such as gloves, masks, and sterilization of supplies; or
 local anesthesia, non-intravenous conscious sedation or analgesia such as nitrous oxide.
20. Dental services arising out of accidental injury to the teeth and supporting structures, except for injuries to the
teeth due to chewing or biting of food.
21. Caries susceptibility tests.
22. Initial installation of a fixed and permanent Denture to replace one or more natural teeth which were missing
before such person was insured for Dental Insurance, except for congenitally missing natural teeth.
23. Other fixed Denture prosthetic services not described elsewhere in this certificate.
24. Precision attachments.
25. Adjustment of a Denture
26 Appliances or treatment for bruxism (grinding teeth), including but not limited to occlusal guards and night
guards.1
27 Diagnosis and treatment of temporomandibular joint (TMJ) disorders. This exclusion does not apply to residents
of Minnesota. 1
28. Repair or replacement of an orthodontic device.1
29. Duplicate prosthetic devices or appliances.
30. Replacement of a lost or stolen appliance, Cast Restoration, or Denture.
31. Intra and extraoral photographic images.

1 Some of these exclusions may not apply. Please see your plan design and certificate for details.

© 2016 METLIFE, INC Page 4 of 7 Metropolitan Life Insurance Company, New York, NY
PEANUTS 2016 © United Feature Syndicate, Inc. L0717497231[exp0418][All States]

2018-01-12_5576163_9999_9999 _Dental_19

COMMON QUESTIONS… IMPORTANT ANSWERS • 12 months on all other Basic Services
• 24 months on Major Services
Who is a participating dentist? • 24 months on Orthodontia Services (if applicable)
A participating dentist is a general dentist or specialist who has agreed to accept MetLife's negotiated fees as
payment in full for services provided to plan participants. Based on internal analysis by MetLife, negotiated fees *If the policy holder participates in a section 125 plan and has an annual open enrollment period, the dental coverage will not be subject to any waiting periods. Please consult your Benefits
typically range from 15-45% below the average fees charged for the same services by dentists in the same Administrator or your certificate for this plan information.
geographic area.
Am I eligible for all benefits the first day of coverage?
*Negotiated Fees refers to the fees that in-network dentists have agreed to accept as payment in full for covered services, subject to any co- Your plan may include benefit waiting periods. Please refer to the certificate of insurance or your Benefits
payments, deductibles, cost sharing and benefits maximums. Negotiated fees are subject to change. Administrator for details about the services that are subject to the waiting periods and the length of time they apply.

How do I find a participating dentist? How can I learn about what dentists in my area charge for different procedures?
You can access a list of participating dentists with directions and mapping capabilities online at If you have MyBenefits you can access the Dental Procedure Tool. You can use the tool to look up average in- and
www.metlife.com/dental or call 1-800-ASK-4-MET (800-275-4638) to have a list faxed or mailed to you based upon out-of-network fees for dental services in your area. * You’ll find fees for services such as exams, cleanings, fillings,
the requested ZIP code. Please Note: Be sure to verify provider participation when you make your appointment. crowns, and more. Just log in at www.metlife.com/mybenefits.

May I choose a non-participating dentist? * The Dental Procedure Fee Tool application is provided by VerifPoint, an independent vendor. Network fee
Yes. You are always free to select the dentist of your choice. However, if you choose a dentist who does not information is supplied to VerifPoint by MetLife and is not available for providers who participate with MetLife through
participate in the MetLife program, your out-of-pocket expenses may be greater, since you will be responsible to pay a third-party. Out-of-network fee information is provided by VerifPoint. This tool does not provide the payment
for any difference between the dentist's fee and your plan's payment for the approved service. If you receive services information used by MetLife when processing your claims. Prior to receiving services, pretreatment estimates through
from a participating dentist, you are only responsible for the difference between the in-network fee for the service your dentist will provide the most accurate fee and payment information
provided and your plan's payment for the approved service. Please note: any plan deductibles must be met before
benefits are paid. Can MetLife help me find a dentist outside of the U.S. if I am traveling?
Yes. Through MetLife’s International Dental Travel Assistance program1 you can obtain a referral to a local dentist by
Can my dentist apply for participation in network? calling 1-312-356-5970 (collect) when outside the U.S. to receive immediate care until you can see your dentist.
Yes. If your current dentist does not participate in the MetLife network and you would like to encourage him or her to Coverage will be considered under your out-of-network2 benefits. Please remember to hold on to all receipts to submit
apply, tell your dentist to visit www.metdental.com, or call 1-877-MET-DDS9 for an application. The website and a dental claim.
phone number are designed for use by dental professionals only.
1 International Dental Travel Assistance services are administered by AXA Assistance USA, Inc. Certain benefits provided under the Travel
How are claims processed? Assistance program are underwritten by Virginia Surety Company, Inc. AXA Assistance and Virginia Surety are not affiliated with MetLife, and the
Dentists may submit your claims for you, which means you have little or no paperwork. You can track your claims services and benefits they provide are separate and apart from the insurance provided by MetLife. Referral services are not available in all
online and even receive e-mail alerts when a claim has been processed. If you need a claim form, you can find one locations.
online at www.metlife.com/dental or request one by calling 1-800-ASK-4-MET (800-275-4638). 2 Refer to your dental benefits plan summary your out-of-network dental coverage.

Can I find out what my out-of-pocket expenses will be before receiving a service?
Yes. With pre-treatment estimates, you never have to wonder what your out-of-pocket expense will be. MetLife
recommends that you request a pre-treatment estimate for services in excess of $300 (This often applies to services
such as crowns, bridges, inlays, and periodontics). To receive a benefit estimate, simply have your dentist submit a
request for a pre-treatment estimate online at www.metdental.com or call 1-877-MET-DDS9 (638-3379). You and
your dentist will receive a benefit estimate online or by fax for most procedures while you are still in the office so you
can discuss treatment and payment options and have the procedure scheduled on the spot. Actual payments may
vary depending upon plan maximums, deductibles, frequency limits and other conditions at time of payment.

Do I need an ID card?
No, you do not need to present an ID card to confirm that you are eligible. You should notify your dentist that you
participate in MetLife's PDP. Your dentist can easily verify information about your coverage through a toll-free
automated Computer Voice Response system.

Do my dependents have to visit the same dentist that I select?
No, you and your dependents each have the freedom to choose any dentist.

If I do not enroll during my initial enrollment period can I still purchase Dental Insurance at a later date?
Yes, eligible employees who do not elect coverage during their 31-day application period may still elect coverage
later. Dental coverage elected after the 31-day application period is subject to the following waiting periods:*

• No waiting period for Preventive Services
• 6 months on Basic Restorative (Fillings)

© 2016 METLIFE, INC Page 5 of 7 Metropolitan Life Insurance Company, New York, NY © 2016 METLIFE, INC Page 6 of 7 Metropolitan Life Insurance Company, New York, NY
PEANUTS 2016 © United Feature Syndicate, Inc. L0717497231[exp0418][All States] PEANUTS 2016 © United Feature Syndicate, Inc. L0717497231[exp0418][All States]

2018-01-12_5576163_9999_9999 _Dental_19 2018-01-12_5576163_9999_9999 _Dental_19

Life is
better in
focusT.M

Get access to the best in eye care and See why we’re consumers’ #1
eyewear with 741¥ 7JTJPO $BSF choice in vision care3.

As a VSP member, you have access to care from great eye Contact us. 800.877.7195
doctors, quality eyewear, and the affordability you deserve, vsp.com
all at the lowest out-of-pocket costs.
© 2016 METLIFE, INC Page 7 of 7 Metropolitan Life Insurance Company, New York, NY
PEANUTS 2016 © United Feature Syndicate, Inc. L0717497231[exp0418][All States] You’ll like what you see with VSP.

2018-01-12_5576163_9999_9999 _Dental_19 Value and Savings. You’ll enjoy more value and the lowest out-of-pocket
costs.

High Quality Vision Care. You’ll get the best care from a VSP network
doctor, including a WellVision Exam®—the most comprehensive exam
designed to detect eye and health conditions. Plus, when you see a VSP
network doctor, your satisfaction is guaranteed.

Choice of Providers. The decision is yours to make—choose a VSP
network doctor or any out-of-network provider.

Great Eyewear. It’s easy to find the perfect frame at a price that fits your
budget.

Using your VSP benefit is easy.

Create an account at vsp.com. Once your plan is effective, review your
benefit information.
Find an eye doctor who’s right for you. Visit vsp.com or call 800.877.7195.
At your appointment, tell them you have VSP. There’s no ID card
necessary. If you’d like a card as a reference, you can print one on
vsp.com.
That’s it! We’ll handle the rest—there are no claim forms to complete when
you see a VSP provider.

Choice in Eyewear

From classic styles to the latest designer frames, you’ll find hundreds of
options. Choose from featured frame brands like bebe®, Calvin Klein,
Cole Haan, Flexon®, Lacoste, Nike, Nine West, and more.1 Visit vsp.com to
find a Premier Program location that carries these brands. Plus, save up to
40% on popular lens enhancements.2 Prefer to shop online? Check out all
of the brands at eyeconic.com®, VSP's preferred online eyewear store.

Your VSP Vision Benefits Summary

VSP XJMM provide you with an affordable eye care plan.

VSP Coverage Effective Date: 01/01/2018 VSP Provider Network: VSP Choice Real Provider Choices

Benefit Description Copay Frequency Looking for a network that offers true freedom of
choice in providers and eyewear, while lowering
Your Coverage with a VSP Provider out-of-pocket costs for your employees?
You're looking for VSP® Vision Care.
WellVision Exam Focuses on your eyes and overall wellness $10 Every 12 months

Prescription Glasses $130 allowance for a wide selection of frames $25 See frame and lenses VSP Network Providers 81,000
Frame $150 allowance for featured frame brands Every 24 months
Lenses 20% savings on the amount over your allowance Included in Every 12 months Your employees can choose their provider from ACCESS POINTS
Lens Enhancements $70 Costco® frame allowance Prescription Every 12 months 81,000 access points, including the largest national
Single vision, lined bifocal, and lined trifocal lenses network of independent doctors and over 5,000 Participating Retail Chains
Polycarbonate lenses for dependent children Glasses participating retail chain locations.
Standard progressive lenses Your employees get the convenience of popular
Premium progressive lenses Included in • Special savings for lowest out-of-pocket costs. retail chains like these and more.
Custom progressive lenses Prescription • Extra $20 to spend on featured frame brands like
Average savings of 20-25% on other lens enhancements
Glasses bebe®, Calvin Klein, Cole Haan, Flexon®, Lacoste,
$55 Nike, Nine West, and more.

$95 - $105 VSP Doctors
$150 - $175
• 91% offer early morning, evening, and weekend
Contacts (instead of $130 allowance for contacts; copay does not apply Up to $60 Every 12 months appointments. 24-hour access to emergency care.
glasses) Contact lens exam (fitting and evaluation)
• Integrated medical management with our Eye
Primary Eyecare Treatment and diagnosis of eye conditions like pink eye, vision loss $20 As needed Health Management Program®.
and monitoring of cataracts, glaucoma and diabetic retinopathy.
Limitations and coordination with medical coverage may apply. Ask • VSP Premier Program gives members the most
your VSP doctor for details. out of their eye care experience at one location.

Extra Savings Glasses and Sunglasses
Extra $20 to spend on featured frame brands. Go to vsp.com/specialoffers for details.
20% savings on additional glasses and sunglasses, including lens enhancements, from any VSP provider within 12
months of your last WellVision Exam.

Retinal Screening
No more than a $39 copay on routine retinal screening as an enhancement to a WellVision Exam

Laser Vision Correction
Average 15% off the regular price or 5% off the promotional price; discounts only available from contracted facilities

Your Coverage with Out-of-Network Providers
Get the most out of your benefits and greater savings with a VSP network doctor. Your coverage with out-of-network providers will be less or you’ll
receive a lower level of benefits. Visit vsp.com for plan details.

Exam .............................................................................. up to $45 Lined Bifocal Lenses ........................................... up to $50 Progressive Lenses ............................................. up to $50
Frame ............................................................................ up to $70 Lined Trifocal Lenses ......................................... up to $65 Contacts .................................................................... up to $105
Single Vision Lenses ........................................... up to $30

VSP guarantees coverage from VSP network providers only. Coverage information is subject to change. In the event of a conflict between this information and your organization’s contract with VSP,
the terms of the contract will prevail. Based on applicable laws, benefits may vary by location. In the state of Washington, VSP Vision Care, Inc., is the legal name of the corporation through which VSP
does business.

Eyeconic® Direct Pay Convenience

Employees have the option to browse and It's simple for your employees to use their
buy online at eyeconic.com®, an easy-to-use, out-of-network VSP benefits at Walmart® and
convenient online eyewear option from VSP. Sam's Club®. Employees say, “I have VSP,”
Eyeconic seamlessly connects employees and we do the rest. Hundreds of frames are
with the latest designer eyewear and the covered-in-full.

VSP doctor network.

Contact us. 800.877.7195 | vsp.com Give your employees real provider choices with VSP.

1. Brands/Promotion subject to change. ©2017 Vision Service Plan. All rights reserved.
2. Savings based on network doctor's retail price and vary by plan and purchase selection; average savings determined after benefits are applied. Available only through VSP network doctors to VSP VSP, Eye Health Management Program, Eyeconic, and eyeconic.com are registered trademarks of Vision Service Plan. Flexon is a
members with applicable plan benefits. Ask your VSP network doctor for details. registered trademark of Marchon Eyewear, Inc. All other company names and brands are trademarks or registered trademarks of
3. Blueocean Market Intelligence National Vision Plan Member Research, 2014 their respective owners. 2114 VCCL
©2017 Vision Service Plan. All rights reserved.
VSP, VSP Vision care for life, eyeconic.com, and WellVision Exam are registered trademarks, and "Life is better in focus." is a trademark of Vision Service Plan. Flexon is a registered trademark of Marchon
Eyewear, Inc. All other company names and brands are trademarks or registered trademarks of their respective owners.

NCSTD1_Value�Employer Paid Short Term Disability Insurance
This this text box here. A post process uses the text above to do a
"Find/Replace" of variable text and the header.
Tempalte: NCSTD_BHS

�m�loyer Paid Short �erm Disability Insurance

Benefit Highlights

Desert Sands Public Charter

Save Up to 60% on Brand-name Hearing Aids What is em�loyer �aid Employer paid short term disability insurance pays you a portion of your earnings if you
short term disability miss time at work because of a disabling illness or in�ury.
Like vision loss, hearing loss can have a huge impact on your insurance? This highlight sheet is an overview of your employer paid short term disability insurance.
quality of life. However, the cost of a pair of quality hearing aids Once a group policy is issued to your employer, a certificate of insurance will be available
usually costs more than $5,000, and few people have hearing to explain your coverage in detail.
aid insurance coverage.
What is disability? Disability is defined in The Hartford’s contract with your employer. Typically, disability
means as a result of in�ury or sickness you are unable to perform with reasonable
continuity the essential duties necessary to pursue your usual occupation.

Am I eligible? You are eligible if you are an Active Full-Time Employee who works at least 30 hours per
week on a regularly scheduled basis.
TruHearing® makes hearing aids affordable by providing exclusive savings to
all VSP® Vision Care members. You can save up to 60% on a pair of hearing Here’s how it works: How much coverage Your employer provides coverage that would pay you a benefit of 60� of your weekly
aids with TruHearing. What’s more, your dependents and even extended would I have? earnings. The maximum employer paid short term disability insurance benefit you could
family members are eligible, too. Contact TruHearing. receive is �1,386 per week.
Call 877.396.7194. You and When can I enroll? Earnings are defined as in The Hartford’s contract with your employer.
In addition to great pricing, TruHearing provides you with: your family members must
• Three provider visits for fitting and adjustments mention VSP. As an eligible employee, you are automatically covered by employer paid short term
• 45-day trial disability insurance� you do not have to enroll.
• Three-year manufacturer warranty for repairs and one-time loss Schedule exam.
TruHearing will answer When is it effective? Coverage goes into effect sub�ect to the terms and conditions of the policy. You must be
and damage replacement your questions and schedule actively at work with your employer on the day your coverage takes effect.
• 48 free batteries per hearing aid a hearing exam with a How long do I have to wait Once you are approved for coverage, you will be eligible to collect your employer paid
local provider. before I can receive my short term disability insurance benefit starting on the 60TH day after your in�ury or 60TH day
Plus, with TruHearing you’ll get: benefit? of sickness. Your benefit could continue for up to 18 weeks.
• Access to a national network of more than 3,800 hearing Attend appointment. If I�m disabled� can the Yes. As described on the following page, your weekly short-term benefit may be reduced
The provider will perform a amount of my benefit be by other income you receive.
healthcare providers hearing exam, make a reduced?
• Straightforward, nationally-fixed pricing on a wide selection of the latest recommendation, order
the hearing aids through Im�ortant Details
brand-name hearing aids TruHearing, and fit them The following is an overview of your employer paid short term disability insurance. Once a group policy is issued to your
• Deep discounts on batteries shipped directly to your door for you. employer, a certificate of insurance will be available to explain your coverage in detail.

Best of all, if you already have a hearing aid benefit from your health plan
or employer, you can combine it with TruHearing prices to reduce your
out-of-pocket expense even more!

Learn more about this VSP Exclusive Member Extra at
truhearing.com/vsp or, call 877.396.7194 with questions.

The relationship between VSP and TruHearing is that of independent contractors. VSP makes no endorsement, representations JOB#5007-16-VCXA 6/16 The Hartford® is The Hartford Financial Services Group, Inc. and its subsidiaries including issuing companies Hartford 79815-0
or warranties regarding any products or services offered by TruHearing, a third-party vendor. TruHearing is solely responsible for Life Insurance Company, Hartford Life and Accident Insurance Company and Hartford Fire Insurance Company. Home
the products or services offered by them. Savings based on a survey of national average retail hearing aid prices compared to Office is Hartford, CT.
average TruHearing pricing. Actual customer savings will vary. Three follow-up visits must be used within one year after the date
of initial purchase. Forty-five-day trial and hearing aid returns, repairs, and replacements subject to provider and manufacturer Desert Sands Public Charter NCSTD BHS
fees. For questions regarding fees, contact TruHearing customer service. Not available in the state of Washington. 00079815
©2016 Vision Service Plan. All rights reserved.
VSP is a registered trademark of Vision Service Plan. All other brands or marks are the property of their respective owners. Creation Date: 1/17/2018
Page 1 of 2

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����������� NCLTD1_Value�Employer Paid Long Term Disability Insurance
You cannot receive employer paid short term disability insurance benefit payments for disabilities that are caused or This this text box here. A post process uses the text above to do a
contributed to by: "Find/Replace" of variable text and the header.
Template: NCLTD_BHS
• war or act of war (declared or not)
• the commission of, or attempt to commit a felony �m�loyer Paid �ong �erm Disability Insurance
• an intentionally self-inflicted in�ury
• any case where your being engaged in an illegal occupation was a contributing cause to your disability Benefit Highlights
• sickness or in�ury for which workers� compensation benefits are paid, or may be paid, if duly claimed
• any in�ury sustained as a result of doing any work for pay or profit for another employer Desert Sands Public Charter
You must be under the regular care of a physician to receive benefits.
Your benefit payments will be reduced by other income you receive or are eligible to receive due to your disability, such as: What is em�loyer �aid long Employer paid long term disability insurance pays you a portion of your earnings if you
• Social Security disability insurance (please see next section for exceptions) term disability insurance? miss time at work because of a disabling illness or in�ury.
• workers� compensation This highlight sheet is an overview of your employer paid long term disability insurance.
• other employer-based insurance coverage you may have Once a group policy is issued to your employer, a certificate of insurance will be available
• unemployment benefits to explain your coverage in detail.
• settlements or �udgments for income loss
• retirement benefits that your employer fully or partially pays for (such as a pension plan) What is disability? Disability is defined in The Hartford’s contract with your employer. Typically, disability
Your benefit payments will not be reduced by certain kinds of other income, such as: means that you cannot perform with reasonable continuity the essential duties necessary
• retirement benefits if you were already receiving them before you became disabled to pursue your usual occupation in the usual or customary way. Once you have been
• retirement benefits you start to receive that are funded by your after-tax contributions disabled for 24 months following the elimination period, you are unable to engage with
• your personal savings, investments, I��s or �eoghs reasonable continuity in any occupation.
• profit-sharing
• personal disability policies Am I eligible? You are eligible if you are an Active Full-Time Employee who works at least 30 hours per
• Social Security increases week on a regularly scheduled basis.
This benefit highlights sheet is an overview of the employer paid short term disability insurance being offered and is provided
for illustrative purposes only and is not a contract. It in no way changes or affects the policy as actually issued. Only the
insurance policy issued to the policyholder (your employer) can fully describe all of the provisions, terms, conditions, limitations
and exclusions of your insurance coverage. In the event of any difference between the benefit highlights sheet and the
insurance policy, the terms of the insurance policy apply.

How much coverage Your employer provides coverage that pays you a benefit of �0� of your earnings to a
would I have? maximum monthly benefit of ��,000 per month. This plan includes a minimum benefit of
the greater of: 10� of the benefit based on monthly income loss before the deduction of
When can I enroll? other income benefits or �100 per month. Earnings are defined as in The Hartford’s
contract with your employer.
As an eligible employee, you are automatically covered by employer paid long term
disability insurance� you do not have to enroll.

When is it effective? Coverage goes into effect sub�ect to the terms and conditions of the policy. You must be
How long do I have to wait actively at work with your employer on the day your coverage takes effect.
You must be disabled for at least 180 days before you can receive an employer paid long
before I can receive my term disability insurance benefit payment.
benefit?

Can the duration or Yes. Your benefit duration may be reduced once you reach certain ages as specified in
amount of my benefit be The Hartford’s contract with your employer. In addition, as described below within the
important details, your monthly long-term benefit may be reduced by other income you
reduced? receive.

Desert Sands Public Charter NCSTD BHS 79815-0 The Hartford® is The Hartford Financial Services Group, Inc. and its subsidiaries including issuing companies Hartford 79815-0
00079815 Life Insurance Company, Hartford Life and Accident Insurance Company and Hartford Fire Insurance Company. Home
Office is Hartford, CT.
Creation Date: 1/17/2018
Page 2 of 2 Desert Sands Public Charter NCLTD BHS
00079815
Version 11/12
Creation Date: 1/17/2018
Page 1 of 3

Version 11/12

How long will my If you become disabled prior to age 63, benefits may continue for as long as you remain This benefit highlights sheet is an overview of the employer paid long term disability insurance being offered and is
�i���ility ��yment� disabled or until the greater of your Social Security normal retirement age or 3.5 years. If provided for illustrative purposes only and is not a contract. It in no way changes or affects the policy as actually issued.
your disability occurs at age 63 or above, the number of payments may reduce. Only the insurance policy issued to the policyholder (your employer) can fully describe all of the provisions, terms,
continue? conditions, limitations and exclusions of your insurance coverage. In the event of any difference between the benefit
highlights sheet and the insurance policy, the terms of the insurance policy apply.

�m�o�t�nt �et�il�
The following is an overview of your employer paid long term disability insurance. Once a group policy is issued to your
employer, a certificate of insurance will be available to explain your coverage in detail.
��clu�ion��
You cannot receive employer paid long term disability insurance benefit payments for disabilities that are caused or
contributed to by:

• war or act of war (declared or not)
• the commission of, or attempt to commit a felony
• an intentionally self-in�icted in�ury
• any case where your being engaged in an illegal occupation was a contributing cause to your disability
You must be under the regular care of a physician to receive benefits.

�ent�l �llne��� �lco�oli�m �n� �u��t�nce ��u�e�
• You can receive benefit payments for long-term disabilities resulting from mental illness, alcoholism and substance abuse
for a total of 24 months for all disability periods during your lifetime.
• Any period of time that you are confined in a hospital or other facility licensed to provide medical care for mental illness,
alcoholism and substance abuse does not count toward the 24 months lifetime limit.

��e�e�i�ting �on�ition��
This policy will not provide coverage for any period of Disability beginning within the first 12 months of the effective date of
your coverage under this policy if the period of disability is caused by or substantially contributed to by a pre-existing
condition or the medical or surgical treatment of a Pre-existing condition.
You have a Pre-existing condition if:

• You received medical treatment, care or services for a diagnosed condition or took prescribed medication for a
diagnosed condition in the 3 months immediately prior to the effective date of coverage under this Insurance� or

• You suffered from a physical or mental condition, whether diagnosed or undiagnosed, which was misrepresented or
not disclosed in your application and

• for which you received a physician’s advice or treatment within 3 months before the date of your coverage under this
policy� or

• which caused symptoms within 3 months before the date of issue for which a prudent person would usually seek
medical advice or treatment.

Your benefit payments will be reduced by other income you receive or are eligible to receive due to your disability, such as:
• Social Security disability insurance (please see next section for exceptions)
• workers� compensation
• other employer-based insurance coverage you may have
• unemployment benefits
• settlements or �udgments for income loss
• retirement benefits that your employer fully or partially pays for (such as a pension plan)

Your benefit payments will not be reduced by certain kinds of other income, such as:
• retirement benefits if you were already receiving them before you became disabled
• retirement benefits that are funded by your after-tax contributions
• your personal savings, investments, I�As or �eoghs
• profit-sharing
• most personal disability policies
• Social Security increases

Desert Sands Public Charter NCLTD BHS 79815-0 Desert Sands Public Charter NCLTD BHS 79815-0
00079815 00079815

Creation Date: 1/17/2018 Creation Date: 1/17/2018
Page 2 of 3 Page 3 of 3

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EEBL1_Value�Basic Life and AD&D Insurance
This this text box here. A post process uses the text above to do a
"Find/Replace" of variable text and the header.
Template: Basic_Life_BHS_NE-FS

�asic �ife and AD�D Insurance

Benefit Highlights

Desert Sands Public Charter

What is basic life and Your employer provides, at no cost to you, basic life and AD&D insurance in an amount
AD�D insurance? e�ual to �50,000. Life insurance pays your beneficiary (please see below) a benefit if you
die while you are covered.
This highlight sheet is an overview of your basic life and AD&D insurance. Once a group
policy is issued to your employer, a certificate of insurance will be available to explain your
coverage in detail.

Am I eligible? You are eligible if you are an Active Full-Time Employee who works at least 30 hours per
week on a regularly scheduled basis.

When can I enroll? As an eligible employee, you are automatically covered by basic life and AD&D insurance�
you do not have to enroll. If you have not already done so, you must designate a
beneficiary as described below.

When is it effective? Coverage goes into effect sub�ect to the terms and conditions of the policy. You must be
actively at work with your employer on the day your coverage takes effect.

�enefit �eductions Your benefit will reduce by �5� at age �5, then by an additional �0� at age 70 and an
additional 20� at age 75. Reductions are based off of the already reduced benefit amount
and are rounded to the next higher increment of �500. All coverage cancels at retirement.

What is a beneficiary? Your beneficiary is the person (or persons) or legal entity (entities) who receives a benefit
payment if you die while you are covered by the policy. You must select your beneficiary
when you complete your enrollment application� your selection is legally binding.

The Hartford® is The Hartford Financial Services Group, Inc. and its subsidiaries including issuing companies Hartford 79815-0
Life Insurance Company, Hartford Life and Accident Insurance Company and Hartford Fire Insurance Company. Home
Office is Hartford, CT.

Desert Sands Public Charter Basic NE-FS Life BHS
00079815

Creation Date: 1/17/2018
Page 1 of 2

Version 11/12

���� �overage AD&D provides benefits due to certain in�uries or death from an accident. The covered Can I keep my Life coverage Yes, subject to the contract, you have the option of:
in�uries or death can occur up to ��5 days after that accident. The insurance pays if I leave my employer? • Converting your group Life coverage to your own individual policy (policies).
• If you leave your employer, Portability is an option that allows you to continue your Life
• 100� of the amount of coverage you purchase in the event of accidental loss of life, What is the Living Benefits
two limbs, the sight of both eyes, one limb and the sight of one eye, or speech and Option? Insurance coverage. To be eligible, you must terminate your employment prior to Social
hearing in both ears or �uadriplegia. Security Normal Retirement Age. This option allows you to continue all or a portion of your
Do I still pay my Life Life Insurance coverage under a separate Portability term policy. Portability is subject to a
• 75� for paraplegia or triplegia (paralysis of three limbs). Insurance premiums if I minimum of $5,000 and a maximum of $250,000 and does include coverage for your
• One-half (50�) for accidental loss of one limb, sight of one eye, or speech or hearing Spouse or Domestic Partner and Child(ren) . To elect Portability, you must apply and pay
become disabled? the premium within 31 days of the termination of your Life Insurance. Evidence of
in both ears or hemiplegia. Insurability will not be required.
• One-�uarter (25�) for accidental loss of thumb and index finger of the same hand or Dependent Spouse or Domestic Partner Portability is subject to a maximum of $50,000.
Dependent Child Portability is subject to a maximum of $10,000.
uniplegia.
�our total benefit for all losses due to the same accident will not be more than 100� of the If you are diagnosed as terminally ill with a 12 month life expectancy, you may be eligible to
amount of coverage you purchase. receive payment of a portion of your Life Insurance. The remaining amount of your Life
Insurance would be paid to your beneficiary when you die.
�an I �ee� �� �es, sub�ect to the contract, you have the option of:
life coverage if I leave • Converting your group life coverage to your own individual policy (policies). If you become totally disabled before age 60 and your disability lasts for at least 9 months, your
Life Insurance premium may be waived. The premium for your dependent’s coverage will also
�� e��lo�er� be waived if you are disabled and approved for waiver of premium. Coverage for your
dependents will end if the policy terminates.

What is the Living If you are diagnosed as terminally ill with a 12 month life expectancy, you may be eligible Important Details
�enefits ��tion� to receive payment of a portion of your life insurance. The remaining amount of your life As is standard with most term life Insurance, this Insurance coverage includes limitations and exclusions:
insurance would be paid to your beneficiary when you die.
• The amount of your coverage may be reduced when you reach certain ages.
I��ortant �etails • Death by suicide (two years).
As is standard with most term life insurance, this insurance coverage includes certain limitations and exclusions: Other exclusions may apply depending upon your coverage. Once a group policy is issued to your employer, a certificate of Insurance
• the amount of your coverage may be reduced when you reach certain ages. will be available to explain your coverage in detail.

AD&D insurance does not cover losses caused by or contributed by: This Benefit Highlights Sheet is an overview of the Insurance being offered and is provided for illustrative purposes only and is not a
contract. It in no way changes or affects the policy as actually issued. Only the Insurance policy issued to the policyholder (your
• sickness� disease� or any treatment for either� • in�ury sustained while in the armed forces of any employer) can fully describe all of the provisions, terms, conditions, limitations and exclusions of your Insurance coverage. In the event
• any infection, except certain ones caused by an country or international authority� of any difference between the Benefit Highlights Sheet and the Insurance policy, the terms of the Insurance policy apply.

accidental cut or wound� • taking prescription or illegal drugs unless prescribed
• intentionally self-in�icted in�ury, suicide or suicide for or administered by a licensed physician�

attempt� • in�ury sustained while committing or attempting to
• war or act of war, whether declared or not� commit a felony�

• the in�ured person�s intoxication.

Other exclusions may apply depending upon your coverage. Once a group policy is issued to your employer, a certificate of
insurance will be available to explain your coverage in detail.
This benefit highlights sheet is an overview of the insurance being offered and is provided for illustrative purposes only and is
not a contract. It in no way changes or affects the policy as actually issued. Only the insurance policy issued to the policyholder
(your employer) can fully describe all of the provisions, terms, conditions, limitations and exclusions of your insurance
coverage. In the event of any difference between the benefit highlights sheet and the insurance policy, the terms of the
insurance policy apply.

Desert Sands Public Charter Basic NE-FS Life BHS 79815-0 The Hartford® is The Hartford Financial Services Group, Inc. and its subsidiaries, including issuing companies Hartford Life Insurance Company and Hartford Life and Accident Insurance Company.
00079815 Policies sold in New York are underwritten by Hartford Life Insurance Company. Home Office of both companies: Simsbury, CT. All benefits are subject to the terms and conditions of the policy. Policies
underwritten by the issuing companies listed above detail exclusions, limitations, reduction of benefits and terms under which the policies may be continued in force or discontinued.
Creation Date: 1/17/2018
Page 2 of 2 Hartford Life and Accident Insurance Company (HLA) Newly Eligible
Rev 03/08
Version 11/12
34092-0
Page 3 of 8

VADDA1_Value|Voluntary Accidental Death and Dismemberment Insurance
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Voluntary Accidental Death and Dismemberment Insurance

Benefit Highlights

What is Voluntary Accidental Voluntary Accidental Death and Dismemberment Insurance pays your beneficiary (please see
Death and Dismemberment below) a death benefit if you die due to a covered accident while you are insured. It also pays
Insurance? you a benefit for certain accidental losses. Once a group policy is issued to your employer, a
certificate of Insurance will be available to explain your coverage in detail.
Why do I need Voluntary
Accidental Death and • Death benefits are paid in addition to any life Insurance benefits.
Dismemberment • Voluntary Accidental Death and Dismemberment Insurance pays benefits for accidental
Insurance?
What does Voluntary loss of limbs, thumb and index finger, speech, hearing, and sight.
Accidental Death and • Voluntary Accidental Death and Dismemberment Insurance covers losses that occur

Dismemberment Insurance away from work or at work. Benefits are paid regardless of any Worker’s Compensation
cover? benefits you collect.
This highlight sheet is an overview of your Voluntary Accidental Death and Dismemberment
What optional benefits has Insurance.
my Employer selected as
part of my Voluntary The need to protect yourself and your family from the financial consequences of a severe injury,
Accidental Death and paralysis or death resulting from an accident at or outside of work is real. According to the
Dismemberment National Safety Council, about one in eight Americans is seriously injured in an accident each
Insurance? year1. Accident Insurance from The Hartford shields you and your family from income loss
whether at home or away from home.
1 National Safety Council: Report on Injuries in America, 2005.

You may receive benefits due to certain losses or death from an accident. The covered losses
or death can occur up to 365 days after that accident. The policy pays for:

• 100% of the amount of coverage you purchase in the event of accidental loss of life, or
speech and hearing in both ears.

• One-half (50%) for accidental loss of one hand or foot, sight of one eye, or speech or
hearing in both ears.

• One-quarter (25%) for accidental loss of thumb and index finger of the same hand.
Additionally, your Employer may have elected optional/supplemental benefits as part of your
AD&D coverage. Refer to the certificate of Insurance for further information.
Your total benefit for all losses due to the same accident will not be more than 100% of the
amount of coverage you purchase.

• Seat Belt & Air Bag

The Hartford® is The Hartford Financial Services Group, Inc. and its subsidiaries, including issuing companies Hartford Life Insurance Company and Hartford Life and Accident Insurance Company.
Policies sold in New York are underwritten by Hartford Life Insurance Company. Home Office of both companies: Simsbury, CT. All benefits are subject to the terms and conditions of the policy. Policies
underwritten by the issuing companies listed above detail exclusions, limitations, reduction of benefits and terms under which the policies may be continued in force or discontinued.

Hartford Life and Accident Insurance Company (HLA) Newly Eligible
Rev 03/08

34092-0
Page 5 of 8

Am I eligible? You are eligible if you are an Active Full-Time Employee who works at least 30 hours per week Voluntary Accidental Death You may also choose Voluntary Accidental Death and Dismemberment Insurance for your
on a regularly scheduled basis. and Dismemberment Spouse or Domestic Partner and/or dependent Children. Dependent coverage is available only
Insurance for your when you elect coverage for yourself.
dependents You may choose Voluntary Accidental Death and Dismemberment Insurance for your Spouse
or Domestic Partner in the following amounts:
When can I enroll? You must elect coverage within 31 days of your eligibility waiting period which is first of the
When is it effective? month following one month of employment. • 50% of the amount you select for yourself if you do not have any Children whom you
cover under this Voluntary Accidental Death and Dismemberment Insurance policy.
How much Voluntary Coverage goes into effect subject to the terms and conditions of the policy. In no case will
Accidental Death and newly elected benefits become effective sooner than first of the month following one month of • 40% if you have Children whom you cover under this Voluntary Accidental Death and
Dismemberment Insurance employment. You must be Actively at Work with your employer on the day your coverage takes Dismemberment Insurance policy.
effect.
can I purchase? You may not elect coverage for your Spouse if your Spouse or Domestic Partner is already
Does my coverage reduce You can purchase Voluntary Accidental Death and Dismemberment Insurance in increments of covered as an Employee under this policy.
$10,000. You may choose guaranteed Voluntary Accidental Death and Dismemberment Insurance for
as I get older? The maximum amount you can purchase cannot be more than 5 times your annual Earnings or each Child up to age 21 (age 24 if a student) in the following amounts:
$500,000. Earnings are as defined in The Hartford’s contract with your employer.
• 15% of the amount you select for yourself if you do not have a Spouse or Domestic
Your benefit will reduce by 60% at age 75, and then by an additional 35% at age 80, 27% at Partner whom you cover under this Voluntary Accidental Death and Dismemberment
age 85, 20% at age 90, 15% at age 95 and 5% at age 100. Reductions are based off of the Insurance policy.
already reduced benefit amount..
• 10% if you have a Spouse or Domestic Partner whom you cover under this Voluntary
Accidental Death and Dismemberment Insurance policy.

Do I have to provide medical No medical information is required. You are guaranteed the amount of coverage that you Important Details
information to receive select, subject to maximum amounts defined in your policy. As is standard with most Insurance, this Voluntary Accidental Death and Dismemberment Insurance includes limitations and exclusions.
coverage? Voluntary Accidental Death and Dismemberment Insurance does not cover losses caused by or contributed by:

What is a beneficiary? Your beneficiary is the person (or persons) or legal entity (entities) who receives a benefit • Sickness; disease; or any treatment for either; • Injury sustained while in the armed forces of any
Are there other limitations to payment if you die while you are covered by the policy. You must select your beneficiary when • Any infection, except certain ones caused by an country or international authority;
you complete your enrollment application; your selection is legally binding.
enrollment? You are automatically the beneficiary for any dependent coverage and for any AD&D losses accidental cut or wound; • Taking prescription or illegal drugs unless
other than life. • Intentionally self-inflicted injury, suicide or prescribed for or administered by a licensed
physician;
This coverage, like most group benefit Insurance, requires that a certain percentage of eligible suicide attempt;
Employees participate. If that group participation minimum is not met, the Insurance coverage • War or act of war, whether declared or not; • Injury sustained while committing or attempting
that you have elected may not be in effect. to commit a felony;

• The injured person’s intoxication.

Other exclusions may apply depending upon the terms of your policy and other requirements. Once a group policy is issued to your
employer, a certificate of Insurance will be available to explain your coverage in detail.
This Benefit Highlights Sheet is an overview of the general purposes of the Voluntary Accidental Death and Dismemberment Insurance
being offered and is provided for illustrative purposes only and is not a contract. It in no way changes or affects the policy as actually
issued. Only the Insurance policy issued to the policyholder (your employer) can fully describe all of the provisions, terms, conditions,
limitations and exclusions of your Insurance coverage. In the event of any difference between the Benefit Highlights Sheet and the
policy, the terms of the Insurance policy apply.

The Hartford® is The Hartford Financial Services Group, Inc. and its subsidiaries, including issuing companies Hartford Life Insurance Company and Hartford Life and Accident Insurance Company. The Hartford® is The Hartford Financial Services Group, Inc. and its subsidiaries, including issuing companies Hartford Life Insurance Company and Hartford Life and Accident Insurance Company.
Policies sold in New York are underwritten by Hartford Life Insurance Company. Home Office of both companies: Simsbury, CT. All benefits are subject to the terms and conditions of the policy. Policies Policies sold in New York are underwritten by Hartford Life Insurance Company. Home Office of both companies: Simsbury, CT. All benefits are subject to the terms and conditions of the policy. Policies
underwritten by the issuing companies listed above detail exclusions, limitations, reduction of benefits and terms under which the policies may be continued in force or discontinued. underwritten by the issuing companies listed above detail exclusions, limitations, reduction of benefits and terms under which the policies may be continued in force or discontinued.

Hartford Life and Accident Insurance Company (HLA) Newly Eligible Hartford Life and Accident Insurance Company (HLA) Newly Eligible
Rev 03/08 Rev 03/08

34092-0 34092-0
Page 6 of 8 Page 7 of 8

SCHEDULE OF BENEFITS /
PLAN HIGHLIGHTS

Help protect your family’s financial future Your Long Term Care (LTC) insurance plan is listed below.

What is long term care? Elimination Period: Your plan’s Elimination Period of 90 consecutive days is the amount of time you must
It is the type of care you may need if — due to an accident or serious illness— you are unable wait before benefits become payable. This time period must be satisfied only once during the life of your plan.
to perform, without Substantial Assistance from another individual, two or more Activities of
Daily Living such as: Newly Hired Employees – once eligible for the plan, will have 30 days to sign up for Guarantee Issue
coverage. Please check with your employer for your effective date.
• Eating • Dressing
All Active Employees & Newly Hired Employees – who enroll after the Guarantee Issue enrollment period
• Bathing • Toileting or choose benefits over the Guarantee Issue limits will be required to fill out a medical questionnaire.
• Continence • Transferring
Medical Underwriting Effective Date – The effective date for those applicants passing medical underwriting
How does this coverage help? between the 1st and 15th of the month is the first of the month following their date of approval. For those
Long Term Care Insurance provides benefits to help you pay for care provided by: approved between the 16th and the end of the month, their effective date is the first of the second month
following their date of approval.
• Adult Day Care • Adult Day Care Facility Medical Underwriting means that you must answer all questions on a medical questionnaire. In some cases,
• Home Health Care • Alzheimer’s Facility an interview may also be necessary.

• Homemaker Services • Nursing Facility Delayed Effective Date – If you are absent from work because you are injured, sick, temporarily laid off or on
a leave of absence, your coverage will not begin on your otherwise expected effective date.

Medical Underwriting for Employees and Family: (Completion of the Benefit Election Form is required for
enrollment). EMPLOYEES: Your employer funded basic plan, as well as additional benefit amounts of up to
and including $6,000 and a Facility Benefit Duration of 3 or 6 years, is being offered on a Guarantee Issue
basis. This does not require completion of the Long Term Care Insurance Application (medical questionnaire)
if you apply during your initial eligibility period. The Long Term Care Insurance Application (medical
questionnaire) is required if enrolling after your initial eligibility period or if you choose to buy $7,000, $8,000 or
the Unlimited Duration coverage. All Family Members must complete the Benefit Election Form and Long
Term Care Insurance Application (medical questionnaire) and must be approved for coverage in order to enroll
in the Long Term Care plan. All Medical Questionnaires must accompany a signed Authorization to Request
Medical Information Form #6720-03-CA located in the enrollment kit.

• Hospice Services • Hospice Facility Benefit Duration 3 Years 6 Years Unlimited
• Personal Care • Residential Care Facility Duration
• Respite Care • Rehabilitation Facility Nursing Facility Benefit Amount $3,000 $3,000
Per $1,000 Increments to $8,000 to $8,000 $3,000
Residential Care Facility to $8,000
70% 70%
70%

What your employer is offering: Home and Community-Based Care 50% 50% 50%
Your employer is providing you with a Plan 1 Benefit amount up to $3,000/month with a
Benefit Duration of 3 years. This includes Nursing, Residential, Home & Community Based Home, Community-Based and Immediate 50% 50% 50%
Care.
Family Member Care - Option

Inflation Protection * - Option Compound Compound Compound

Uncapped Uncapped Uncapped
* If you selected an inflation option, and you terminate that inflation option at a future date, you can purchase
You have the option to enroll in additional coverage up to $8,000 with an unlimited Benefit the inflated coverage amount at your original age.
Duration. You can also elect coverage for your spouse and dependent children.
Lifetime Maximum: The Lifetime Maximum is the maximum benefit dollar amount Unum will pay over the life
*Guaranteed Issue: You can elect up to $6,000 monthly benefit without answering any of your coverage. This dollar amount is based on the Facility Benefit Amount and Benefit Duration. For
medical questions if you enroll within your initial eligibility period. Example: If you choose $3,000 Facility Monthly Benefit Amount & 3 Year Duration, your Lifetime Maximum is
calculated as follows, $3,000 per Month X 12 Months X 3 Years = $108,000 Lifetime Maximum.
*Evidence of Insurability: If you enroll in the period outside of your initial eligibility, an
evidence of insurability will be required. EOI is needed for all family coverage elected. Insurance Age: Insurance Age is used to determine the cost of your coverage. Insurance Age is your age on
the plan effective date if you enroll for coverage prior to the plan effective date. If you enroll for coverage on or
after the plan effective date, insurance age is your age on the date you sign the enrollment form.

Questions: Please call 1-800-227-4165 with questions regarding your Long Term Care Insurance.

How to enroll:
You can learn more about coverage for you and your eligible family members by visiting the
enrollment site: http://unuminfo.com/dspc/index.aspx





CRITICAL ILLNESS INSURANCE

not your finances HOSPITAL ADMISSION
BENEFIT
An antidote for expenses not covered by medical insurance
For Employees
Treatment of critical illnesses such as cancer, heart attack and stroke can lead to
unexpected expenses that create an additional financial burden. Critical Illness Fills the coverage and comfort
gap when a hospitalization
include travel to treatment centers, ongoing household bills, co-pays to occurs from a non-critical
experimental treatment, and everyday expenses like groceries, rent and illnesses:
mortgage.
Payment up to $250 per
How it works day that the insured is in
the hospital for any
Choose the level of coverage $5,000 to $25,000 that works best for you and condition other than a listed
your family. As an actively at work employee, you, your spouse and your critical illness
children can be covered (spouses and children covered at 50%).
Benefit duration:
10 days per year

Two day elimination period

Critical Illness insurance pays a lump-sum amount upon diagnosis of:

COVERED EVENTS STANDARD
1st Ever Occurrence 2nd Ever Occurrence

Cancer - Category 1 (invasive) 100% 50%

Heart Attack 100% 50%

Kidney Failure 100% 50%

Organ Transplant 100% 50%

Stroke 100% 50%

Cancer - Category 2 (non-invasive) 25% 0%

Coronary Artery Bypass Graft 25% 0%

This plan will also pay for additional occurrences*. The maximum benefit payable is 300% of the selected benefit
amount. Benefits reduce by 50% at age 70.

Group Number
503357

The Guardian Life Insurance Company of America, 7 Hanover Square, New York, NY 10004

GUARDIAN® and the GUARDIAN G® logo are registered service marks of The Guardian Life Insurance Company of America and are used with express permission.
Page 1 of 2
Group Number 503357 is offering Guardian Critical Illness Insurance to its employees.


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