Portsmouth Public Schools

Transcription

1 January thru December Plan Benefit Descriptions Portsmouth Public Schools Medical Reimbursement Dependent/Child Care Reimbursement Short Term Disability Insurance Life Insurance Cancer and Specified Disease Insurance Heart/Stroke Insurance Accident Insurance Critical Illness Insurance Vision Insurance Retirement Solutions Do not discard this booklet. Keep for future reference.

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3 TABLE OF CONTENTS What is a Section 125 Plan? Page 1 (This section will explain the following topics) **How does it work? **Who is eligible to participate? **How do I enroll? **What benefits are available under the plan to be pre taxed? Benefit Brochures First Financial Debit Card Page 8 Short Term Disability Page 19 Life Insurance Page 22 Cancer Insurance Page 49 Heart/Stroke Insurance Page 57 Critical Illness Insurance Page 64 Accident Insurance Page 69 Vision Page 77 Retirement Solutions Page 78 What are the costs of the benefits? Page 83 Portsmouth Public Schools has adopted a Section 125 Flexible Benefit Plan for all eligible employees. The purpose of this booklet is to provide you with a brief description of the Plan and the benefits available to you under the Plan. In the event that a conflict develops between this booklet and the terms of the Plan, the latter instrument must control since it is the legal instrument which actually constitutes the Plan. Although the employer currently intends to continue all of the benefits described in this booklet, the employer reserves the right to amend, reduce or terminate any of these benefits at any time.

4 WHAT IS A SECTION 125 FLEXIBLE BENEFIT PLAN? A Section 125 Flexible Benefit Plan allows you, the employee to spend benefit dollars for benefits that you choose to meet your needs. The benefits from which you may choose are listed later in this booklet. The benefits that you elect under the Plan are paid for with benefit dollars made available to you by your employer or through a salary reduction agreement with your employer. Salary reduction means that you are able to use "pre-tax" dollars to pay for certain benefits that you may have previously paid for with "after-tax" dollars. HOW CAN THIS PLAN HELP YOU? By implementing this Plan, your employer is helping you reduce your taxes and increase your spendable income. The cost saving advantage of the Plan is simple. Any benefit costs or insurance premiums you pay under the plan are paid on a pre-tax basis. The example below illustrates the advantage of the Section 125 Plan in comparison with a situation without the benefits of a Plan. The bottom line is that you may have more dollars available to you for the purchase of other benefits you may need or available to you as increased take-home pay. WITHOUT SECTION 125 WITH SECTION 125 Average Monthly Salary $2,000 Less Estimated Federal Withholding (20%) -400 $1,600 Less Insurance Premium(s) -200 Net Take-Home Pay $1,400 Less Out-of-Pocket "Flex" Expenses -50 Spendable Income $1,350 Average Monthly Salary $2,000 Less Qualified Insurance Premium(s) -200 Less Out-of-Pocket "Flex" Expenses -50 Taxable Income $1,750 Less Estimated Federal Withholding (20%) -350 Net Take-Home Pay/Spendable $1,400 Income 1

5 WHAT BENEFITS ARE AVAILABLE? The following benefits are available to you under the plan to be pre taxed: Expense Reimbursement Accounts: Medical Expense Reimbursement Dependent Care Expense Reimbursement Insurance Benefits: Cancer, Critical Illness, Heart/Stroke, Accident, Vision, Disability* and Life* * Coverage available outside Section 125 only * If maternity benefits are provided: Group health plans and health insurance issuers offering group insurance coverage generally, under federal law, may not restrict benefits for any hospital length of stay in connection with childbirth for the mother or newborn child to less than 48 hours following a normal vaginal delivery, or less than 96 hours following a caesarian section, or require that a provider obtain authorization from the plan or the insurance issuer for prescribing a length of stay not in excess of the above periods. WHO CAN PARTICIPATE IN THE PLAN? If you are a contract employee and work at least 20 hours per week, you are eligible for supplemental benefits, 20 hours for annuities. HOW MUCH DOES IT COST TO PARTICIPATE? There is no charge to participate in the Flex Accounts and no charge for the Debit Card. Rates for Supplemental Benefits both pre and post tax, are in the back of this booklet. 2

6 HOW DO I ENROLL IN THE PLAN? During the enrollment period, there will be group meetings scheduled for all employees to attend. These meetings will allow you the opportunity to hear a presentation concerning how the Plan works and information on the benefits available. Following the meeting, you will have the opportunity to visit with a representative from FFGA on a one-on-one basis concerning your individual needs. At this meeting, you will again have the opportunity to ask questions and you will complete an election form. This election form must be completed and signed by each employee, whether or not you wish to elect to participate in the benefit portion of the Plan. This is when you decide to waive all elections offered, elect new products and deductions or continue current deductions with no changes. CAN I STAY IN THE PLAN IF I AM ABSENT ON A FAMILY MEDICAL LEAVE? If you are absent from work on a leave of absence covered by the Family Medical Leave Act (FMLA) for periods totaling 12 weeks during the plan year, you are entitled to maintain the coverage you have under the Plan during your absence. Of course, you must pay the premiums for the coverage during your absence using one of the following methods: Prepayment: Under the prepayment option, you may (at your option) increase your salary reduction in an amount sufficient to cover the premiums that will come due during the FMLA leave. Pay-as-you-go: With the pay-as-you-go option, you continue to pay premiums on a regular basis through the FMLA leave. If you continue to receive your salary while you are gone, the premiums will be paid with pre-tax money as if you had not taken the leave. On the other hand, if your FMLA leave is unpaid and you choose this option, you will have to reimburse the Plan at regular intervals from your after-tax funds for the premiums that come due during the leave. The language above regarding the two payment methods assumes that both the prepayment and the pay-as-you-go methods are offered under the Plan. CAN I STAY IN THE PLAN IF I LEAVE OR RETIRE? If you leave Portsmouth Public Schools for any reason, you may take these products with you. You may pay for these in many different ways such as monthly bank draft, quarterly, semi annually or annually. Dental, Vision and Health are also available for continuation under COBRA guidelines. 3

7 PREMIUM CONVERSION The following insurance products may be purchased under the Section 125 Flexible Benefit Plan with the premiums paid on a pre-tax basis: Health, Cancer, Heart/Stroke, Accident, Critical Illness, Hospital Protection, Dental and Vision Enrolling in any of these benefits on the election form does not enroll you in the insurance product itself. In most cases, an insurance application to the company issuing the insurance product must also be completed. EXPENSE REIMBURSEMENT ACCOUNTS The following expense reimbursement accounts are available under the Section 125 Flexible Benefit Plan with your contributions to the account paid on a pre-tax basis: Dependent Care Expense Reimbursement Medical Expense Reimbursement IMPORTANT GUIDELINES FOR ENROLLMENT IN REIMBURSEMENT ACCOUNTS 1. Be sure that the amount set aside is conservative amounts not used for qualified expenses cannot be carried over or returned to you. 2. You cannot be reimbursed for these expenses from any other source. 3. All expenses to be reimbursed must be incurred in the plan year in which your contributions are made. 4. Expenses reimbursed under the Plan may not be used when calculating your medical expense deduction or the dependent care tax credit. 5. You have a 90-day grace period at the end of the plan year to request reimbursement of expenses you incurred during the plan year. 6. You should consult with your tax advisor concerning participation in the reimbursement accounts. 4

8 MEDICAL EXPENSE REIMBURSEMENT ACCOUNTS The Medical Expense Reimbursement Account can benefit you if you have any predictable out-ofpocket medical, dental or vision care expenses. Only expenses incurred for you or your dependents during the plan year may be reimbursed. For the Medical Expense Reimbursement Account, you will only be allowed to change your benefit election due to termination of your employment. HOW MUCH IS AVAILABLE FOR REIMBURSEMENT? The total amount of a qualified expense is available for reimbursement upon receipt of a voucher and original bill or receipt. The amount of the reimbursement, however, will not exceed the total contribution for the plan year less any reimbursements paid to date. Total reimbursements for the plan year will not exceed the contribution amount for the plan year. IS THERE A CONTRIBUTION LIMIT? Maximum amount available under the Medical Expense Reimbursement Account is $2550 per plan year. DEPENDENT CARE REIMBURSEMENT WHAT IS THE MAXIMUM I CAN CONTRIBUTE? In most cases, you may contribute up to $5,000 per year; however, that amount may be reduced if: 1. If you are married and file a separate tax return, the maximum contribution is $2, If you or your spouse earns less than $5,000 a year, the maximum contribution is equal to the lesser income amount. WHAT IS AVAILABLE FOR REIMBURSEMENT? Upon receipt of the voucher and acknowledgement form, you will be reimbursed for the expense you claimed up to the amount you have in your account. If your voucher is for an amount in excess of the amount in your account, the balance of the expense will be carried forward to future months as additional payments are received for your account. 5

9 TAX CREDIT ALTERNATIVE You should be aware that you may be able to take a federal tax credit on the amount you pay for dependent care expenses instead of participating in the dependent care expense reimbursement account. You cannot claim the tax credit for expenses that have been reimbursed through the plan. Please consult you tax advisor to determine which plan may be most advantageous to you. IMPORTANT TAX INFORMATION Regardless of whether you participate in the dependent day care plan under Section 125 or claim the credit on you income tax, you must provide the IRS with the name, address and taxpayer identification number (TIN) of your dependent day care provider(s) by completing Schedule 2 of Form 1040A or Form 2441 and attaching it to you annual income tax return. Failure to provide this information to the IRS could result in loss of the pre-tax exemption for your dependent day care expenses. 6

10 First Financial Group of America EMPLOYEE EXPENSE WORKSHEET EMPLOYER: NAME OF EMPLOYEE: SOCIAL SECURITY #: DATE OF BIRTH: MARITAL STATUS: NUMBER OF DEPENDENTS: ESTIMATED USE ONLY I.OUT-OF-POCKET MEDICAL EXPENSES: ANNUAL COST ELECTION Type of Expense $ Health insurance Deductibles Doctor Office Visits Over the Counter Medications Physicals Prescription Drugs Dental Costs (check-ups, cleaning, fillings) Orthodontia Costs (braces, exams, etc.) Vision & Eye Care (glasses, contacts) Surgery Other Health Related Expenses Specify TOTAL AVERAGE MONTHLY EXPENSE (divide total by 12 or number of months being paid if less than 12) II. DEPENDENT OR CHILD CARE EXPENSES: Child Care Expenses $ Other Employment Related DDC Costs TOTAL: AVERAGE MONTHLY EXPENSE (divide total by 12 or number of months being paid if less than 12) This is a worksheet only and does not obligate you in any way. If you decide to participate in either of the expense reimbursement accounts or in both of them, there may be a monthly administration fee to be payroll deducted. Remember that you should review you tax situation carefully as to the tax advantage of the dependent care tax credit compared with participation in the dependent care expense reimbursement portion of the Section 125 Flexible Benefit Plan. 7

11 SECTION 125 FLEXIBLE BENEFITS PLAN PARTICIPANT GUIDELINES FOR SPENDING ACCOUNTS - Medical Expense Reimbursement - Dependent Care Reimbursement PREPARED BY: First Financial Administrators, Inc. For your Employer s Plan 8

12 Section 125 Flexible Spending Account First Financial Administrators, Inc. WE ARE COMMITTED First Financial Administrators, Inc. is dedicated to providing excellent service to our customers and are delighted to serve as your cafeteria plan service provider. Our role is to process your requests for reimbursement according to the plan designed by your employer.» There are two types of Flexible Spending Accounts (FSAs): The first is unreimbursed medical (URM) and the second is dependent day care (DDC).» Your participation in an FSA program allows a portion of your salary to be redirected to provide reimbursement for these types of expenses on a tax-exempt basis.» At the beginning of each plan year, you elect a specific dollar amount for each FSA you wish to participate.» Participation in one or both FSAs can save you money by reducing your taxable income. This is because taxes will be calculated after the elected amount is deducted from your salary.» If applicable, your taxable income will be reduced for Social Security purposes; therefore, there may be a corresponding reduction In Social Security benefits.» Once you have elected your annual amount, you cannot change your election unless you experience a change in family status. See Election Irrevocability» To ensure that you are aware of your account balance at all times, we send a new explanation of benefits with each claim that is paid. The explanation of benefits will provide you with information regarding your account balance, claims paid to date, and claims pending.» We send notifications 45 days prior to the end of the plan year. The notification reflects your current available balance. You can view account information by logging into our secure website. FILING A CLAIM Before submitting your claim, make sure you have had the service(s). TO FILE YOUR CLAIM 1. Complete a claim form, and be sure to sign and date it. 2. Attach a legible receipt(s) from the service provided or an EOB (Explanation Of Benefits) showing:» A description of the service or a list of supplies furnished.» The charge(s) for each service.» The date(s) of service.» The name of the person(s) receiving the service.» The amount you are responsible for. 3. For convenient direct deposit, complete the Automatic Deposit Agreement form. Or use your FFA Benefits Card REQUESTING SERVICES (Toll-free) For Inquires: For Claim Forms: To Submit Claims by Fax:

13 General IRS Rules & Information The following rules apply to both URM and DDC FSAs ELECTION IRREVOCABILITY You may not make changes before the beginning of the next plan year unless there is a qualified change in status (as permitted by your plan) that affects Eligibility. Qualified changes in status may include:» Change in employee s legal marital status» Change in number of tax dependents» Change in employment status that affects eligibility» Dependent satisfies or ceases to satisfy eligibility requirements» Change in residence that affects eligibility» Judgment, decree, or court order dictating provision of coverage» Entitlement of Medicare or Medicaid (URM only)» Change in cost of the benefit (DDC only) Addition or elimination of benefit option Change in coverage of spouse or dependent under his/her employer s plan Significant curtailment of coverage If a change in status occurs, you may make changes consistent with the qualifying event or as otherwise defined by your plan document. See your plan Sponsor for further details about making changes. Dollar Limits Unreimbursed Medical Account: Your plan sponsor determines the maximum benefit that may be elected. Please see your employer for the maximum benefit amount allowed under your plan. Note: Due to Healthcare Reform, all URM Accounts will have an annual maximum of $2,500 starting January 1, Dependent Daycare Account: This reimbursement (when aggregated with all other dependent care reimbursements during the same calendar year) may not exceed the least of the following:» $5,000, or» $2,500, if married but filing separate tax returns Use-it-or-lose-it-Rule Money remaining in your FSA account(s) will not be returned to you at the end of the plan year. Any amount remaining after the end of the runoff or grace period, if your employer offers one, will be forfeited. Because of the use-it-or-lose-it rule, it is important for you to carefully estimate your out-of-pocket URM and DDC expenses for the upcoming plan year. TERMINATION OF EMPLOYMENT URM Account: Your salary redirections will end; however, you may still file claims for dates of service that were incurred within your employment period. You have 90 days after termination to submit a claim. DDC Account: If you have not received reimbursement for all contributions made to your DDC account upon termination, you have 90 days after the end of the plan year to submit a claim. COBRA COBRA does not apply to DDC. However, it may apply to your URM account and allow you to continue participation in your URM, thus allowing you to receive reimbursement for medical expenses incurred after your employment termination if:» The plan sponsor is subject to COBRA, and» When you terminate employment and you have contributed more for URM than you have received in URM benefits. Note: Under COBRA you must elect coverage within 60 days and continue to submit contributions to your employer to continue coverage under your URM account for the current year. 10

14 General IRS Rules & Information UNREIMBURSED MEDICAL FSA Almost every person has a number of necessary and predictable expenses that are not paid by their insurance plans. You can save money by putting that amount directly into your Unreimbursed Medical FSA. The FSA will help you pay for these predictable expenses with your pre-tax dollars. Please be aware of change in tax law Beginning Jan. 1, 2011, money from flexible spending accounts will no longer be available to pay for most over-the-counter drugs and medicines without a doctor s prescription. ELIGIBLE EXPENSES With the FSA, you can pay out-of-pocket health care expenses for yourself, your spouse and all of your eligibile dependents for health, dental, and vision care expenses. The services must be incurred while you are actively participating in the FSA plan. The eligible expenses may be reimbursed regardless of whether you, your spouse or dependents are covered by your employer s medical, dental, or health plan. Expenses for medical care will be limited to expenses incurred primarily for the prevention or improvement of a physical or mental defect or illness. An expense that is merely beneficial to your general health is not an eligible expense. It must be an expense to treat an existing medical condition. INELIGIBLE EXPENSES Some expenses that you incur during your plan year may not be eligible for reimbursement under current IRS regulations.» EXPENSES NOT YET INCURRED - Expenses that have been paid, but not yet incurred (i.e. Prepayment of service), cannot be reimbursed until the service is rendered. Expenses don t necessarily have to be PAID, but merely incurred.» PREMIUMS FOR INSURANCE - Premiums and payments to insurance policies are not eligible for reimbursement.» EXPENSES PAID BY ANOTHER PLAN OR THIRD PARTY - Expenses that have already been paid by an insurance company or other reimbursement through your FSA plan.» EXPENSES INCURRED AFTER TERMINATION/SEPARATION FROM YOUR EMPLOYER - If you are no longer participating in the FSA plan through your employer (termination, resignation, etc) any claims incurred after your participation ends are not eligible for reimbursement. COMMON ELIGIBLE EXPENSES» Co-Payments» Co-Insurance» Deductibles» Over-the Counter Drugs (with physician s prescription)» Dental Treatment» Orthodontia» Lab Fees» X-Rays» Vision Expenses» Lasik Surgery» Physical Therapy» Chiropractor Services» Acupuncture» Eye Contact Solution» Eye Drops COMMON INELIGIBLE EXPENSES» Cosmetic Surgery» Teeth Whitening» Veneers» Botox» Non Prescribed Vitamins and Supplements» Toiletries» Medical Insurance Premiums» Health Club Membership Fees 11

15 General IRS Rules & Information EXAMPLES OF ELIGIBLE MEDICAL CARE EXPENSES The following lists are examples of the types of expenses that may or may not be reimbursed. These lists are not intended to be complete, as other expenses may also be eligible or ineligible under federal tax law or under employer s plan. To be eligible under an FSA URM account, the medical expense(s) must be incurred for medical care that is not reimbursed from any other source. Medical care means the drug or service is needed to treat a medical condition. First Financial Administrators, Inc. may request additional information from you to substantiate that an expense is for health care. ELIGIBLE MEDICAL EXPENSES INELIGIBLE EXPENSES» Acupuncture» Alcohol and drug rehabilitation expenses» Ambulance» Anesthetist» Artificial limbs and teeth» Birth control pills» Blood donor (expense)» Chiropodist» Chiropractor» Christian Science Practitioners» Certain corrective surgery» Contact lens solution and cleaner» Co-payment for health insurance» Dental care and dentures» Drugs and medical supplies» Examinations» Eye exam, eyeglasses, and contacts» Gynecologist» Hearing aids and batteries» Home health care» Hospital and skilled nursing facility expenses» Laboratory fees» Lip-reading lessons» Midwife» Nursing care» Obstetrical expense» Oculist» Operations and related treatments» Optometrist» Orthodontist**» Osteopath» Outpatient clinic» Over-the-Counter Medications (with physician s prescription)» Pediatrician» Physician» Podiatrist» Practical nurse» Prescription drugs» Psychiatrist» Psychologist» Rental or purchase of medical equipment, including special equipment for use by handicapped persons» Sanitarium» Stop Smoking Programs and Drugs» Support or corrective devices» Surgery» Therapy» Transportation expenses» Weight Loss for Obesity*» X-ray» Dancing or swimming lessons» Medications purchased outside US» Expenses reimbursed under any health plan or other source» Health Club Dues» Face creams, moisturizers, etc.» Hair removal treatments/waxes» Vacation» Cosmetic Surgery» Teeth Whitening» Vitamins taken for overall health» OTC Medications not for Medical Care» Toothpaste/Toothbrushes» Mouth washes, oral anesthetics, etc. * This service requires a letter of medical necessity with a diagnosis from the referring physician. ** Requires an active orthodontia contract be on file. 12

16 General IRS Rules & Information The following rules apply to both URM and DDC FSAs DEPENDENT CARE FSA The Dependent Care FSA allows you to pay for day care expenses for your qualified dependent/child with pre-tax dollars while you (and your spouse) are working, seeking employment, or attending school as a full-time student for at least 5 months during the year. ELIGIBILITY REQUIREMENTS Eligible dependents must be claimed as an exemption on your tax return. These dependents can include step-children, grandchildren, adopted children, or foster children. In a divorce situation, you must have custody of the child in order for the child to be considered an eligible dependent. Under IRS regulations, eligible dependents are further defined as: under the age of 13, and/or physically or mentally unable to care for themselves, such as a disabled spouse, disabled child, or elderly parents that live with you. ELIGIBLE EXPENSES Eligible dependent care expenses are those expenses you must pay for the care of a dependent so that you and your spouse can work. The care may be provided in your home or at a licensed center outside of your home. If the care is in your home, the service cannot be provided by another child of yours under the age of 19, by your spouse, or by your dependents. INELIGIBLE EXPENSES Only those dependents care expenses that enable you and your spouse to work are eligible. Some expenses that you incur during your plan year may not be eligible for reimbursement under current IRS regulations» Educational Costs» Weekends/Evening-out babysitting» Transportation, books, clothing, food, activities, entertainment, and registration fees are ineligible if these expenses are shown separately on your bill COMMON ELIGIBLE EXPENSES» Day Camps» Before/After School Care» Babysitters/Day Care Centers» Au Pair» Nanny» Nursery School COMMON INELIGIBLE EXPENSES» Registration Fees» Care for child while not working» Kindergarten» Food/Activity expenses if separate from cost of care» Care provided by anyone under age 19» Pre-School» Books and Supplies» Field Trips 13

17 Claims Information THE REIMBURSEMENT PROCESS REIMBURSEMENTS- The healthcare/medical FSAs are pre-funded; therefore, you are eligible to receive reimbursement up to your elected annual contribution from the beginning of your FSA plan year. The healthcare/medical FSA funds that are reimbursed to you will be recovered as your deductions are taken from your paycheck throughout the plan year. Dependent Care FSAs are NOT pre-funded; therefore, you will only receive reimbursement up to your year-to-date contributions from payroll deductions. The remainder of the reimbursement request is paid when additional funds are received from payroll deductions. PAYMENT METHOD CHOICE- For Unreimbursed Medical expenses you may pay with your FFA Benefits Flex Card at the time you incur the expense, or pay the provider out-of-pocket and file a manual (paper) claim to receive a reimbursement. The FFA Benefits Flex Card is only available for Healthcare/Medical FSAs. MANUAL CLAIMS-To obtain reimbursement from your FSA, you must complete a manual claim form and attach all itemized receipts from the service provider. Cancelled checks, bankcard/credit card receipts, and credit card statements are NOT acceptable forms of documentation. The receipt must come from the service provider or the Explanation of Benefits from your medical health carrier and must include the following information:» Patient name» Date of service incurred» Provider / Merchant name» Amount of your out-of-pocket charge incurred» Type of service incurred» Must include prescription number REMEMBER-You must sign and date all claim forms. FFGA recommends submitting an Explanation of Benefits (EOB) from your insurance company, if available. CLAIMS PROCESSING AND PAYMENTS All claim reimbursements are handled with strict adherence to IRS adjudication and reporting regulations. Claims are processed daily, and our turn around time upon receipt is 3-5 business days and during peak periods (December-March) 5-10 business days. Your reimbursement check will be mailed to your home address on file. You may also elect to receive payment via direct deposit. You have a 2 ½ month grace period (employer permitting) to incur claims with an additional 2 weeks to file claims. Online Service to View Account Information, visit 14

18 FFA Benefits Flex Card Medical reimbursement accounts only BENEFITS FLEX CARD The First Financial Administrators, Inc. Benefits Flex Card is available for Medical Reimbursement Flexible Spending Accounts. Cards can be issued to spouses and dependent children (ages 18 to 26) for no additional fee. The initial cards are free, but if a replacement card is issued, the cost is $10.00 per card and will be deducted from your account balance. Cards are good for three years from the issue date as long as you participate each consecutive plan year. Claims can also be submitted directly for reimbursement. If funds remain in your account after the end of the plan year, you may use the debit card during the 2½ month grace period (if your employer has elected to participate in the grace period option). The system will deduct all remaining funds from your old plan year and then deduct any balance from the new plan year, if you continue to participate. New cards (not replacement cards) are only activated with the upcoming plan year -- they are not activated to use money from the prior plan year. The IRS requires validation of most transactions you must submit receipts for verification of expenses when requested. If you fail to substantiate by providing a receipt to us within 60 days of purchase, your card will be suspended until the necessary receipt or explanation of benefits from your insurance provider is received. Claim forms can be found on our website, Copies can either be mailed to: First Financial Administrators, Inc. P.O. Box Houston, TX or faxed to: (800) WHERE TO USE YOUR DEBIT CARD FOR ELIGIBLE UNREIMBURSED MEDICAL EXPENSES:» Pharmacies always use your debit card at the pharmacy counter only.» In-Store Pharmacies If merchant code is programmed pharmacy, the expense will be authorized. However, if the MasterCard transaction code is programmed grocery/retail, the transaction may be denied. The debit card may not work, and the expense may be declined in some grocery/discount stores. (Your FFA Benefits Flex Card cannot be used past your termination date. If you have available funds in your account, a manual claim will be required.) First Financial Administrators, Inc. can provide you with a list of eligible expenses associated with your Medical Reimbursement Flexible Spending Account. This card is a signature debit card and does not require a PIN for use. Transactions must always be submitted as credit. Participants may review Flexible Spending Account balances online at CALL (866) 853-FLEX FOR MORE INFORMATION.» Physician Offices» Specialist Physician Offices» Dental Offices» Over-the-counter drugs (must be accompanied by a Physician s Rx)» Vision Care Providers» Medical Facilities» Medical Clinics» Hospitals, including Emergency Rooms 15

19 Flexible Benefits Reimbursement Voucher PO Box , Houston, TX Telephone: (866) Fax: (800) PARTICIPANT INFORMATION ADDRESS CHANGE? Yes No NAME MAILING ADDRESS CITY STATE ZIP COMPLETE ONLY FOR DEPENDENT CARE PROVIDER NAME ADDRESS CITY STATE ZIP SS # TAX ID # SIGNATURE OF PROVIDER EMPLOYER SOCIAL SECURITY # ADDRESS TELEPHONE ( ) COMPLETE ONLY FOR ORTHODONTIA REIMBURSEMENT NAME AMOUNT DUE $ DATE SERVICE PERFORMED I certify that the dental procedure for the above patient HAS BEEN COMPLETED IS IN PROGRESS SIGNATURE OF DENTIST / ORTHODONTIST BENEFIT TYPE (please check as appropriate) MEDICAL REIMBURSEMENT DEPENDENT CARE REIMBURSEMENT PREMIUM REIMBURSEMENT DATE OF SERVICE FAMILY MEMBER DESCRIPTION OF EXPENSE AMOUNT GRAND TOTAL ALL PAGES $0.00 IMPORTANT NOTICE Effective January 1, 2011, all over-the-counter drugs eligible for reimbursement must be accompanied by a doctor s prescription and a reimbursement voucher. ADDITIONAL FORMS AVAILABLE AT: and click on Participant Forms I hereby affirm that, to the best of my knowledge, all expenses listed above are eligible for reimbursement under Section 105(h) or 129 of the IRS Code and in accordance with my contract with First Financial Administrators, Inc. I further certify that these expenses have not been, nor will not be, reimbursed under any other health plan coverage. If you need verification of the eligibility of an expense, please contact First Financial Administrators, Inc. at Please send me additional envelopes (additional voucher given with every reimbursement) NOTE: If you have direct deposit, First Financial Administrators, Inc. will not pay bank charges for Insufficient funds. Please call your financial Institution to verify deposit before writing any checks on the amount SIGNATURE DATE Mail or Fax Completed Form To: First Financial Administrators, Inc. P.O. Box , Houston, TX Fax Number:

20 Reimbursement Itemization Continued DATE OF SERVICE FAMILY MEMBER DESCRIPTION OF EXPENSE AMOUNT SUB-TOTAL THIS PAGE $0.00 MEDICAL REIMBURSEMENT SUBMISSION GUIDELINES: ACCEPTABLE DOCUMENTATION to accompany the reimbursement voucher: 1. Professional bill or receipt that includes:» Provider of service» Type of service rendered» Original date of service» Charges for the service 2. Insurance company Explanation of Benefits 3. Pharmacy statement that includes Rx number and name of the prescription DAYCARE SUBMISSION GUIDELINES: ACCEPTABLE DOCUMENTATION to accompany the reimbursement voucher: 1. Vouchers for Dependent Care signed by the Provider. Voucher must also be completed with the Provider s tax identification number or Social Security number and dates of service, Or Voucher with receipt from Provider, including Provider name, Provider signature, dates of service, amount for service, and tax identification/social security number. I.R.S Regulations prevent us from reimbursing dependent care yearly contracts. Monthly submissions are required. UNACCEPTABLE DOCUMENTATION 1. Cancelled checks / Credit card receipts 2. Bill or receipt that only shows a balance forward or previous balance 3. Cash register receipt Note: It is important to note that the date of service, not the date of payment, must fall within the dates of the plan year for which you are enrolled. 17

21 Debit Card Agreement Medical reimbursement accounts only I ACCEPT RESPONSIBILITY FOR THE FOLLOWING: All card transactions will be solely for qualified expenditures incurred (not billed or paid) during the plan year; To the extent that if I misrepresent any card transaction as a qualified expenditure when it is a non-qualified expenditure, I hold you harmless for whatever penalties and consequences that may occur as a result of my actions; If I misrepresent any card transaction on a non-qualified expenditure, I must immediately repay all expenses to the account upon notification; if not repaid, I understand the amount will be considered taxable income. I agree to submit expense receipts to the third party administrator for all purchases when requested; If failure to substantiate, card will be suspended. Each time I present the card for payment, I will sign a receipt evidencing that the expense has been incurred and reaffirming my representation that it is a qualified expenditure that has not been and will not be reimbursed from any other source. DEBIT CARD VALID FOR 3 YEARS OF CONTINUAL PARTICIPATION PLEASE PRINT SCHOOL DISTRICT NAME SOCIAL SECURITY NUMBER MAILING ADDRESS CITY / STATE / ZIP DAYTIME TELEPHONE NUMBER ADDRESS SIGNATURE DATE ADDITIONAL CARDS DEPENDENT CARDS ISSUED TO SPOUSES AND/OR DEPENDENT CHILDREN (AGES 18-26) NAME RELATIONSHIP DATE PLEASE MAIL COMPLETED FORM TO: FIRST FINANCIAL ADMINISTRATORS, INC. PO BOX , HOUSTON TX PHONE: OR FAX:

22 Disability Income Plus Virginia Disability Income Plus provides a monthly disability income benefit as a result of a non-occupational off-the-job accident or sickness. If you re totally disabled by an accident or illness, Disability Income Plus can be there to help, helping pay the bills that won t go away just because you can t work: housing costs, food, car payments, and additional medical costs. You can focus on a full recovery and successful return to the workplace. Coverage type Disability Income Plus is a group disability income insurance policy that provides a monthly disability income benefit due to a non-occupational off-the-job accident or injury. Benefit amount Minimum benefit of $200 and maximum benefit of $3,000 per month ($5,000 for Superintendents and County Administrators), not to exceed 65% of base monthly income. Plan design Accident & Sickness: Provides coverage for disabilities caused by either an accidental injury or sickness. Pregnancy is covered the same as any other illness. Twelve months Benefit period Elimination period Definition of disability Provides non-occupational coverage for injuries after 0, 7, 14 or 30 days and off-the job sicknesses after 7, 14 or 30 days of total disability (depending on your selection). Total disability: the complete inability to perform the material and substantial duties of the employee s regular occupation as certified by the employee s attending physician. Regular occupation is that which the employee was performing immediately before total disability began. The total disability must be the result of and accident, if accident only coverage is show in the policy specification, or accident or sickness, if accident and sickness coverage is shown in the policy specifications. The employee must be under the regular care of a physician and not, in fact, engaged in any employment or occupation for wages or profit. Recurrent disability: total disability that is due to the same or related causes as a prior period of disability, follows a prior period for which a monthly benefit was paid, and occurs within 180 days after the end of a prior period for which a monthly benefit was paid. Presented by Bill Mode Frequency Action Monthly Semi-Monthly Divide modal premium by 2 Monthly Bi-Weekly Multiply modal premium by 12, then divide by 26 Monthly Weekly Multiply modal premium by 12, then divide by 52 Thirteenthly (Billed every 28 days) Bi-Weekly Divide modal premium by 2 Thirteenthly (Billed every 28 days) Weekly Divide modal premium by 4 Tenthly Monthly for 10 Months Multiply modal premium by 12, then divide by Pay Semi-monthly for 10 Months Multiply modal premium by 12, then divide by 20 Ninthly Monthly for 9 Months Multiply modal premium by 12, then divide by 9 This is not a complete disclosure of plan qualifications and limitations. Please access our website to obtain a completed list for the Workplace Voluntary Benefit products at Disclosure.Humana.com. Please review this information before applying for coverage. The amount of benefits provided depends on the plan selected. Premiums will vary according to the selection made. THIS POLICY PROVIDES LIMITED BENEFITS. Policy: 8000 Insured by Kanawha Insurance Company, a Humana company HumanaVoluntaryBenefits.com VAHJEK8EN 19

23 Disability Income Plus rates Disability Income plus rates Monthly deductions for a 12 month benefit period with 0/7 accident/sickness elimination period. Age Benefit Amount BENEFIT: $200 $300 $400 $500 $600 $700 $800 $900 $1,000 $1, $7.72 $11.58 $15.44 $19.31 $23.17 $27.03 $30.89 $34.75 $38.61 $ $11.24 $16.86 $22.48 $28.10 $33.73 $39.35 $44.97 $50.59 $56.21 $ $17.40 $26.10 $34.80 $43.51 $52.21 $60.91 $69.61 $78.31 $87.01 $95.71 BENEFIT: $1,200 $1,300 $1,400 $1,500 $1,600 $1,700 $1,800 $1,900 $2,000 $2, $46.33 $50.19 $54.05 $57.92 $61.78 $65.64 $69.50 $73.36 $77.22 $ $67.45 $73.07 $78.69 $84.31 $89.94 $95.56 $ $ $ $ $ $ $ $ $ $ $ $ $ $ BENEFIT: $2,200 $2,300 $2,400 $2,500 $2,600 $2,700 $2,800 $2,900 $3, $84.94 $88.80 $92.66 $96.53 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ Monthly deductions for a 12 month benefit period with 7/7 accident/sickness elimination period. Age Benefit Amount BENEFIT: $200 $300 $400 $500 $600 $700 $800 $900 $1,000 $1, $7.61 $11.42 $15.22 $19.03 $22.84 $26.64 $30.45 $34.25 $38.06 $ $11.07 $16.60 $22.13 $27.67 $33.20 $38.73 $44.26 $49.80 $55.33 $ $17.09 $25.64 $34.19 $42.74 $51.28 $59.83 $68.38 $76.92 $85.47 $94.02 BENEFIT: $1,200 $1,300 $1,400 $1,500 $1,600 $1,700 $1,800 $1,900 $2,000 $2, $45.67 $49.48 $53.28 $57.09 $60.90 $45.67 $49.48 $53.28 $57.09 $ $66.40 $71.93 $77.46 $83.00 $88.53 $66.40 $71.93 $77.46 $83.00 $ $ $ $ $ $ $ $ $ $ $ BENEFIT: $2,200 $2,300 $2,400 $2,500 $2,600 $2,700 $2,800 $2,900 $3, $83.73 $87.54 $91.34 $95.15 $98.96 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ Monthly deductions for a 12 month benefit period with 14/14 accident/sickness elimination period. Age Benefit Amount BENEFIT: $200 $300 $400 $500 $600 $700 $800 $900 $1,000 $1, $6.05 $9.07 $12.10 $15.12 $18.15 $21.17 $24.20 $27.22 $30.25 $ $9.46 $14.19 $18.92 $23.65 $28.38 $33.11 $37.84 $42.57 $47.30 $ $15.71 $23.56 $31.42 $39.27 $47.12 $54.98 $62.83 $70.69 $78.54 $86.39 BENEFIT: $1,200 $1,300 $1,400 $1,500 $1,600 $1,700 $1,800 $1,900 $2,000 $2, $36.30 $39.32 $42.35 $45.37 $48.40 $51.42 $54.45 $57.47 $60.50 $ $56.76 $61.49 $66.22 $70.95 $75.68 $80.41 $85.14 $89.87 $94.60 $ $94.25 $ $ $ $ $ $ $ $ $ BENEFIT: $2,200 $2,300 $2,400 $2,500 $2,600 $2,700 $2,800 $2,900 $3, $66.55 $69.57 $72.60 $75.62 $78.65 $81.67 $84.70 $87.72 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ HumanaVoluntaryBenefits.com VAHJEK8EN 20

24 Disability Income Plus rates Disability Income plus rates Monthly deductions for a 12 month benefit period with 30/30 accident/sickness elimination period. Age Benefit Amount BENEFIT: $200 $300 $400 $500 $600 $700 $800 $900 $1,000 $1, $3.81 $5.71 $7.61 $9.51 $11.42 $13.32 $15.22 $17.13 $19.03 $ $6.47 $9.70 $12.94 $16.17 $19.40 $22.64 $25.87 $29.11 $32.34 $ $11.62 $17.42 $23.23 $29.04 $34.85 $40.66 $46.46 $52.27 $58.08 $63.89 BENEFIT: $1,200 $1,300 $1,400 $1,500 $1,600 $1,700 $1,800 $1,900 $2,000 $2, $22.84 $24.74 $26.64 $28.54 $30.45 $32.35 $34.25 $36.16 $38.06 $ $38.81 $42.04 $45.28 $48.51 $51.74 $54.98 $58.21 $61.45 $64.68 $ $69.70 $75.50 $81.31 $87.12 $92.93 $98.74 $ $ $ $ BENEFIT: $2,200 $2,300 $2,400 $2,500 $2,600 $2,700 $2,800 $2,900 $3, $41.87 $43.77 $45.67 $47.57 $49.48 $51.38 $53.28 $55.19 $ $71.15 $74.38 $77.62 $80.85 $84.08 $87.32 $90.55 $93.79 $ $ $ $ $ $ $ $ $ $ HumanaVoluntaryBenefits.com VAHJEK8EN 21

25 Life Insurance Highlights For the employee purelife-plus Flexible Premium Life Insurance to Age 121 Policy Form PRFNG-NI-10 Voluntary permanent life insurance can be an ideal complement to the group term and optional term your employer might provide. Designed to be in force when you die, this voluntary universal life product is yours to keep, even when you change jobs or retire, as long as you pay the necessary premium. Group and voluntary term, on the other hand, typically are not portable if you change jobs and, even if you can keep them after you retire, usually costs more and declines in death benefit. The policy, purelife-plus, is underwritten by Texas Life Insurance Company, and it has these outstanding features: High Death Benefit. With one of the highest death benefits available at the worksite, 1 purelife-plus gives your loved ones peace of mind, knowing there will be significant life insurance in force should you die prematurely. Minimal Cash Value. Designed to provide high death benefit, purelife-plus does not compete with the cash accumulation in your employer-sponsored retirement plans. Long Guarantees. Enjoy the assurance of a policy that has a guaranteed death benefit to age 121 and level premium that guarantees coverage for a significant period of time (after the guaranteed period, premiums may go down, stay the same, or go up). Refund of Premium. Unique in the marketplace, purelife-plus offers you a refund of 10 years premium, should you surrender the policy if the premium you pay when you buy the policy ever increases. (Conditions apply.) Accelerated Death Benefit Rider. Should you be diagnosed as terminally ill with the expectation of death within 12 months (24 months in Illinois), you will have the option to receive 92% (84% in Illinois) of the death benefit, minus a $150 ($100 in Florida) administrative fee. This valuable living benefit gives you peace of mind knowing that, should you need it, you can take the large majority of your death benefit while still alive. (Conditions apply.) You may apply for this permanent, portable coverage, not only for yourself, but also for your spouse, minor children and grandchildren by answering just 3 questions: During the last six months, has the proposed insured: a. Been actively at work on a full time basis, performing usual duties? b. Been absent from work due to illness or medical treatment for a period of more than five consecutive working days? c. Been disabled or received tests, treatment or care of any kind in a hospital or nursing home or received chemotherapy, hormonal therapy for cancer, radiation therapy, dialysis treatment, or treatment for alcohol or drug abuse? Like most life insurance policies, Texas Life policies contain certain exclusions, limitations, exceptions, reductions of benefits, waiting periods and terms for keeping them in force. Please contact a Texas Life representative for costs and complete details. 1 Voluntary and Universal Whole Life Products, Eastbridge Consulting Group, October 2008 See the purelife-plus brochure for details. 10M055-C 1040 (exp0612) 22 Not for use in WA.

26 20peryear premiums PureLife Standard Risk Table Premiums Express & Simplified Issue GUARANTEED 20 per year Premiums for Life Insurance Face Amounts Shown PERIOD Includes Added Cost for Age to Which Issue Accidental Death Benefit (Ages 17-59) Coverage is Age Employee Group Size Guaranteed at (ALB) $10,000 $15,000 $20,000 $25,000 $50,000 $100,000 $150,000 $200,000 $250,000 Table Premium 15D PureLife is permanent life insurance to Attained Age 121 that can never be cancelled as long as you pay the necessary premiums. After the Guaranteed Period, the premiums can be lower, the same, or higher than the Table Premium. See the brochure under Permanent Coverage. PL-B4AHB5ABD9CH 23

27 20peryear premiums PureLife Standard Risk Table Premiums Express & Simplified Issue Life Insurance Face Amounts for 20 per year Premiums Shown GUARANTEED PERIOD Prem Includes Added Cost for Age to Which Issue For Accidental Death Benefit (Ages 17-59) Coverage is Age $10,000 Employee Group Size Guaranteed at (ALB) Face $7.00 $8.00 $10.00 $12.00 $14.00 $16.00 $18.00 $20.00 Table Premium ,470 35,470 45,470 55,470 65,470 75,470 85,470 95, ,745 33,462 42,896 52,330 61,764 71,198 80,632 90, ,745 33,462 42,896 52,330 61,764 71,198 80,632 90, ,954 32,541 41,716 50,890 60,064 69,239 78,413 87, ,205 31,670 40,598 49,527 58,455 67,384 76,312 85, ,496 30,843 39,539 48,235 56,930 65,626 74,322 83, ,822 30,059 38,534 47,008 55,483 63,958 72,432 80, ,182 29,314 37,579 45,843 54,107 62,372 70,636 78, ,929 35,803 43,677 51,551 59,425 67,299 75, ,669 34,188 41,707 49,226 56,744 64,263 71, ,518 32,712 39,906 47,101 54,295 61,489 68, ,723 37,480 44,236 50,993 57,750 64, ,526 36,019 42,513 49,006 55,500 61, ,419 34,669 40,919 47,169 53,419 59, ,905 32,822 38,740 44,657 50,574 56, ,122 30,646 36,171 41,696 47,221 52, ,741 33,922 39,104 44,285 49, ,668 31,476 36,284 41,091 45, ,590 32,956 37,323 41, ,188 30,188 34,188 38, ,849 31,539 35, ,583 28,973 32, ,793 29, ,138 28, , ,724 13,083 15,441 17,800 20,158 22, ,981 14,140 16,300 18,460 20, ,855 12,812 14,769 16,726 18, ,712 13,501 15,290 17, ,786 12,433 14,081 15, ,088 11,629 13,169 14, ,115 12,588 14, ,781 12,210 13, ,424 11,805 13, ,009 11,336 12, ,043 12, ,139 11, , PureLife is permanent life insurance to Attained Age 121 that can never be cancelled as long as you pay the necessary premiums. After the Guaranteed Period, the premiums can be lower, the same, or higher than the Table Premium. See the brochure under Permanent Coverage. PL-B4AHB5ABD9CH 24

28 Humana Whole Life 65 Virginia Child(ren) Summary - Portsmouth Public Schools If people depend financially on you, you need life insurance, no matter what your age or marital status. With life insurance, you can help spare your grieving loved ones the additional stress of economic difficulties and preserve their quality of life. Premiums for this whole life product are payable to age 65. The policy providers guaranteed coverage and cash values stay with the policy for its lifetime you can take funds as loans or use to buy paid-up coverage. Coverage type Benefit type Policyholder Benefit amount Humana Whole Life 65 is an individual whole life insurance product with premiums payable to age 65. Defined benefit Child Benefit amounts are available at various levels. You can choose: Child(ren): $2,500 to $25,000 for each eligible child Stand-alone Child(ren) Coverage Simplified Issue - Up to $25,000 For child stand-alone coverage Humana Whole Life to age 65 is only plan available. Issue ages Child(ren) stand-alone coverage: 14 days - 24 years Additional included benefits Terminal illness acceleration benefit: For the primary insured provides an acceleration of up to 50 percent of the original death benefit, base and term rider, amount including any ABI amounts, upon diagnosis of a terminal illness. 12-month waiting period. This is not a complete disclosure of plan qualifications and limitations. Please access our website to obtain a completed list for the Workplace Voluntary Benefit products at Disclosure.Humana.com. Please review this information before applying for coverage. The amount of benefits provided depends on the plan selected. Premiums will vary according to the selection made. Policy: Underwritten by Kanawha Insurance Company, a Humana company. VOL HumanaVoluntaryBenefits.com

29 Humana Whole Life 65 Virginia Child(ren) Summary - Portsmouth Public Schools Additional included benefits Product restrictions Age calculation Portability Guarantee renewable Cash value Facility Care Acceleration Benefit: provides an acceleration of one percent of the face amount, up to $2,000/month up to a maximum of 36 months for Licensed Adult Day Care and/or up to two percent of the face amount, up to $4,000/month up to a maximum of 18 months for inpatient resident care. Benefits cannot exceed the lesser of 36 percent of the face amount, $72,000, or the face amount of the policy less the cash value. Total amount of permanent life insurance coverage and term life insurance coverage with Kanawha Insurance Company not to exceed $300,000. If both parents are eligible employees, their eligible children may be insured by either spouse but not both. Purchasing option, whether money purchase or flat face amount, will be determined by the employer. When optional riders are selected, the weekly money purchase premium will be calculated to include the base benefit and any rider(s) (per applicant). If an employee's base policy, rider(s), and any additional Kanawha Insurance Company life insurance products exceed our company maximum of $300,000, we will first reduce the applicant's rider(s) on this coverage. If additional reductions are necessary, we will reduce the face amount of the base policy. Age at effective date of policy Yes Yes Whole Life 65 is a whole life policy with guaranteed values, not an interest sensitive policy. As such, there is not an interest rate associated with the cash value of the policy; the cash values are all guaranteed in the table of cash values inside each and every Whole Life policy. This is not a complete disclosure of plan qualifications and limitations. Please access our website to obtain a completed list for the Workplace Voluntary Benefit products at Disclosure.Humana.com. Please review this information before applying for coverage. The amount of benefits provided depends on the plan selected. Premiums will vary according to the selection made. Policy: Underwritten by Kanawha Insurance Company, a Humana company. VOL HumanaVoluntaryBenefits.com

30 Humana Whole Life 65 rates Virginia Child(ren) Summary - Portsmouth Public Schools Humana Whole Life 65 rates Child, Non-tobacco coverage, Defined Benefit amounts displaying monthly payroll deductions based on monthly premium calculation. Age Benefit Amount BENEFIT: $5,000 CASH VALUE* $10,000 CASH VALUE* $15,000 CASH VALUE* 0 $3.42 $2,405 $4.76 $4,811 $6.11 $7,216 1 $3.42 $2,405 $4.76 $4,811 $6.11 $7,216 2 $3.42 $2,405 $4.76 $4,811 $6.11 $7,216 3 $3.42 $2,405 $4.76 $4,811 $6.11 $7,216 4 $3.42 $2,405 $4.76 $4,811 $6.11 $7,216 5 $3.42 $2,405 $4.76 $4,811 $6.11 $7,216 6 $3.50 $2,405 $4.91 $4,811 $6.33 $7,216 7 $3.57 $2,405 $5.06 $4,811 $6.55 $7,216 8 $3.65 $2,405 $5.21 $4,811 $6.78 $7,216 9 $3.72 $2,405 $5.35 $4,811 $6.99 $7, $3.79 $2,405 $5.51 $4,811 $7.22 $7, $3.88 $2,405 $5.69 $4,811 $7.49 $7, $3.97 $2,405 $5.86 $4,811 $7.75 $7, $4.06 $2,405 $6.05 $4,811 $8.03 $7, $4.15 $2,405 $6.23 $4,811 $8.30 $7, $4.24 $2,405 $6.41 $4,811 $8.57 $7, $4.40 $2,405 $6.73 $4,811 $9.05 $7, $4.57 $2,405 $7.05 $4,811 $9.54 $7, $4.73 $2,405 $7.38 $4,811 $10.03 $7, $4.89 $2,405 $7.70 $4,811 $10.50 $7, $5.05 $2,405 $8.02 $4,811 $10.99 $7, $5.21 $2,405 $8.35 $4,811 $11.48 $7, $5.37 $2,405 $8.66 $4,811 $11.95 $7, $5.53 $2,405 $8.99 $4,811 $12.44 $7, $5.70 $2,405 $9.31 $4,811 $12.93 $7, $5.85 $2,405 $9.63 $4,811 $13.40 $7, $6.08 $2,405 $10.09 $4,811 $14.09 $7,216 *Cash values are calculated as of age 65. The proposed rates are for an effective date no later than January 1, HumanaVoluntaryBenefits.com Policy: Underwritten by Kanawha Insurance Company, a Humana company. 27

31 Humana Whole Life 65 rates Virginia Child(ren) Summary - Portsmouth Public Schools Humana Whole Life 65 rates Child, Non-tobacco coverage, Defined Benefit amounts displaying monthly payroll deductions based on monthly premium calculation. Age Benefit Amount BENEFIT: $20,000 CASH VALUE* $25,000 CASH VALUE* 0 $7.45 $9,622 $8.79 $12,027 1 $7.45 $9,622 $8.79 $12,027 2 $7.45 $9,622 $8.79 $12,027 3 $7.45 $9,622 $8.79 $12,027 4 $7.45 $9,622 $8.79 $12,027 5 $7.45 $9,622 $8.79 $12,027 6 $7.75 $9,622 $9.16 $12,027 7 $8.05 $9,622 $9.54 $12,027 8 $8.35 $9,622 $9.91 $12,027 9 $8.63 $9,622 $10.27 $12, $8.93 $9,622 $10.64 $12, $9.30 $9,622 $11.10 $12, $9.65 $9,622 $11.54 $12, $10.01 $9,622 $12.00 $12, $10.38 $9,622 $12.45 $12, $10.74 $9,622 $12.90 $12, $11.38 $9,622 $13.70 $12, $12.03 $9,622 $14.52 $12, $12.68 $9,622 $15.33 $12, $13.31 $9,622 $16.12 $12, $13.96 $9,622 $16.93 $12, $14.61 $9,622 $17.75 $12, $15.25 $9,622 $18.54 $12, $15.90 $9,622 $19.35 $12, $16.55 $9,622 $20.16 $12, $17.18 $9,622 $20.95 $12, $18.10 $9,622 $22.10 $12,027 *Cash values are calculated as of age 65. The proposed rates are for an effective date no later than January 1, HumanaVoluntaryBenefits.com Policy: Underwritten by Kanawha Insurance Company, a Humana company. 28

32 Humana Whole Life 99 Virginia Employee Summary - Portsmouth Public Schools Here's a simple, voluntary whole life policy you can get at a reasonable cost during your working years, when you and your families need coverage the most. It's also a benefit that'll stay in place when retirement rolls around, too. You buy a policy with guaranteed coverage and actual cash value. Coverage stays level and cash values stay with the policy for as long as you have it, enabling you to take out funds as loans or buy paid-up coverage. Coverage type Benefit type Policyholder Benefit amount Humana Whole Life 99 is an individual whole life insurance product with premiums payable to age 99. Defined benefit Employee Benefit amounts are available at various levels. You can choose: $2,500 to $300,000 for employees Employee Simplified Issue Amount up to $300,000 all ages Issue ages Employee base coverage: Additional included benefits Terminal illness acceleration benefit: For the primary insured provides an acceleration of up to 50 percent of the original death benefit, base and term rider, amount including any ABI amounts, upon diagnosis of a terminal illness. 12-month waiting period. Facility Care Acceleration Benefit: provides an acceleration of one percent of the face amount, up to $2,000/month up to a maximum of 36 months for Licensed Adult Day Care and/or up to two percent of the face amount, up to $4,000/month up to a maximum of 18 months for inpatient resident care. Benefits cannot exceed the lesser of 36 percent of the face amount, $72,000, or the face amount of the policy less the cash value. This is not a complete disclosure of plan qualifications and limitations. Please access our website to obtain a completed list for the Workplace Voluntary Benefit products at Disclosure.Humana.com. Please review this information before applying for coverage. The amount of benefits provided depends on the plan selected. Premiums will vary according to the selection made. Policy: Underwritten by Kanawha Insurance Company, a Humana company. VOL HumanaVoluntaryBenefits.com

33 Humana Whole Life 99 Virginia Employee Summary - Portsmouth Public Schools Product restrictions Age calculation Portability Guarantee renewable Cash value Total amount of permanent life insurance coverage and term life insurance coverage with Kanawha Insurance Company not to exceed $300,000. If both parents are eligible employees, their eligible children may be insured by either spouse but not both. Purchasing option, whether money purchase or flat face amount, will be determined by the employer. When optional riders are selected, the weekly money purchase premium will be calculated to include the base benefit and any rider(s) (per applicant). If an employee's base policy, rider(s), and any additional Kanawha Insurance Company life insurance products exceed our company maximum of $300,000, we will first reduce the applicant's rider(s) on this coverage. If additional reductions are necessary, we will reduce the face amount of the base policy. Age at effective date of policy Yes Yes Whole Life 99 is a whole life policy with guaranteed values, not an interest sensitive policy. As such, there is not an interest rate associated with the cash value of the policy; the cash values are all guaranteed in the table of cash values inside each and every Whole Life policy. This is not a complete disclosure of plan qualifications and limitations. Please access our website to obtain a completed list for the Workplace Voluntary Benefit products at Disclosure.Humana.com. Please review this information before applying for coverage. The amount of benefits provided depends on the plan selected. Premiums will vary according to the selection made. Policy: Underwritten by Kanawha Insurance Company, a Humana company. VOL HumanaVoluntaryBenefits.com

34 Humana Whole Life 99 rates Virginia Employee Summary - Portsmouth Public Schools Humana Whole Life 99 rates Employee, Non-tobacco coverage, Defined Benefit amounts displaying monthly payroll deductions based on monthly premium calculation. Age Benefit Amount BENEFIT: $10,000 CASH VALUE* $20,000 CASH VALUE* $30,000 CASH VALUE* 18 $6.72 $4,628 $11.36 $9,256 $16.00 $13, $6.96 $4,628 $11.85 $9,256 $16.73 $13, $7.08 $4,628 $12.08 $9,256 $17.08 $13, $7.28 $4,628 $12.48 $9,256 $17.68 $13, $7.49 $4,628 $12.90 $9,256 $18.30 $13, $7.69 $4,628 $13.30 $9,256 $18.90 $13, $7.90 $4,628 $13.71 $9,256 $19.53 $13, $8.10 $4,628 $14.11 $9,256 $20.13 $13, $8.35 $4,628 $14.61 $9,256 $20.88 $13, $8.59 $4,628 $15.10 $9,256 $21.60 $13, $8.84 $4,620 $15.60 $9,239 $22.35 $13, $9.08 $4,572 $16.08 $9,144 $23.08 $13, $9.33 $4,527 $16.58 $9,054 $23.83 $13, $9.71 $4,475 $17.35 $8,950 $24.98 $13, $10.10 $4,422 $18.11 $8,845 $26.13 $13, $10.48 $4,367 $18.88 $8,733 $27.28 $13, $10.86 $4,308 $19.65 $8,616 $28.43 $12, $11.25 $4,246 $20.41 $8,493 $29.58 $12, $11.73 $4,181 $21.38 $8,363 $31.03 $12, $12.21 $4,113 $22.35 $8,225 $32.48 $12, $12.70 $4,041 $23.31 $8,081 $33.93 $12, $13.18 $3,964 $24.28 $7,929 $35.38 $11, $13.66 $3,884 $25.25 $7,768 $36.83 $11, $14.35 $3,799 $26.61 $7,598 $38.88 $11, $15.04 $3,709 $28.00 $7,418 $40.95 $11, $15.72 $3,614 $29.36 $7,229 $43.00 $10, $16.41 $3,515 $30.75 $7,029 $45.08 $10, $17.10 $3,409 $32.11 $6,818 $47.13 $10, $18.11 $3,471 $34.15 $6,942 $50.18 $10, $19.12 $3,535 $36.16 $7,069 $53.20 $10, $20.14 $3,601 $38.20 $7,202 $56.25 $10, $21.15 $3,670 $40.23 $7,340 $59.30 $11,010 *Cash values are for age 65 through age 45 and for 20 years for ages over 45. The proposed rates are for an effective date no later than January 1, HumanaVoluntaryBenefits.com Policy: Underwritten by Kanawha Insurance Company, a Humana company. 31

35 Humana Whole Life 99 rates Virginia Employee Summary - Portsmouth Public Schools Humana Whole Life 99 rates Employee, Non-tobacco coverage, Defined Benefit amounts displaying monthly payroll deductions based on monthly premium calculation. Age Benefit Amount BENEFIT: $10,000 CASH VALUE* $20,000 CASH VALUE* $30,000 CASH VALUE* 50 $22.16 $3,742 $42.25 $7,483 $62.33 $11, $23.50 $3,816 $44.93 $7,631 $66.35 $11, $24.85 $3,892 $47.61 $7,783 $70.38 $11, $26.19 $3,970 $50.29 $7,939 $74.40 $11, $27.53 $4,050 $52.98 $8,099 $78.43 $12, $28.86 $4,132 $55.64 $8,265 $82.43 $12, $31.14 $4,218 $60.19 $8,436 $89.25 $12, $33.40 $4,306 $64.73 $8,613 $96.05 $12, $35.67 $4,397 $69.26 $8,794 $ $13, $37.94 $4,488 $73.79 $8,977 $ $13, $40.20 $4,496 $78.33 $8,993 $ $13, $43.27 $4,618 $84.46 $9,237 $ $13, $46.34 $4,737 $90.60 $9,474 $ $14, $49.41 $4,854 $96.73 $9,707 $ $14, $52.48 $4,968 $ $9,936 $ $14, $55.55 $5,080 $ $10,159 $ $15, $58.57 $5,190 $ $10,380 $ $15, $61.81 $5,306 $ $10,612 $ $15, $65.26 $5,419 $ $10,838 $ $16, $69.05 $5,525 $ $11,051 $ $16, $73.15 $5,630 $ $11,260 $ $16,889 *Cash values are for age 65 through age 45 and for 20 years for ages over 45. The proposed rates are for an effective date no later than January 1, Humana Whole Life 99 rates Employee, Tobacco coverage, Defined Benefit amounts displaying monthly payroll deductions based on monthly premium calculation. Age Benefit Amount BENEFIT: $10,000 CASH VALUE* $20,000 CASH VALUE* $30,000 CASH VALUE* 18 $8.74 $5,293 $15.40 $10,587 $22.05 $15, $9.07 $5,293 $16.06 $10,587 $23.05 $15, $9.29 $5,293 $16.50 $10,587 $23.70 $15, $9.62 $5,293 $17.16 $10,587 $24.70 $15,880 *Cash values are for age 65 through age 45 and for 20 years for ages over 45. The proposed rates are for an effective date no later than January 1, HumanaVoluntaryBenefits.com Policy: Underwritten by Kanawha Insurance Company, a Humana company. 32

36 Humana Whole Life 99 rates Virginia Employee Summary - Portsmouth Public Schools Humana Whole Life 99 rates Employee, Tobacco coverage, Defined Benefit amounts displaying monthly payroll deductions based on monthly premium calculation. Age Benefit Amount BENEFIT: $10,000 CASH VALUE* $20,000 CASH VALUE* $30,000 CASH VALUE* 22 $9.95 $5,293 $17.81 $10,587 $25.68 $15, $10.28 $5,293 $18.48 $10,587 $26.68 $15, $10.61 $5,293 $19.15 $10,587 $27.68 $15, $10.94 $5,293 $19.80 $10,587 $28.65 $15, $11.38 $5,293 $20.68 $10,587 $29.98 $15, $11.82 $5,293 $21.56 $10,587 $31.30 $15, $12.26 $5,259 $22.45 $10,517 $32.63 $15, $12.70 $5,206 $23.33 $10,412 $33.95 $15, $13.14 $5,151 $24.20 $10,302 $35.25 $15, $13.70 $5,092 $25.31 $10,184 $36.93 $15, $14.25 $5,030 $26.41 $10,060 $38.58 $15, $14.80 $4,965 $27.53 $9,929 $40.25 $14, $15.35 $4,896 $28.63 $9,791 $41.90 $14, $15.90 $4,823 $29.73 $9,646 $43.55 $14, $16.65 $4,746 $31.23 $9,492 $45.80 $14, $17.40 $4,665 $32.73 $9,330 $48.05 $13, $18.15 $4,580 $34.23 $9,159 $50.30 $13, $18.90 $4,489 $35.73 $8,978 $52.55 $13, $19.65 $4,394 $37.23 $8,788 $54.80 $13, $20.60 $4,293 $39.13 $8,586 $57.65 $12, $21.55 $4,186 $41.01 $8,372 $60.48 $12, $22.50 $4,074 $42.91 $8,147 $63.33 $12, $23.44 $3,955 $44.79 $7,910 $66.15 $11, $24.39 $3,830 $46.69 $7,660 $69.00 $11, $25.86 $3,872 $49.64 $7,744 $73.43 $11, $27.35 $3,916 $52.61 $7,832 $77.88 $11, $28.82 $3,962 $55.56 $7,923 $82.30 $11, $30.30 $4,009 $58.53 $8,018 $86.75 $12, $31.78 $4,059 $61.48 $8,118 $91.18 $12, $33.72 $4,110 $65.36 $8,221 $97.00 $12, $35.66 $4,163 $69.24 $8,327 $ $12, $37.60 $4,217 $73.13 $8,434 $ $12, $39.54 $4,272 $76.99 $8,545 $ $12,817 *Cash values are for age 65 through age 45 and for 20 years for ages over 45. The proposed rates are for an effective date no later than January 1, HumanaVoluntaryBenefits.com Policy: Underwritten by Kanawha Insurance Company, a Humana company. 33

37 Humana Whole Life 99 rates Virginia Employee Summary - Portsmouth Public Schools Humana Whole Life 99 rates Employee, Tobacco coverage, Defined Benefit amounts displaying monthly payroll deductions based on monthly premium calculation. Age Benefit Amount BENEFIT: $10,000 CASH VALUE* $20,000 CASH VALUE* $30,000 CASH VALUE* 55 $41.48 $4,330 $80.88 $8,661 $ $12, $44.28 $4,391 $86.48 $8,782 $ $13, $47.08 $4,454 $92.08 $8,909 $ $13, $49.88 $4,519 $97.68 $9,037 $ $13, $52.68 $4,584 $ $9,167 $ $13, $55.48 $4,565 $ $9,130 $ $13, $59.16 $4,661 $ $9,322 $ $13, $62.85 $4,759 $ $9,519 $ $14, $66.53 $4,857 $ $9,714 $ $14, $70.21 $4,951 $ $9,902 $ $14, $73.90 $5,040 $ $10,079 $ $15, $77.76 $5,126 $ $10,251 $ $15, $81.84 $5,207 $ $10,413 $ $15, $86.25 $5,276 $ $10,553 $ $15, $90.89 $5,336 $ $10,673 $ $16, $95.96 $5,392 $ $10,784 $ $16,177 *Cash values are for age 65 through age 45 and for 20 years for ages over 45. The proposed rates are for an effective date no later than January 1, HumanaVoluntaryBenefits.com Policy: Underwritten by Kanawha Insurance Company, a Humana company. 34

38 Humana Whole Life 99 rates Virginia Employee Summary - Portsmouth Public Schools Humana Whole Life 99 rates Employee, Non-tobacco coverage, Defined Benefit amounts displaying monthly payroll deductions based on monthly premium calculation. Age Benefit Amount BENEFIT: $40,000 CASH VALUE* $50,000 CASH VALUE* $75,000 CASH VALUE* 18 $20.65 $18,512 $25.29 $23,140 $36.89 $34, $21.61 $18,512 $26.50 $23,140 $38.70 $34, $22.08 $18,512 $27.08 $23,140 $39.58 $34, $22.88 $18,512 $28.08 $23,140 $41.08 $34, $23.71 $18,512 $29.12 $23,140 $42.64 $34, $24.51 $18,512 $30.12 $23,140 $44.14 $34, $25.35 $18,512 $31.16 $23,140 $45.70 $34, $26.15 $18,512 $32.16 $23,140 $47.20 $34, $27.15 $18,512 $33.41 $23,140 $49.08 $34, $28.11 $18,512 $34.62 $23,140 $50.89 $34, $29.11 $18,478 $35.87 $23,098 $52.77 $34, $30.08 $18,288 $37.08 $22,860 $54.58 $34, $31.08 $18,109 $38.33 $22,636 $56.45 $33, $32.61 $17,900 $40.25 $22,374 $59.33 $33, $34.15 $17,689 $42.16 $22,111 $62.20 $33, $35.68 $17,467 $44.08 $21,833 $65.08 $32, $37.21 $17,232 $45.99 $21,540 $67.95 $32, $38.75 $16,985 $47.91 $21,231 $70.83 $31, $40.68 $16,725 $50.33 $20,907 $74.45 $31, $42.61 $16,451 $52.74 $20,564 $78.08 $30, $44.54 $16,163 $55.16 $20,203 $81.70 $30, $46.48 $15,857 $57.58 $19,822 $85.33 $29, $48.41 $15,536 $59.99 $19,419 $88.95 $29, $51.14 $15,195 $63.41 $18,994 $94.08 $28, $53.91 $14,837 $66.87 $18,546 $99.26 $27, $56.64 $14,458 $70.29 $18,072 $ $27, $59.41 $14,058 $73.74 $17,573 $ $26, $62.14 $13,637 $77.16 $17,046 $ $25, $66.21 $13,883 $82.24 $17,354 $ $26, $70.24 $14,139 $87.28 $17,673 $ $26, $74.31 $14,404 $92.37 $18,005 $ $27, $78.38 $14,680 $97.45 $18,350 $ $27,525 *Cash values are for age 65 through age 45 and for 20 years for ages over 45. The proposed rates are for an effective date no later than January 1, HumanaVoluntaryBenefits.com Policy: Underwritten by Kanawha Insurance Company, a Humana company. 35

39 Humana Whole Life 99 rates Virginia Employee Summary - Portsmouth Public Schools Humana Whole Life 99 rates Employee, Non-tobacco coverage, Defined Benefit amounts displaying monthly payroll deductions based on monthly premium calculation. Age Benefit Amount BENEFIT: $40,000 CASH VALUE* $50,000 CASH VALUE* $75,000 CASH VALUE* 50 $82.41 $14,966 $ $18,708 $ $28, $87.78 $15,263 $ $19,078 $ $28, $93.14 $15,567 $ $19,458 $ $29, $98.51 $15,878 $ $19,848 $ $29, $ $16,198 $ $20,248 $ $30, $ $16,530 $ $20,662 $ $30, $ $16,872 $ $21,090 $ $31, $ $17,225 $ $21,532 $ $32, $ $17,587 $ $21,984 $ $32, $ $17,954 $ $22,442 $ $33, $ $17,986 $ $22,482 $ $33, $ $18,474 $ $23,092 $ $34, $ $18,949 $ $23,686 $ $35, $ $19,414 $ $24,268 $ $36, $ $19,872 $ $24,840 $ $37, $ $20,319 $ $25,399 $ $38, $ $20,761 $ $25,951 $ $38, $ $21,224 $ $26,530 $ $39, $ $21,675 $ $27,094 $ $40, $ $22,102 $ $27,627 $ $41, $ $22,519 $ $28,149 $ $42,224 *Cash values are for age 65 through age 45 and for 20 years for ages over 45. The proposed rates are for an effective date no later than January 1, Humana Whole Life 99 rates Employee, Tobacco coverage, Defined Benefit amounts displaying monthly payroll deductions based on monthly premium calculation. Age Benefit Amount BENEFIT: $40,000 CASH VALUE* $50,000 CASH VALUE* $75,000 CASH VALUE* 18 $28.71 $21,174 $35.37 $26,467 $52.02 $39, $30.05 $21,174 $37.04 $26,467 $54.52 $39, $30.91 $21,174 $38.12 $26,467 $56.14 $39, $32.25 $21,174 $39.79 $26,467 $58.64 $39,701 *Cash values are for age 65 through age 45 and for 20 years for ages over 45. The proposed rates are for an effective date no later than January 1, HumanaVoluntaryBenefits.com Policy: Underwritten by Kanawha Insurance Company, a Humana company. 36

40 Humana Whole Life 99 rates Virginia Employee Summary - Portsmouth Public Schools Humana Whole Life 99 rates Employee, Tobacco coverage, Defined Benefit amounts displaying monthly payroll deductions based on monthly premium calculation. Age Benefit Amount BENEFIT: $40,000 CASH VALUE* $50,000 CASH VALUE* $75,000 CASH VALUE* 22 $33.55 $21,174 $41.41 $26,467 $61.08 $39, $34.88 $21,174 $43.08 $26,467 $63.58 $39, $36.21 $21,174 $44.74 $26,467 $66.08 $39, $37.51 $21,174 $46.37 $26,467 $68.51 $39, $39.28 $21,174 $48.58 $26,467 $71.83 $39, $41.05 $21,174 $50.79 $26,467 $75.14 $39, $42.81 $21,035 $52.99 $26,293 $78.45 $39, $44.58 $20,825 $55.20 $26,031 $81.76 $39, $46.31 $20,603 $57.37 $25,754 $85.01 $38, $48.54 $20,369 $60.16 $25,461 $89.20 $38, $50.74 $20,121 $62.91 $25,151 $93.33 $37, $52.98 $19,859 $65.70 $24,824 $97.51 $37, $55.18 $19,583 $68.45 $24,478 $ $36, $57.38 $19,291 $71.20 $24,114 $ $36, $60.38 $18,984 $74.95 $23,730 $ $35, $63.38 $18,660 $78.70 $23,325 $ $34, $66.38 $18,318 $82.45 $22,898 $ $34, $69.38 $17,957 $86.20 $22,446 $ $33, $72.38 $17,575 $89.95 $21,969 $ $32, $76.18 $17,171 $94.70 $21,464 $ $32, $79.94 $16,744 $99.41 $20,931 $ $31, $83.74 $16,295 $ $20,368 $ $30, $87.51 $15,820 $ $19,774 $ $29, $91.31 $15,320 $ $19,150 $ $28, $97.21 $15,489 $ $19,361 $ $29, $ $15,663 $ $19,579 $ $29, $ $15,846 $ $19,808 $ $29, $ $16,036 $ $20,045 $ $30, $ $16,235 $ $20,294 $ $30, $ $16,442 $ $20,552 $ $30, $ $16,653 $ $20,816 $ $31, $ $16,868 $ $21,085 $ $31, $ $17,090 $ $21,362 $ $32,044 *Cash values are for age 65 through age 45 and for 20 years for ages over 45. The proposed rates are for an effective date no later than January 1, HumanaVoluntaryBenefits.com Policy: Underwritten by Kanawha Insurance Company, a Humana company. 37

41 Humana Whole Life 99 rates Virginia Employee Summary - Portsmouth Public Schools Humana Whole Life 99 rates Employee, Tobacco coverage, Defined Benefit amounts displaying monthly payroll deductions based on monthly premium calculation. Age Benefit Amount BENEFIT: $40,000 CASH VALUE* $50,000 CASH VALUE* $75,000 CASH VALUE* 55 $ $17,321 $ $21,652 $ $32, $ $17,564 $ $21,955 $ $32, $ $17,817 $ $22,271 $ $33, $ $18,075 $ $22,594 $ $33, $ $18,334 $ $22,918 $ $34, $ $18,261 $ $22,826 $ $34, $ $18,643 $ $23,304 $ $34, $ $19,038 $ $23,797 $ $35, $ $19,429 $ $24,286 $ $36, $ $19,803 $ $24,754 $ $37, $ $20,158 $ $25,198 $ $37, $ $20,503 $ $25,628 $ $38, $ $20,826 $ $26,033 $ $39, $ $21,106 $ $26,382 $ $39, $ $21,345 $ $26,682 $ $40, $ $21,569 $ $26,961 $ $40,442 *Cash values are for age 65 through age 45 and for 20 years for ages over 45. The proposed rates are for an effective date no later than January 1, HumanaVoluntaryBenefits.com Policy: Underwritten by Kanawha Insurance Company, a Humana company. 38

42 Humana Whole Life 99 rates Virginia Employee Summary - Portsmouth Public Schools Humana Whole Life 99 rates Employee, Non-tobacco coverage, Defined Benefit amounts displaying monthly payroll deductions based on monthly premium calculation. Age Benefit Amount BENEFIT: $80,000 CASH VALUE* $90,000 CASH VALUE* $100,000 CASH VALUE* 18 $39.21 $37,024 $43.85 $41,652 $48.49 $46, $41.15 $37,024 $46.03 $41,652 $50.91 $46, $42.08 $37,024 $47.08 $41,652 $52.08 $46, $43.68 $37,024 $48.88 $41,652 $54.08 $46, $45.34 $37,024 $50.75 $41,652 $56.16 $46, $46.94 $37,024 $52.55 $41,652 $58.16 $46, $48.61 $37,024 $54.43 $41,652 $60.24 $46, $50.21 $37,024 $56.23 $41,652 $62.24 $46, $52.21 $37,024 $58.48 $41,652 $64.74 $46, $54.14 $37,024 $60.65 $41,652 $67.16 $46, $56.14 $36,956 $62.90 $41,576 $69.66 $46, $58.08 $36,577 $65.08 $41,149 $72.08 $45, $60.08 $36,217 $67.33 $40,744 $74.58 $45, $63.14 $35,799 $70.78 $40,274 $78.41 $44, $66.21 $35,378 $74.23 $39,801 $82.24 $44, $69.28 $34,933 $77.68 $39,300 $86.08 $43, $72.34 $34,464 $81.13 $38,772 $89.91 $43, $75.41 $33,970 $84.58 $38,216 $93.74 $42, $79.28 $33,450 $88.93 $37,632 $98.58 $41, $83.14 $32,902 $93.28 $37,015 $ $41, $87.01 $32,325 $97.63 $36,366 $ $40, $90.88 $31,715 $ $35,679 $ $39, $94.74 $31,071 $ $34,955 $ $38, $ $30,391 $ $34,190 $ $37, $ $29,674 $ $33,383 $ $37, $ $28,915 $ $32,530 $ $36, $ $28,116 $ $31,631 $ $35, $ $27,273 $ $30,682 $ $34, $ $27,766 $ $31,237 $ $34, $ $28,277 $ $31,812 $ $35, $ $28,807 $ $32,408 $ $36, $ $29,360 $ $33,030 $ $36,700 *Cash values are for age 65 through age 45 and for 20 years for ages over 45. The proposed rates are for an effective date no later than January 1, HumanaVoluntaryBenefits.com Policy: Underwritten by Kanawha Insurance Company, a Humana company. 39

43 Humana Whole Life 99 rates Virginia Employee Summary - Portsmouth Public Schools Humana Whole Life 99 rates Employee, Non-tobacco coverage, Defined Benefit amounts displaying monthly payroll deductions based on monthly premium calculation. Age Benefit Amount BENEFIT: $80,000 CASH VALUE* $90,000 CASH VALUE* $100,000 CASH VALUE* 50 $ $29,932 $ $33,674 $ $37, $ $30,525 $ $34,341 $ $38, $ $31,133 $ $35,025 $ $38, $ $31,756 $ $35,726 $ $39, $ $32,396 $ $36,446 $ $40, $ $33,059 $ $37,192 $ $41, $ $33,744 $ $37,962 $ $42, $ $34,451 $ $38,757 $ $43, $ $35,175 $ $39,571 $ $43, $ $35,907 $ $40,395 $ $44, $ $35,971 $ $40,468 $ $44, $ $36,948 $ $41,566 $ $46, $ $37,898 $ $42,635 $ $47, $ $38,828 $ $43,682 $ $48, $ $39,744 $ $44,712 $ $49, $ $40,638 $ $45,717 $ $50, $ $41,522 $ $46,712 $ $51, $ $42,449 $ $47,755 $ $53, $ $43,351 $ $48,769 $ $54, $ $44,203 $ $49,728 $ $55, $ $45,038 $ $50,668 $ $56,298 *Cash values are for age 65 through age 45 and for 20 years for ages over 45. The proposed rates are for an effective date no later than January 1, Humana Whole Life 99 rates Employee, Tobacco coverage, Defined Benefit amounts displaying monthly payroll deductions based on monthly premium calculation. Age Benefit Amount BENEFIT: $80,000 CASH VALUE* $90,000 CASH VALUE* $100,000 CASH VALUE* 18 $55.34 $42,348 $62.00 $47,641 $68.66 $52, $58.01 $42,348 $65.00 $47,641 $71.99 $52, $59.74 $42,348 $66.95 $47,641 $74.16 $52, $62.41 $42,348 $69.95 $47,641 $77.49 $52,934 *Cash values are for age 65 through age 45 and for 20 years for ages over 45. The proposed rates are for an effective date no later than January 1, HumanaVoluntaryBenefits.com Policy: Underwritten by Kanawha Insurance Company, a Humana company. 40

44 Humana Whole Life 99 rates Virginia Employee Summary - Portsmouth Public Schools Humana Whole Life 99 rates Employee, Tobacco coverage, Defined Benefit amounts displaying monthly payroll deductions based on monthly premium calculation. Age Benefit Amount BENEFIT: $80,000 CASH VALUE* $90,000 CASH VALUE* $100,000 CASH VALUE* 22 $65.01 $42,348 $72.88 $47,641 $80.74 $52, $67.68 $42,348 $75.88 $47,641 $84.08 $52, $70.34 $42,348 $78.88 $47,641 $87.41 $52, $72.94 $42,348 $81.80 $47,641 $90.66 $52, $76.48 $42,348 $85.78 $47,641 $95.08 $52, $80.01 $42,348 $89.75 $47,641 $99.49 $52, $83.54 $42,069 $93.73 $47,328 $ $52, $87.08 $41,650 $97.70 $46,856 $ $52, $90.54 $41,206 $ $46,357 $ $51, $95.01 $40,738 $ $45,830 $ $50, $99.41 $40,241 $ $45,272 $ $50, $ $39,718 $ $44,682 $ $49, $ $39,165 $ $44,061 $ $48, $ $38,583 $ $43,406 $ $48, $ $37,968 $ $42,714 $ $47, $ $37,321 $ $41,986 $ $46, $ $36,636 $ $41,216 $ $45, $ $35,914 $ $40,403 $ $44, $ $35,150 $ $39,544 $ $43, $ $34,342 $ $38,635 $ $42, $ $33,489 $ $37,675 $ $41, $ $32,589 $ $36,663 $ $40, $ $31,639 $ $35,594 $ $39, $ $30,640 $ $34,470 $ $38, $ $30,978 $ $34,850 $ $38, $ $31,327 $ $35,243 $ $39, $ $31,693 $ $35,654 $ $39, $ $32,072 $ $36,081 $ $40, $ $32,471 $ $36,530 $ $40, $ $32,884 $ $36,994 $ $41, $ $33,306 $ $37,470 $ $41, $ $33,736 $ $37,953 $ $42, $ $34,180 $ $38,452 $ $42,725 *Cash values are for age 65 through age 45 and for 20 years for ages over 45. The proposed rates are for an effective date no later than January 1, HumanaVoluntaryBenefits.com Policy: Underwritten by Kanawha Insurance Company, a Humana company. 41

45 Humana Whole Life 99 rates Virginia Employee Summary - Portsmouth Public Schools Humana Whole Life 99 rates Employee, Tobacco coverage, Defined Benefit amounts displaying monthly payroll deductions based on monthly premium calculation. Age Benefit Amount BENEFIT: $80,000 CASH VALUE* $90,000 CASH VALUE* $100,000 CASH VALUE* 55 $ $34,643 $ $38,973 $ $43, $ $35,127 $ $39,518 $ $43, $ $35,634 $ $40,089 $ $44, $ $36,150 $ $40,669 $ $45, $ $36,668 $ $41,252 $ $45, $ $36,522 $ $41,087 $ $45, $ $37,286 $ $41,947 $ $46, $ $38,076 $ $42,835 $ $47, $ $38,857 $ $43,714 $ $48, $ $39,606 $ $44,557 $ $49, $ $40,317 $ $45,356 $ $50, $ $41,005 $ $46,131 $ $51, $ $41,652 $ $46,859 $ $52, $ $42,211 $ $47,488 $ $52, $ $42,690 $ $48,027 $ $53, $ $43,138 $ $48,530 $ $53,922 *Cash values are for age 65 through age 45 and for 20 years for ages over 45. The proposed rates are for an effective date no later than January 1, HumanaVoluntaryBenefits.com Policy: Underwritten by Kanawha Insurance Company, a Humana company. 42

46 Humana Whole Life 99 Virginia Spouse Summary - Portsmouth Public Schools Here's a simple, voluntary whole life policy you can get at a reasonable cost during your working years, when you and your families need coverage the most. It's also a benefit that'll stay in place when retirement rolls around, too. You buy a policy with guaranteed coverage and actual cash value. Coverage stays level and cash values stay with the policy for as long as you have it, enabling you to take out funds as loans or buy paid-up coverage. Coverage type Benefit type Policyholder Benefit amount Humana Whole Life 99 is an individual whole life insurance product with premiums payable to age 99. Defined benefit Spouse Benefit amounts are available at various levels. You can choose: Spouse: $2,500 to $50,000 Stand-alone Spouse Coverage Simplified Issue - Up to $50,000 Issue ages Spouse stand-alone coverage: Additional included benefits Terminal illness acceleration benefit: For the primary insured provides an acceleration of up to 50 percent of the original death benefit, base and term rider, amount including any ABI amounts, upon diagnosis of a terminal illness. 12-month waiting period. Facility Care Acceleration Benefit: provides an acceleration of one percent of the face amount, up to $2,000/month up to a maximum of 36 months for Licensed Adult Day Care and/or up to two percent of the face amount, up to $4,000/month up to a maximum of 18 months for inpatient resident care. Benefits cannot exceed the lesser of 36 percent of the face amount, $72,000, or the face amount of the policy less the cash value. This is not a complete disclosure of plan qualifications and limitations. Please access our website to obtain a completed list for the Workplace Voluntary Benefit products at Disclosure.Humana.com. Please review this information before applying for coverage. The amount of benefits provided depends on the plan selected. Premiums will vary according to the selection made. Policy: Underwritten by Kanawha Insurance Company, a Humana company. VOL HumanaVoluntaryBenefits.com

47 Humana Whole Life 99 Virginia Spouse Summary - Portsmouth Public Schools Product restrictions Age calculation Portability Guarantee renewable Cash value Total amount of permanent life insurance coverage and term life insurance coverage with Kanawha Insurance Company not to exceed $300,000. If both parents are eligible employees, their eligible children may be insured by either spouse but not both. Purchasing option, whether money purchase or flat face amount, will be determined by the employer. When optional riders are selected, the weekly money purchase premium will be calculated to include the base benefit and any rider(s) (per applicant). If an employee's base policy, rider(s), and any additional Kanawha Insurance Company life insurance products exceed our company maximum of $300,000, we will first reduce the applicant's rider(s) on this coverage. If additional reductions are necessary, we will reduce the face amount of the base policy. Age at effective date of policy Yes Yes Whole Life 99 is a whole life policy with guaranteed values, not an interest sensitive policy. As such, there is not an interest rate associated with the cash value of the policy; the cash values are all guaranteed in the table of cash values inside each and every Whole Life policy. This is not a complete disclosure of plan qualifications and limitations. Please access our website to obtain a completed list for the Workplace Voluntary Benefit products at Disclosure.Humana.com. Please review this information before applying for coverage. The amount of benefits provided depends on the plan selected. Premiums will vary according to the selection made. Policy: Underwritten by Kanawha Insurance Company, a Humana company. VOL HumanaVoluntaryBenefits.com

48 Humana Whole Life 99 rates Virginia Spouse Summary - Portsmouth Public Schools Humana Whole Life 99 rates Spouse, Non-tobacco coverage, Defined Benefit amounts displaying monthly payroll deductions based on monthly premium calculation. Age Benefit Amount BENEFIT: $5,000 CASH VALUE* $10,000 CASH VALUE* $15,000 CASH VALUE* 18 $4.53 $2,405 $6.98 $4,811 $9.43 $7, $4.66 $2,405 $7.25 $4,811 $9.83 $7, $4.80 $2,405 $7.51 $4,811 $10.23 $7, $4.93 $2,405 $7.78 $4,811 $10.63 $7, $5.06 $2,405 $8.05 $4,811 $11.03 $7, $5.20 $2,405 $8.31 $4,811 $11.43 $7, $5.33 $2,405 $8.58 $4,811 $11.83 $7, $5.46 $2,405 $8.85 $4,811 $12.23 $7, $5.64 $2,405 $9.20 $4,811 $12.77 $7, $5.82 $2,405 $9.55 $4,811 $13.29 $7, $6.00 $2,394 $9.91 $4,787 $13.83 $7, $6.18 $2,371 $10.27 $4,741 $14.37 $7, $6.35 $2,346 $10.63 $4,692 $14.90 $7, $6.59 $2,320 $11.10 $4,641 $15.60 $6, $6.82 $2,293 $11.56 $4,586 $16.30 $6, $7.05 $2,265 $12.02 $4,529 $16.99 $6, $7.28 $2,234 $12.49 $4,469 $17.69 $6, $7.52 $2,202 $12.95 $4,405 $18.39 $6, $7.84 $2,169 $13.60 $4,338 $19.37 $6, $8.16 $2,133 $14.25 $4,267 $20.33 $6, $8.48 $2,096 $14.89 $4,192 $21.29 $6, $8.80 $2,057 $15.53 $4,113 $22.25 $6, $9.13 $2,015 $16.17 $4,030 $23.22 $6, $9.56 $1,971 $17.04 $3,942 $24.52 $5, $9.99 $1,924 $17.90 $3,849 $25.82 $5, $10.43 $1,875 $18.77 $3,751 $27.12 $5, $10.86 $1,824 $19.64 $3,647 $28.42 $5, $11.29 $1,769 $20.50 $3,539 $29.72 $5, $11.91 $1,800 $21.75 $3,599 $31.58 $5, $12.53 $1,831 $22.99 $3,662 $33.44 $5, $13.16 $1,864 $24.24 $3,727 $35.32 $5, $13.78 $1,897 $25.48 $3,795 $37.18 $5, $14.40 $1,932 $26.72 $3,865 $39.04 $5,797 *Cash values are for age 65 through age 45 and for 20 years for ages over 45. The proposed rates are for an effective date no later than January 1, HumanaVoluntaryBenefits.com Policy: Underwritten by Kanawha Insurance Company, a Humana company. 45

49 Humana Whole Life 99 rates Virginia Spouse Summary - Portsmouth Public Schools Humana Whole Life 99 rates Spouse, Non-tobacco coverage, Defined Benefit amounts displaying monthly payroll deductions based on monthly premium calculation. Age Benefit Amount BENEFIT: $5,000 CASH VALUE* $10,000 CASH VALUE* $15,000 CASH VALUE* 51 $15.20 $1,969 $28.33 $3,938 $41.45 $5, $16.01 $2,006 $29.94 $4,012 $43.87 $6, $16.82 $2,044 $31.55 $4,088 $46.29 $6, $17.62 $2,083 $33.16 $4,166 $48.70 $6, $18.43 $2,123 $34.77 $4,247 $51.12 $6, $19.78 $2,165 $37.48 $4,330 $55.18 $6, $21.13 $2,208 $40.19 $4,416 $59.24 $6, $22.49 $2,252 $42.90 $4,503 $63.30 $6, $23.84 $2,295 $45.60 $4,591 $67.36 $6, $25.20 $2,297 $48.31 $4,594 $71.43 $6, $27.83 $2,355 $53.58 $4,709 $79.33 $7, $30.47 $2,411 $58.85 $4,821 $87.23 $7, $33.10 $2,465 $64.12 $4,931 $95.14 $7, $35.74 $2,519 $69.39 $5,038 $ $7, $38.37 $2,571 $74.66 $5,142 $ $7, $40.37 $2,628 $78.66 $5,256 $ $7, $42.56 $2,682 $83.04 $5,365 $ $8, $44.88 $2,733 $87.67 $5,466 $ $8, $47.44 $2,780 $92.80 $5,560 $ $8, $50.13 $2,825 $98.18 $5,650 $ $8,476 *Cash values are for age 65 through age 45 and for 20 years for ages over 45. The proposed rates are for an effective date no later than January 1, HumanaVoluntaryBenefits.com Policy: Underwritten by Kanawha Insurance Company, a Humana company. 46

50 Humana Whole Life 99 rates Virginia Spouse Summary - Portsmouth Public Schools Humana Whole Life 99 rates Spouse, Non-tobacco coverage, Defined Benefit amounts displaying monthly payroll deductions based on monthly premium calculation. Age Benefit Amount BENEFIT: $20,000 CASH VALUE* $25,000 CASH VALUE* 18 $11.88 $9,622 $14.33 $12, $12.41 $9,622 $15.00 $12, $12.95 $9,622 $15.66 $12, $13.48 $9,622 $16.33 $12, $14.01 $9,622 $17.00 $12, $14.55 $9,622 $17.66 $12, $15.08 $9,622 $18.33 $12, $15.61 $9,622 $19.00 $12, $16.33 $9,622 $19.89 $12, $17.03 $9,622 $20.77 $12, $17.75 $9,574 $21.66 $11, $18.46 $9,482 $22.56 $11, $19.18 $9,385 $23.45 $11, $20.11 $9,282 $24.62 $11, $21.05 $9,173 $25.79 $11, $21.96 $9,058 $26.93 $11, $22.90 $8,937 $28.10 $11, $23.83 $8,810 $29.27 $11, $25.13 $8,675 $30.89 $10, $26.41 $8,533 $32.50 $10, $27.70 $8,384 $34.10 $10, $28.98 $8,226 $35.70 $10, $30.26 $8,060 $37.31 $10, $32.00 $7,883 $39.47 $9, $33.73 $7,698 $41.64 $9, $35.46 $7,502 $43.81 $9, $37.20 $7,295 $45.97 $9, $38.93 $7,077 $48.14 $8, $41.41 $7,198 $51.24 $8, $43.89 $7,324 $54.35 $9, $46.39 $7,454 $57.47 $9, $48.88 $7,590 $60.58 $9, $51.36 $7,730 $63.68 $9,662 *Cash values are for age 65 through age 45 and for 20 years for ages over 45. The proposed rates are for an effective date no later than January 1, HumanaVoluntaryBenefits.com Policy: Underwritten by Kanawha Insurance Company, a Humana company. 47

51 Humana Whole Life 99 rates Virginia Spouse Summary - Portsmouth Public Schools Humana Whole Life 99 rates Spouse, Non-tobacco coverage, Defined Benefit amounts displaying monthly payroll deductions based on monthly premium calculation. Age Benefit Amount BENEFIT: $20,000 CASH VALUE* $25,000 CASH VALUE* 51 $54.58 $7,876 $67.70 $9, $57.79 $8,025 $71.72 $10, $61.03 $8,176 $75.76 $10, $64.24 $8,333 $79.79 $10, $67.46 $8,494 $83.81 $10, $72.88 $8,660 $90.58 $10, $78.29 $8,832 $97.35 $11, $83.71 $9,007 $ $11, $89.13 $9,182 $ $11, $94.54 $9,187 $ $11, $ $9,419 $ $11, $ $9,643 $ $12, $ $9,862 $ $12, $ $10,076 $ $12, $ $10,284 $ $12, $ $10,511 $ $13, $ $10,730 $ $13, $ $10,933 $ $13, $ $11,120 $ $13, $ $11,301 $ $14,126 *Cash values are for age 65 through age 45 and for 20 years for ages over 45. The proposed rates are for an effective date no later than January 1, HumanaVoluntaryBenefits.com Policy: Underwritten by Kanawha Insurance Company, a Humana company. 48

52 If you were told you had cancer, what might you or your family have to do without? CAR SAVINGS HOME Cancer Insurance Supplements existing coverage and can provide cash to help with medical and living expenses Cancer Insurance from Allstate Benefits pays cash benefits for cancer and 20 specified diseases to help with the costs associated with treatments and expenses as they happen. ABJ Page 1 of 6 49

53 cancer Receiving a diagnosis of cancer or a specified disease can be difficult on anyone, both emotionally and financially. Having the right coverage to help when undergoing treatments is important. Our cancer coverage can help provide added financial support when it is needed most. Cancer coverage can help offer peace of mind when a diagnosis of cancer or a specified disease occurs. Below is an example of how benefits might be paid.* Jane Chooses Cancer Coverage from the plan benefits her employer is offering Jane s annual wellness exam results in her first diagnosis of cancer and she is told she needs surgery. She gets a second surgical opinion and undergoes pre-op testing. She is admitted to the hospital, undergoes inpatient surgery, anesthesia, private nursing, and is visited by a doctor during a 3-day hospital stay. Every 2 weeks she has radiation/ chemo 120 miles from her home and a family member drives her to her appointments. Our cancer insurance policy paid Jane the following: Wellness $ 50 Second Opinion $ 200 Hospital Confinement $ 600 Surgery $ 3,000 Anesthesia $ 750 Radiation/Chemo $10,000 Inpatient Medicine $ 30 Private Nursing $ 300 Cancer Initial Diagnosis $ 2,000 Non-Local Transportation $ 280 Physician Attendance $ 90 Total Benefits: $17,300 *The example shown may vary from the plan your employer is offering. Your individual experience may also vary. Please see pages 2a and/or 2b for your plan details. meeting your needs Our cancer and specified disease coverage can help offer you and your family financial support. Here s what you get: Coverage for cancer and 20 other specified diseases Benefits that are paid in addition to any other insurance you may have Can be used for non-medical expenses health insurance might not cover Guaranteed renewable for life, subject to change in premiums by class Premiums do not increase due to age Waiver of premium after 90 days of disability due to cancer for as long as your disability lasts** ** primary insured only benefit coverage highlights Cancer and specified disease benefits can help cover the costs of specific treatments and expenses as they happen. Terms and conditions for each benefit will vary. Benefit amounts are shown on pages 2a and/or 2b. See pages 4 and 5 for limits and conditions, and page 5 for state variations. 20 Specified Diseases Covered - Muscular Dystrophy, Poliomyelitis, Multiple Sclerosis, Encephalitis, Rabies, Tetanus, Typhoid Fever, Bubonic Plague, Tuberculosis, Osteomyelitis, Diphtheria, Scarlet Fever, Epidemic Cerebrospinal Meningitis, Undulant Fever, Sickle Cell Anemia, Rocky Mountain Spotted Fever, Smallpox, Addison s Disease, Hansen s Disease, Tularemia. RIDER BENEFIT Cancer Initial Diagnosis Level Benefit - Pays a one-time benefit if diagnosed for the first time with cancer (except skin cancer). RADIATION/CHEMOTHERAPY BENEFITS Radiation Therapy, Radioactive Isotopes Therapy, Chemotherapy or Immunotherapy - Pays a benefit for covered treatment to destroy or modify cancerous tissue. Blood, Plasma and Platelets - Pays a benefit for blood, plasma and platelets. Includes charges for transfusions, administration, processing, procurement and cross-matching. Page 2 of 6 ABJ

54 October 18 A doctor visit is scheduled Tests are run and results received You get cash benefits SURGERY AND RELATED BENEFITS Inpatient Surgery* - Pays a benefit for an inpatient operation. Outpatient Surgery*- Pays a benefit for an outpatient operation. Second Surgical Opinion - Pays a benefit when you get a second surgical opinion. Anesthesia - Pays a benefit for anesthesia received during a covered surgery. Ambulatory Surgical Center - Pays a daily benefit for surgery at an ambulatory surgical center. HOSPITAL CONFINEMENT BENEFITS Hospital Confinement - Pays a daily benefit for inpatient confinement. Extended Hospital Confinement - Pays a daily benefit when continuously confined in a hospital for more than 70 days. In lieu of all other benefits. Government or Charity Hospital - Pays a daily benefit for inpatient confinement to a U.S. government hospital or a hospital that does not charge for its services. In lieu of all other benefits. Private Duty Nursing Services - Pays a daily benefit when receiving physician-authorized inpatient private nursing services. Extended Care Facility - Pays a daily benefit for physicianauthorized inpatient confinement (within 14 days of a hospital stay). At Home Nursing - Pays a daily benefit for physicianauthorized private nursing care (within 14 days of a hospital stay). LODGING AND TRANSPORTATION BENEFITS Ambulance - Pays a benefit for transfer by ambulance service to or from a hospital. Non-Local Transportation - Pays a benefit for transportation for treatment not available locally (up to 700 miles). Family Member Lodging and Transportation - Pays a benefit for one adult family member when confined at a non-local hospital for specialized treatment (more than 100 miles from family member s home). Outpatient Lodging - Pays a daily benefit for lodging when receiving radiation or chemotherapy on an outpatient basis non-locally (more than 100 miles from home). MISCELLANEOUS BENEFITS Hospice Care (Freestanding Hospice Care Center or Hospice Care Team) - Pays a daily benefit when physician approves and determines terminal illness requires hospice care at home or in a freestanding hospice care center (within 14 days of hospital stay). Inpatient Drugs and Medicine - Pays a daily benefit for inpatient drugs and medicine. Physician s Attendance - Pays a daily benefit for one inpatient visit. New or Experimental Treatment - Pays a benefit for physician-approved new or experimental treatments not covered under other benefits. Physical or Speech Therapy - Pays a daily benefit for therapy to restore normal body function. Prosthesis - Pays a benefit for a surgically implanted prosthetic device. Skin Cancer - Pays a benefit for removal of skin cancer diagnosed by a doctor who is not a pathologist. Waiver of Premium (primary insured only) - Pays premiums after being disabled 90 days in a row due to cancer, for as long as disability lasts. *Assistant and cosurgeons are not covered. Two or more surgical procedures done at the same time, through one incision, are considered one operation. The operation with the largest benefit will be paid. 51 ABJ Page 3 of 6

55 RIDER BENEFITS Wellness Benefit - Pays a benefit when you receive one of the following: Biopsy for skin cancer Blood test for triglycerides Bone Marrow Testing CA15-3 (cancer antigen blood test for breast cancer) CA125 (cancer antigen 125 blood test for ovarian cancer) CEA (carcinoembryonic antigen blood test for colon cancer) Chest X-ray Colonoscopy Doppler screening for carotids Doppler screening for peripheral vascular disease Echocardiogram EKG (Electrocardiogram) Flexible sigmoidoscopy Hemoccult stool analysis HPV (Human Papillomavirus) Vaccination Lipid panel (total cholesterol count) Mammography, including Breast Ultrasound Pap Smear, including ThinPrep Pap Test PSA (prostate specific antigen blood test for prostate cancer) Serum Protein Electrophoresis (test for myeloma) Stress test on bike or treadmill Thermography Ultrasound screening of the abdominal aorta for abdominal aortic aneurysms Hospital Intensive Care - Pays a daily benefit for intensive care and ambulance transportation. Cancer and Specified Disease Additional Benefit (CAB) - Enhances some benefits of the base policy and adds new ones not in the base policy. The rider benefit amount is included with each of these base policy benefits. Benefits enhanced by the CAB rider are: Hospital Confinement; Extended Hospital Confinement; Inpatient Drugs and Medicine; Second Surgical Opinion; Physician s Attendance; Private Duty Nursing Services; Radiation Therapy, Radioactive Isotopes Therapy, Chemotherapy, or Immunotherapy; Blood, Plasma and Platelets; Non-Local Transportation; Family Member Transportation; Ambulatory Surgical Center; Hospice Care; and Physical or Speech Therapy. The rider benefit amount is included with each of these base policy benefits. The following benefits are paid in addition to the base policy. Medical Imaging - Pays a benefit when a covered imaging exam leads to an initial diagnosis or follow-up evaluation. Comfort/Anti-Nausea - Pays a benefit for prescribed anti-nausea medication taken on an outpatient basis. Hematological Drugs - Pays a benefit for drugs to boost cell lines when Radiation Therapy, Radioactive Isotopes Therapy, Chemotherapy or Immunotherapy benefit is paid. Hair Prosthesis - Pays a benefit for a wig or hairpiece when hair loss is experienced. Nonsurgical External Breast Prosthesis - Pays a benefit for the initial nonsurgical breast prosthesis after a covered mastectomy. CERTIFICATE SPECIFICATIONS Renewability - The policy is guaranteed renewable for life, subject to change in premiums by class. All premiums may change on a class basis. A notice is mailed in advance of any change. Eligibility/Termination - (a) Coverage may include you, your spouse and children. (b) Coverage for children ends when the child reaches age 26, unless he or she continues to meet the requirements of an eligible dependent. (c) Spouse coverage ends upon valid decree of divorce. Rider Termination - The riders terminate at the end of the grace period, if the policy terminates, or on the next renewal date after you request termination. Policy and Rider(s) Waiting Period - (a) The policy and rider(s) have a 30-day waiting period that starts on the effective date. Benefits are not paid for any person diagnosed with cancer or a specified disease before coverage is in force 30 days from the effective date. (b) If diagnosis is after signing the application, but before the end of the waiting period, benefits for treatment of that cancer or specified disease will apply to losses beginning after 2 years from the effective date; or, you may void the policy and receive a full refund of premium. Exceptions and Limitations - (a) Benefits are not paid for any loss except for losses due to cancer or specified disease. (b) Benefits are not paid for losses caused or aggravated by cancer or a specified disease or as a result of treatment. (c) Treatment must be received in the U.S. or its territories. Cancer and Specified Disease Additional Benefit (CAB) Rider must be purchased to receive the additional benefits described. 52 ABJ Page 4 of 6

56 Hospice Care Team Benefit Limitation - Services are not covered for food or meals, well-baby care, volunteers or support for the family after the covered person s death. Radiation Therapy, Radioactive Isotopes Therapy, Chemotherapy or Immunotherapy Benefit Limitations - Does not pay for: treatment or emergency room charges; treatment planning, management, devices, or supplies; medications other than chemotherapeutic drugs; X-rays, scans, and their interpretations; or any other drug, charge or expense that does not directly modify or destroy cancerous tissues. Hospital Intensive Care Rider Exceptions and Limitations - (a) Benefits are not paid due to: (1) attempted suicide or self-inflicted injury; (2) intoxication or being under the influence of drugs not prescribed by a physician; (3) alcoholism or drug addiction. (b) Benefits are not paid for continuous intensive-care confinements occurring during hospitalization that begins before the effective date. (c) Children born within 10 months of the effective date are not covered for confinement occurring or beginning during the first 30 days of the child s life. STATE VARIATIONS North Carolina (changes affect pages 3, 4, and 5) - The following is added as a policy benefit: Wellness Benefit - Pays a benefit when you receive one of the following: Mammography - low-dose mammography is covered at the following intervals: (a) one or more per year, as recommended by a physician, for women at risk for breast cancer; (b) every other year for women 35 to 39 years of age, inclusive; (c) every other year for any woman 40 to 49 years of age, inclusive, or more frequently upon recommendation of a physician; and (d) every year for women 50 years of age or older; Pap Smears - every year, or more frequently if recommended by a physician; Biopsy for skin cancer; Blood tests for triglycerides, CA15-3 (breast cancer), CA125 (ovarian cancer), CEA (colon cancer), and PSA (prostate cancer); Bone Marrow Testing, Chest X-ray; Colonoscopy; Doppler screening for carotids or peripheral vascular disease; Echocardiogram; EKG; Flexible sigmoidoscopy; Hemoccult stool analysis; HPV Vaccination; Lipid panel (total cholesterol count); Serum Protein Electrophoresis (test for myeloma); Stress test on bike or treadmill; Thermography; and Ultrasound screening for abdominal aortic aneurysms. In the Policy and Rider(s) Waiting Period paragraph, item (b) is replaced with: If diagnosis is after signing the application, but before the end of the waiting period, benefits for that cancer or specified disease will apply to losses beginning after 12 months from the effective date; or you may void the policy and receive a full refund of premium. In the Hospital Intensive Care Rider Exceptions and Limitations paragraph, item (a)(2) is replaced with: from being intoxicated or under the influence of any narcotic not prescribed by a physician; item (c) is deleted. South Carolina (changes affect pages 3 and 4) The Government or Charity Hospital benefit is replaced with: Charity Hospital - Pays a daily benefit for inpatient confinement to a hospital that does not charge for its services. In lieu of all other benefits. In the Exceptions and Limitations paragraph, item (a) is replaced with: Benefits are not paid for any loss except for losses due to cancer or specified disease or other conditions or diseases caused or aggravated by cancer or a specified disease. Item (b) is deleted. Tennessee (changes affect pages 4 and 5) - The Hospital Intensive Care Rider is renamed Hospital Intensive Care Policy. In the Hospital Intensive Care Policy Exceptions and Limitations paragraph, item (a)(2) is replaced with: from being intoxicated or under the influence of any narcotic unless taken on the advice of a physician. Virginia (change affects page 4) - In the Exceptions and Limitations paragraph, item (b) is deleted. West Virginia (changes affect pages 3 and 5) The following is added to the Inpatient Drugs and Medicine benefit: Pays a benefit for rental of equipment necessary for the treatment of the disease. The Radiation Therapy, Radioactive Isotopes Therapy, Chemotherapy, or Immunotherapy Benefit Limitations paragraph is replaced with: Does not pay for: treatment or emergency room charges; treatment planning, management, devices, or supplies; medications other than chemotherapeutic drugs; or any other drug, charge or expense that does not directly modify or destroy cancerous tissues. Page 5 of 6 ABJ

57 Rev. 5/14. This material is valid as long as information remains current, but in no event later than July 1, Policy benefits provided by policy CP10B, or state variations thereof. Riders provided by riders CLR1, WBR5, CABR1, and ICR2, or state variations thereof. The policy and riders provide Limited Benefit Supplemental Cancer and Specified Disease Insurance. The policy is not a Medicare Supplement Policy. If eligible for Medicare, review Medicare Supplement Buyer s Guide available from Allstate Benefits. This brochure highlights some features of the policy but is not the insurance contract. Only the actual policy provisions control. For complete details, contact your Allstate Benefits Agent. Underwritten by American Heritage Life Insurance Company (Home Office, Jacksonville, FL). This coverage does not constitute comprehensive health insurance coverage (often referred to as major medical coverage ) and does not satisfy the requirement of minimum essential coverage under the Affordable Care Act. This brochure is for use in: KY, NC, OH, SC, TN, VA, WV Allstate Benefits is the marketing name used by American Heritage Life Insurance Company, a subsidiary of The Allstate Corporation Allstate Insurance Company. or allstatebenefits.com. Page 6 of 6 ABJ

58 cancer RIDER BENEFIT Basic Enhanced Premier Cancer Initial Diagnosis Level Benefit $2,000 1 $4,000 1 $5,000 1 RADIATION/CHEMOTHERAPY BENEFITS Radiation Therapy, Radioactive Isotopes $10,000 2 $15,000 2, 3 $20,000 2, 3 Therapy, Chemotherapy, and Immunotherapy* Blood, Plasma, and Platelets* $10,000 2 $15,000 2, 3 $20,000 2, 3 SURGERY AND RELATED BENEFITS Inpatient Surgery* $3,000 $3,000 $3,000 Outpatient Surgery* $4,500 $4,500 $4,500 Second Surgical Opinion* $200 $250 3 $300 3 Anesthesia* (% of surgery) 25% 4 25% 4 25% 4 Ambulatory Surgical Center* (daily) $250 $375 3 $500 3 HOSPITAL CONFINEMENT BENEFITS Hospital Confinement (daily, up to 70 days) $200 $250 3 $300 3 Extended Hospital Confinement* (daily) $200 $300 3 $400 3 Government or Charity Hospital (daily) $100 $100 $100 Private Duty Nursing Services* (daily) $100 $150 3 $200 3 Extended Care Facility* (daily) $100 $100 $100 At Home Nursing* (daily) $100 $100 $100 LODGING AND TRANSPORTATION BENEFITS Ambulance* $200 $200 $200 Non-Local Transportation (per trip or mile) Coach Fare Coach Fare Coach Fare or $0.40 or $ or $ Family Member Lodging* (daily) $100 $100 $100 and Transportation (per trip or mile) Coach Fare Coach Fare Coach Fare or $0.40 or $ or $ Outpatient Lodging* (daily) $100 5 $100 5 $100 5 MISCELLANEOUS BENEFITS Hospice Care* (per day) $100 $150 3 $200 3 Inpatient Drugs and Medicine* (daily) $10 $20 3 $30 3 Physician s Attendance* (daily) $30 $40 3 $50 3 New or Experimental Treatment* $10,000 2 $10,000 2 $10,000 2 Physical or Speech Therapy* (daily) $25 $50 3 $75 3 Prosthesis* $2,000 6 $2,000 6 $2,000 6 Skin Cancer* $120 7 $120 7 $120 7 Waiver of Premium Yes Yes Yes RIDER BENEFITS Wellness (per year) $50 $100 $100 Hospital Intensive Care (+Ambulance) (per day) $600 8 $600 8 $600 8 Cancer and Specified Disease Additional Benefits Medical Imaging* (yearly) No $250 $500 Comfort/Anti-Nausea* (yearly) No $100 $200 Hematological Drugs* (yearly) No $100 $200 Hair Prosthesis (every 2 years) No $25 $50 Nonsurgical External Breast Prosthesis* No $50 $100 Listed to the left are benefit amounts associated with the benefits described in the brochure. * Benefit pays for charges/ costs up to amount listed 1 One-time benefit 2 Per 12 mo. 3 Includes the CAB Rider which increases the base policy benefit 4 $100 for Skin Cancer 5 Limit $4,000 per 12 mo. period 6 Per amputation 7 For first removal. $60 each additional removal 8 Reduces to $300 at age 70. Also pays charges for transportation to ICU. Ambulance ICR Benefit not paid if the base policy ambulance benefit is paid. ABJ Insert-GLT-BEP 55 Page 2a (BEP)

59 premiums MODE PLAN EMPLOYEE FAMILY Weekly Monthly Weekly Monthly Weekly Monthly Basic 200 $4.21 $7.25 Basic 200+ICU $5.59 $10.02 Basic 200 $18.22 $31.42 Basic 200+ICU $24.21 $43.41 Enhanced 300 $6.11 $10.86 Enhanced 300+ICU $7.49 $13.62 Enhanced 300 $26.47 $47.03 Enhanced 300+ICU $32.46 $59.02 Premier 400 $7.47 $13.53 Premier 400+ICU $8.85 $16.30 Premier 400 $32.35 $58.63 Premier 400+ICU $38.34 $70.62 Issue Ages: This insert is for use in: KY, OH, TN, VA This insert is part of brochure ABJ and is not to be used on its own. This material is valid as long as information remains current, but in no event later than July 1, Allstate Benefits is the marketing name used by American Heritage Life Insurance Company, a subsidiary of The Allstate Corporation Allstate Insurance Company. or allstatebenefits.com. ABJ Insert-GLT-BEP 56 Page 2b (BEP)

60 What if you suffered from a heart attack or a stroke... could you pay for your out-of-pocket treatment expenses, plus cover daily living expenses? GROCERIES CAR HOME PRESCRIPTIONS Heart/Stroke Insurance Helps cover costs associated with heart attack, stroke, or heart disease No one likes to think about getting heart disease. While you may not be able to prevent the disease, HeartCare Plus and HeartCare Direct (HSP2) from Allstate Benefits can help protect you and your family from its costs. ABJ23234 Page 1 of 6 (B) 57

61 heart/stroke It s probably crossed your mind that you or your family may need treatment some day for heart disease or stroke. And you may have thought about the ways it would affect your life and your loved ones. But have you considered how cardiovascular diseases could impact your financial security? Heart/Stroke coverage can help offer peace of mind if you have a heart attack, stroke, or are diagnosed with heart disease. Below is an example of how benefits might be paid. Jane chooses benefit coverage from the Plan Benefits Offered Jane suffers a mild heart attack and is taken to the hospital by ambulance. A physician in the emergency room runs several heart-related tests, and the results show she needs an angioplasty and pacemaker surgery. Jane is admitted for a 3-day hospital stay, she is seen by her physician and receives private nursing services. Jane s prognosis is good and she is expected to make a full recovery. Our insurance policy paid Jane the following: Ambulance $ Hospital Confinement $ Physician's Attendance $ Coronary Angioplasty $ Pacemaker Insertion $ Private Duty Nursing $ Total Benefits: $1, The example shown may vary from the plan your employer is offering. Your individual experience may also vary. Please see pages 2a and/or 2b for your plan details. meeting your needs Our coverage can help provide financial support when a heart attack, heart disease or stroke occurs. Here s what you get: Pays you benefits that can be used for non-medical expenses that health insurance might not cover Benefits are paid as you go to help cover the costs of specific treatments and expenses as they happen Supplemental coverage; it pays in addition to other insurance you may have, such as medical and disability Guaranteed renewable for life, subject to change in premiums by class Coverage for yourself or your entire family your benefit coverage HOSPITALIZATION AND RELATED BENEFITS Hospital Confinement Pays a daily benefit for inpatient confinement due to heart attack, heart disease or stroke. Physician s Attendance Pays a daily benefit for one inpatient visit. Inpatient Drugs and Medicine Pays a daily benefit for inpatient drugs and medicine. Private Duty Nursing Services* Pays a daily benefit when receiving physician-authorized inpatient private nursing services Physiotherapy* Pays a benefit for physiotherapy by a licensed physical therapist during a covered hospital stay. Oxygen** Pays a benefit for oxygen equipment during a covered hospital stay. Cardiograms** Pays a benefit for an electro, echo, phono, or vectorcardiogram required during a covered hospital stay. Cerebral or Carotid Angiogram** Pays a benefit for a cerebral or carotid angiogram required during a covered hospital stay. Page 2 of 6 ABJ23234 *Maximum of 60 days per confinement. **Maximum of 1 payment per confinement. Benefit amounts are shown on pages 2a and/or 2b. See pages 3 and 4 for conditions and limits and also see page 4 for state variations. 58

62 Heart Disease tests covered October 18 You're admitted to the hospital Cardiogram tests received You get paid a cash benefit SURGERY AND RELATED BENEFITS Blood, Plasma and Platelets** Pays a benefit for blood, plasma, or platelets during a covered hospital stay. Cardiac Catheterization Pays a benefit for a cardiac catheterization. Pacemaker Insertion Pays a benefit for the initial insertion of a permanent pacemaker. Thromboendarterectomy Pays a benefit for a thromboendarterectomy. Heart Transplant Pays a benefit for the implantation of a natural human heart. Payable once per covered person. Coronary Angioplasty Pays a benefit for a coronary angioplasty, regardless of the number of blood vessels repaired during the procedure. Coronary Artery Bypass Graft Operation Pays a benefit for a coronary artery bypass graft, regardless of the number of grafts performed during the operation. Second Surgical Opinion Pays a benefit for a second opinion. Surgery and Anesthesia 1. Surgery - Pays a benefit for an inpatient or outpatient operation listed in the Policy Surgical Schedule. 2. Anesthesia - Pays 25% of surgery benefit. 3. Ambulatory Surgical Center - Pays when surgery benefit is paid for surgery at an ambulatory surgical center. These benefits do not pay for surgeries covered by other benefits. TRANSPORTATION AND LODGING BENEFITS Ambulance Pays a benefit for transfer to or from a hospital. Non-Local Transportation** Pays a benefit for transportation for physician-prescribed treatment not available locally (more than 100 miles from home). Family Member Lodging* and Transportation** Pays a benefit for lodging and transportation for one adult family member to accompany you when you have physician-prescribed treatment at a hospital or treatment center more than 100 miles from the family member's home. OPTIONAL RIDER BENEFIT Cancer Initial Diagnosis Pays a one-time benefit if diagnosed for the first time with cancer (except skin cancer). POLICY AND RIDER SPECIFICATIONS Please read your policy carefully. This section details some specifics of the policy and rider. Renewability The policy and rider are guaranteed renewable for life, subject to change in premiums by class. Eligibility/Termination (a) Family coverage may include you, your spouse and children under age 26. Spouse coverage ends upon divorce or your death. (b) Coverage for children ends when the child reaches age 26, unless he or she continues to meet the requirements of an eligible dependent. Policy Exclusions and Limitations (a) The policy pays benefits only for heart attack, heart disease or stroke. (b) The policy does not cover any other disease or sickness or incapacity even though caused, complicated or otherwise affected by heart attack, heart disease or stroke. (c) If a covered confinement is due to more than one covered condition, benefits are paid as though the confinement was due to one condition. Pre-Existing Condition Limitation for Policy and Rider (a) We do not pay benefits for pre-existing conditions during the 12-month period beginning on each covered person's effective date. (b) A pre-existing condition is a condition not revealed in the application for which symptoms existed within a 1-year period before the effective date; or medical advice or treatment was recommended by or received from a doctor within the 1-year period before the effective date. Cancer Initial Diagnosis Rider Exclusions and Limitations Benefits are not paid for any disease other than cancer as defined in the rider. Pre-cancerous and skin cancer are not included. *Maximum of 60 days per confinement. **Maximum of 1 payment per confinement. 59 ABJ23234 Page 3 of 6

63 STATE VARIATIONS Delaware (change affects page 3) In the Policy Exclusions and Limitations, item (b) is deleted. In the Pre-Existing Condition Limitation, item (b) is replaced with: A pre-existing condition is the existence of symptoms which would cause an ordinarily prudent person to seek diagnosis, care or treatment within the 1-year period before the effective date, or medical advice or treatment was recommended by or received from a physician within the 1-year period before the effective date. Virginia (changes affect page 3) - In the Exclusions and Limitations, item (b) is deleted. In the Pre-Existing Condition Limitation, item (b) is replaced with: A pre-existing condition is a condition not revealed in the application for which symptoms existed which would cause an ordinarily prudent person to seek diagnosis, care or treatment within one year before the effective date. District of Colombia (change affects page 3) In Eligibility/ Termination paragraph, item (a) is replaced with: Family coverage may include you; your spouse, domestic partner, or civil union partner; and children under 26. Spouse coverage ends upon divorce or your death. If your civil union partner is a covered person, your civil union partner's coverage ends upon termination of the civil union partnership or your death. If your domestic partner is a covered person, your domestic partner's coverage ends upon termination of the domestic partnership or your death. Maryland (change affects page 3) In the Exclusions and Limitations, item (b) is deleted. North Carolina (change affects page 3) In the Pre-Existing Condition Limitation, item (b) is replaced with: A preexisting condition is a condition not revealed in the application for which symptoms existed within a 1-year period before the effective date; and medical advice or treatment was recommended by or received from a doctor within the 1-year period before the effective date. South Carolina (changes affect pages 3) In the Policy Exclusions and Limitations, item (b) is deleted. In the Pre-Existing Condition Limitation, item (b) is replaced with: A pre-existing condition is a condition which is misrepresented or not revealed in the application and for which symptoms existed before the effective date that would cause an ordinarily prudent person to seek diagnosis, care or treatment or medical advice or treatment was recommended by or received from a physician. Tennessee (changes affect page 3) - In the Exclusions and Limitations, item (a) is replaced with: The policy provides benefits only for Heart Attack, Coronary Artery Disease or Stroke; item (b) is replaced with: This policy does not cover any other disease or sickness or incapacity other than Heart Attack, Coronary Artery Disease or Stroke even though such disease, sickness or incapacity may be caused, complicated or otherwise affected by Heart Attack, Coronary Artery Disease or Stroke. 60 ABJ23234 Page 4 of 6

64 Don t wait for a sign... A heart attack or stroke can happen unexpectedly and can be costly, especially if you are financially unprepared. Your current medical coverage will help pay for expenses associated with a heart attack or stroke, but won t cover all of the out-of-pocket expenses you may face. Don t wait until you are rushed to the emergency room to realize you need more protection. Start thinking about the future or your finances today and plan for emergencies that might come your way. You can rely on our insurance to help provide the financial assistance you need, when you need it most, so you can focus on the challenges of recovery. If you suffer a heart attack or stroke, would you be able to handle the extra expenses associated with your recovery? It s never too early to prepare for the future. Page 5 of 6 ABJ

65 This material is valid as long as information remains current, but in no event later than February 15, Policy benefits provided by policy form HSP2, or state variations thereof. Cancer Initial Diagnosis Rider benefit provided by CIDR1, or state variations thereof. The policy and rider provides supplemental, limited benefit insurance. The policy and rider are not Medicare Supplement Policies. If eligible for Medicare, review Medicare Supplement Buyer's Guide available from Allstate Benefits. The policy and rider set forth, in detail, the rights and obligations of both the insured and the insurance company. This brochure highlights some features of the policy but is not the insurance contract. Only the actual policy provisions control. For complete details, contact your Insurance Agent, or call Underwritten by American Heritage Life Insurance Company (Home Office, Jacksonville, FL). This brochure is for use in: DE, DC, KY, MD, NC, OH, SC, TN, VA Allstate Benefits is the marketing name used by American Heritage Life Insurance Company, a subsidiary of The Allstate Corporation Allstate Insurance Company. or allstatebenefits.com Page 6 of 6 ABJ

66 heart/stroke HeartCare Plus HOSPITALIZATION AND RELATED BENEFITS LOW PLAN HIGH PLAN Hospital Confinement (daily) $100 $200 Physician s Attendance (daily) $12.50 $25 Inpatient Drugs and Medicine (daily) $12.50 $25 Private Duty Nursing Services (daily) $50 $100 Physiotherapy (daily) $25 $50 Oxygen $100 $200 Cardiograms $50 $100 Cerebral or Carotid Angiogram $75 $150 SURGERY AND RELATED BENEFITS LOW PLAN HIGH PLAN Blood, Plasma and Platelets $100 $200 Cardiac Catheterization $250 $500 Pacemaker Insertion $500 $1,000 Thromboendarterectomy $1,250 $2,500 Heart Transplant $50,000 $100,000 Coronary Angioplasty $375 $750 Coronary Artery Bypass Graft Operation $1,250 $2,500 Second Surgical Opinion $50 $100 Surgery and Anesthesia 1. Surgery 1. $2,500 max. 1. $5,000 max. 2. Anesthesia 2. 25% 2. 25% 3. Ambulatory Surgical Center 3. $ $250 TRANSPORTATION AND LODGING BENEFITS LOW PLAN HIGH PLAN Ambulance Non-Air Ambulance $100 $200 Air Ambulance $200 $400 Non-Local Transportation $100 $200 Family Member Lodging (daily) $25 $50 Family Member Transportation $100 $200 RIDER BENEFIT LOW PLAN HIGH PLAN Cancer Initial Diagnosis Rider 1 $5,000 $10,000 PACKAGES Low Plan Heart/Stroke + Cancer Initial Diagnosis Rider High Plan Heart/Stroke + Cancer Initial Diagnosis Rider 1 One time benefit. premiums MODE PLAN EMPLOYEE FAMILY Weekly Low $3.65 $7.14 Monthly Low $15.78 $30.92 Weekly High $7.29 $14.27 Monthly High $31.56 $61.84 Issue Ages: This insert is for use in: DE, DC, KY, OH, TN, VA This insert is part of brochure ABJ23234 and is not to be used on its own. Allstate Benefits is the marketing name used by American Heritage Life Insurance Company (Home Office, Jacksonville, FL), a subsidiary of The Allstate Corporation Allstate Insurance Company. or allstatebenefits.com. ABJ23234-Insert-GLT-B 63 Page 2a (B)

67 Peace of Mind and Real Cash Benefits GROUP CRITICAL ILLNESS Includes Cancer and Wellness This brochure is a brief description of coverage and is not a contract. Read your certificate carefully for exact terms and conditions. Definitions, waiting period, pre-existing condition limitation, limitations and exclusions, benefits, 64 see your agent for the plan termination, portability, etc., may vary based on your employer's home office. Please details specific to your employer. CI G CAI2875 IC(3/10)

68 CI G GROUP Critical Illness Policy Series CAI2800 This brochure is a brief description of coverage and is not a contract. Read your certificate carefully for exact terms and conditions. You can win the battle against a critical illness, but can you handle the added costs? A g rou p cri tica l illne ss pla n he lps pr ep ar e y ou f or th e ad d ed costs o f ba ttling a spe cific cr it ical illn es s. The good news is that many people with a critical illness survive these lifethreatening battles. Unfortunately, as the recovery process begins, people become aware of the medical bills that have piled up. Y ou r recov ery do e sn t ha ve to be spo iled b y m ed ical b ills. With this plan, our goal is to help you and your family cope with and recover from the financial stress of surviving a critical illness. COVERAGE WORK SHEET Employee Benefit: $ Spouse Benefit: $ Child Benefit: $ Total Weekly Deduction: $ (25 percent of the primary insured amount) This work sheet is for illustration purposes only. It does not imply coverage. 65

69 BENEFITS This brochure is a brief description of coverage and is not a contract. Read your certificate carefully for exact terms and conditions. Covered Critical Illnesses: 1 CANCER (Internal or Invasive) 100% HEART ATTACK (Myocardial Infarction) 100% STROKE (Apoplexy or Cerebral Vascular Accident) 100% MAJOR ORGAN TRANSPLANT 100% FIRST-OCCURRENCE BENEFIT After the waiting period, a lump sum benefit is payable upon initial diagnosis of a covered critical illness. Employee benefit amounts available from $5,000 to $50,000. Spouse coverage is also available in benefit amounts up to $25,000. If you are deemed ineligible due to a previous medical condition, you still retain the ability to purchase Spouse coverage. ADDITIONAL OCCURRENCE BENEFIT If an insured collects full benefits for a critical illness under the plan and later has one of the remaining covered critical illnesses, then we will pay the full benefit amount for each additional illness. Occurrences must be separated by at least six months. $50 Health Screening Benefit (Employee and Spouse only) After the waiting period, an insured may receive a maximum of $50 for any one covered health screening test per calendar year. We will pay this benefit regardless of the results of the test. Payment of this benefit will not reduce the critical illness benefit payable under your certificate. There is no limit to the number of years the insured can receive the health screening benefit; it will be paid as long as the certificate remains in force. This benefit is payable for the covered Employee and Spouse. This benefit is not paid for Dependent Children. Covered health screening tests include: Mammography Colonoscopy Pap smear Breast ultrasound Chest X-ray PSA (blood test for prostate cancer) Stress test on a bicycle or treadmill Bone marrow testing CA 15-3 (blood test for breast cancer) RENAL FAILURE (End-Stage) 100% CARCINOMA IN SITU 2 25% CORONARY ARTERY BYPASS SURGERY 2 25% RE-OCCURRENCE BENEFIT If an insured collects full benefits for a covered condition and is later diagnosed with the same condition, we will pay the full benefit again. The two dates of diagnosis must be separated by at least 12 months, or for cancer, 12 months treatment free. Cancer that has spread (metastasized) even though there is a new tumor, will not be considered an additional occurrence unless the Insured has gone treatment free for 12 months. CHILD COVERAGE AT NO ADDITIONAL COST Each Dependent Child is covered at 25 percent of the primary insured amount at no additional charge. OVER 1.4 FACT MILLION The number of new cancer cases that were expected to be diagnosed in Cancer Facts & Figures 2009, American Cancer Society. CA 125 (blood test for ovarian cancer) CEA (blood test for colon cancer) Flexible sigmoidoscopy Hemocult stool analysis Serum protein electrophoresis (blood test for myeloma) Thermography Fasting blood glucose test Serum cholesterol test to determine level of HDL and LDL 1 All covered conditions are subject to the definitions found in your certificate. 2 If a benefit is paid for Carcinoma in Situ, the Internal Cancer benefit will be reduced by 25 percent. If a benefit is paid for Coronary Artery Bypass Surgery, the Heart Attack benefit will be reduced by 25 percent. What is Not Covered, Limitations and EXCLUSIONS, AND TERMS YOU NEED TO KNOW If diagnosis occurs after the age of 70, half of the benefit is payable. The plan contains a 30-day waiting period. This means that no benefits are payable for any insured who has been diagnosed before your coverage has been in force 30 days from the effective date. If an insured is first diagnosed during the waiting period, benefits for treatment of that critical illness will apply only to loss starting after 12 months from the Effective Date or the Employee can elect to void the coverage and receive a full refund of premium. The applicable benefit amount will be paid if: the date of diagnosis is after the waiting period; the date of diagnosis occurs while the certificate is in force; and the cause of the illness is not excluded by name or specific description. exclusions Benefits will not be paid for loss due to: Intentionally self-inflicted injury or action; Suicide or attempted suicide while sane or insane; Illegal activities or participation in an illegal occupation; 66

70 What is Not Covered, Limitations and EXCLUSIONS, AND TERMS YOU NEED TO KNOW War, whether declared or undeclared or military conflicts, participation in an insurrection or riot, civil commotion or state of belligerence; Substance abuse; or Pre-Existing Conditions (except as stated below). No benefits will be paid for loss which occurred prior to the Effective Date. No benefits will be paid for diagnosis made or treatment received outside of the United States. Pre-existing Condition Limitation Pre-Existing Condition means a sickness or physical condition which, within the 12-month period prior to the Effective Date, resulted in the insured receiving medical advice or treatment. We will not pay benefits for any critical illness starting within 12 months of the Effective Date which is caused by, contributed to, or resulting from a Pre- Existing Condition. A claim for benefits for loss starting after 12 months from the Effective Date will not be reduced or denied on the grounds that it is caused by a Pre-Existing Condition. A critical illness will no longer be considered pre-existing at the end of 12 consecutive months starting and ending after the Effective Date. TERMS YOU NEED TO KNOW The Effective Date of your insurance will be the date shown in your Certificate Schedule. Employee means the insured as shown in the Certificate Schedule. Spouse means an Employee's legal wife or husband. Dependent Children means your natural children, stepchildren, legally adopted children, or children placed for adoption, who are unmarried, chiefly dependent on you or your Spouse for support, and younger than age 25. However, if any child is incapable of self-sustaining employment due to mental retardation or physical handicap and is dependent on a parent(s) for support, the above age of 25 limitation shall not apply. Proof of such incapacity and dependency must be furnished to the company within 31 days following such child s 25th birthday. Treatment means consultation, care, or services provided by a physician, including diagnostic measures and taking prescribed drugs and medicines. Major Organ Transplant means undergoing surgery as a recipient of a transplant of a human heart, lung, liver, kidney, or pancreas. Myocardial Infarction (Heart Attack) means the death of a portion of the heart muscle (myocardium) resulting from a blockage of one or more coronary arteries. Heart Attack does not include any other disease or injury involving the cardiovascular system. Cardiac arrest not caused by a Myocardial Infarction is not a Heart Attack. The diagnosis must include all of the following criteria: 1. New and serial eletrocardiographic (EKG) findings consistent with Myocardial Infarction; 2. Elevation of cardiac enzymes above generally accepted laboratory levels of normal [in case of creatine phosphokinase (CPK), a CPK-MB measurement must be used]; and 3. Confirmatory imaging studies such as thallium scans, MUGA scans, or stress echocardiograms. Stroke means apoplexy (due to rupture or acute occlusion of a cerebral artery), or a cerebral vascular accident or incident which is first manifested on or after your Effective Date. Stroke does not include transient ischemic attacks and attacks of vertebrobasilar ischemia. We will pay a benefit for Stroke that produces permanent clinical neurological sequela following an initial diagnosis We ve got you under our wing. aflacgroupinsurance.com The certificate to which this sales material pertains is written only in English; the certificate prevails if interpretation of this material varies. made after any applicable Waiting Period. We must receive evidence of the permanent neurological damage provided from computed axial tomography (CAT scan) or magnetic resonance imaging (MRI). Stroke does not mean head injury, transient ischemic attack, or chronic cerebrovascular insufficiency. Cancer (Internal or Invasive) means a malignant tumor characterized by the uncontrolled growth and spread of malignant cells and the invasion of distant tissue. Cancer includes leukemia. Excluded are Cancers that are noninvasive, such as (1) Premalignant tumors or polyps; (2) Carcinoma in Situ; (3) Any skin cancers except melanomas; (4) Basal cell carcinoma and squamous cell carcinoma of the skin; and (5) Melanoma that is diagnosed as Clark s Level I or II or Breslow thickness less than.77 mm. Cancer is also defined as a disease which meets the diagnosis criteria of malignancy established by The American Board of Pathology after a study of the histocytologic architecture or pattern of the suspect tumor, tissue, or specimen. Carcinoma in Situ means Cancer that is in the natural or normal place, confined to the site of origin without having invaded neighboring tissue. Renal Failure (Kidney Failure) means the end-stage renal failure presenting as chronic, irreversible failure of both of your kidneys to function. The Kidney Failure must necessitate regular renal dialysis, hemodialysis or peritoneal dialysis (at least weekly); or which results in kidney transplantation. Renal failure is covered, provided it is not caused by a traumatic event, including surgical traumas. Coronary Artery Bypass Surgery means undergoing open heart surgery to correct narrowing or blockage of one or more coronary arteries with bypass grafts, but excluding procedures such as but not limited to balloon angioplasty, laser relief, stents or other nonsurgical procedures. A doctor, physician, or pathologist does not include an insured or a family member. Portable Coverage When coverage would otherwise terminate because the Employee ends employment with the employer, coverage may be continued. The Employee will continue the coverage that is in force on the date employment ends, including dependent coverage then in effect. The Employee will be allowed to continue the coverage until the earlier of the date the Employee fails to pay the required premium or the date the group master policy is terminated. Coverage may not be continued if the Employee fails to pay any required premium or the group master policy terminates. termination Coverage will terminate on the earliest of: (1) The date the master policy is terminated; (2) The 31st day after the premium due date if the required premium has not been paid; (3) The date the insured ceases to meet the definition of an Employee as defined in the master policy; or (4) The date the Employee is no longer a member of the class eligible. Coverage for an insured Spouse or Dependent Child will terminate on the earliest of: (1) The date the master policy is terminated; (2) The 31st day after the premium due date if the required premium has not been paid; (3) The premium due date following the date the Spouse or Dependent Child ceases to be a dependent; or (4) The premium due date following the date we receive a written request to terminate coverage for a Spouse and/or Dependent Children. 67 Underwritten by: Continental American Insurance Company 2801 Devine Street Columbia, South Carolina This brochure is a brief description of coverage and is not a contract. Read your certificate carefully for exact terms and conditions. This brochure is subject to the terms, conditions, and limitations of Policy Form Series CAI2800.

71 Portsmouth 20 pay Rate sheet prepared by Web User on 12/10/ :40:27 AM. Virginia Payroll Premium rates are 20pp/yr. Aflac Group coverage is underwritten by Continental American Insurance Company (CAIC) The rates shown on this insert page are for illustration purposes only; they do not imply coverage. For more information about policy/plan benefits and limitations, please refer to the accompanying product brochure for each insurance policy/plan listed below. CAIC GROUP CRITICAL ILLNESS Series NON- TOBACCO for Employee Age $5,000 $10,000 $15,000 $20,000 $25,000 $30,000 $35,000 $40,000 $45,000 $50, $2.16 $3.27 $4.38 $5.49 $6.60 $7.71 $8.82 $9.93 $11.04 $ $3.09 $5.13 $7.17 $9.21 $11.25 $13.29 $15.33 $17.37 $19.41 $ $5.19 $9.33 $13.47 $17.61 $21.75 $25.89 $30.03 $34.17 $38.31 $ $8.53 $16.01 $23.49 $30.97 $38.45 $45.93 $53.41 $60.89 $68.37 $ $13.05 $25.05 $37.05 $49.05 $61.05 $73.05 $85.05 $97.05 $ $ CAIC GROUP CRITICAL ILLNESS Series NON-TOBACCO for Spouse Age $5,000 $7,500 $10,000 $12,500 $15,000 $17,500 $20,000 $22,500 $25, $2.16 $2.72 $3.27 $3.83 $4.38 $4.94 $5.49 $6.05 $ $3.09 $4.11 $5.13 $6.15 $7.17 $8.19 $9.21 $10.23 $ $5.19 $7.26 $9.33 $11.40 $13.47 $15.54 $17.61 $19.68 $ $8.53 $12.27 $16.01 $19.75 $23.49 $27.23 $30.97 $34.71 $ $13.05 $19.05 $25.05 $31.05 $37.05 $43.05 $49.05 $55.05 $61.05 CAIC GROUP CRITICAL ILLNESS Series TOBACCO for Employee Age $5,000 $10,000 $15,000 $20,000 $25,000 $30,000 $35,000 $40,000 $45,000 $50, $2.91 $4.77 $6.63 $8.49 $10.35 $12.21 $14.07 $15.93 $17.79 $ $4.56 $8.07 $11.58 $15.09 $18.60 $22.11 $25.62 $29.13 $32.64 $ $9.75 $18.45 $27.15 $35.85 $44.55 $53.25 $61.95 $70.65 $79.35 $ $16.05 $31.05 $46.05 $61.05 $76.05 $91.05 $ $ $ $ $25.05 $49.05 $73.05 $97.05 $ $ $ $ $ $ CAIC GROUP CRITICAL ILLNESS Series TOBACCO for Spouse Age $5,000 $7,500 $10,000 $12,500 $15,000 $17,500 $20,000 $22,500 $25, $2.91 $3.84 $4.77 $5.70 $6.63 $7.56 $8.49 $9.42 $ $4.56 $6.32 $8.07 $9.83 $11.58 $13.34 $15.09 $16.85 $ $9.75 $14.10 $18.45 $22.80 $27.15 $31.50 $35.85 $40.20 $ $16.05 $23.55 $31.05 $38.55 $46.05 $53.55 $61.05 $68.55 $ $25.05 $37.05 $49.05 $61.05 $73.05 $85.05 $97.05 $ $ Rates include cancer benefit. Rates include $50 Health Screening Benefit. 68

72 LIMITED BENEFIT ACCIDENT ONLY Insurance Plan Underwritten by American Fidelity Assurance Company Wellness Benefit Benefits Paid Directly to You Excellent Customer Service Learn More»» Marketed by: First Financial Administrators, Inc. P.O. Box Houston, TX Local (281) Toll Free (800) Fax (866)

73 Accident Only Insurance Life Provides the Accidents, First Financial Offers a Solution! Whether you re a weekend warrior with an active lifestyle or just a busy family, accidents can happen to you anytime, anywhere without warning. First Financial is pleased to offer American Fidelity Assurance Company s (AFA) Limited Benefit Accident Only Insurance. Accident Only Insurance can offer a solution to help you and your family prepare for those rising medical costs if you have to receive medical treatment for an Accidental injury. Think It Couldn t Happen to You? Consider this... Know The Facts: Total costs of accidental injuries averaged $19,216 per injury in National Safety Council, Injury Facts, 2012 Edition, p $19,216 How Would You Cover Your Out-of-Pocket Costs? Just going for a walk around the block or heading to your driveway could lead to a twisted knee and torn meniscus, one of the more common claims submitted under this plan. EMERGENCY ACCIDENT - Hypothetical Example 1 Twisted knee in the parking lot resulting in a torn meniscus and treatment is received within 72 hours. ENHANCED PLAN BENEFITS Accident Emergency Treatment $200 Accident Follow-Up Treatment (4 visits) $200 Physical Therapy (8 treatments) $200 Medical Imaging $200 X-Ray $100 Appliances $100 Surgical Facility $250 Torn Knee Cartilage Repair $500 Anesthesia $200 Total $1,950 Paid Directly To You! 1 Hypothetical example of a covered accident based on policy AO-03 and rider AMDI

74 Marketed by: First Financial Group of America Solutions For Life s Accidents... The Accident Only Plan is the insurance policy that provides payments direct to you protecting you and your family from some of the expenses brought about by injuries suffered in an Accident, regardless of any additional coverage you may have. It s guaranteed renewable for as long as you pay your premiums. Accident Only Insurance Features:» No medical questions.» Benefits paid directly to you, to be used however you see fit.» Benefits regardless of other coverage.» Coverage for you and each covered family member 24 hours a day, 7 days a week.» Available conveniently through your employer with payroll deduction.» Policy is guaranteed renewable at the option of the primary insured for life as long as premiums are paid as required. Any additional insureds must meet eligibility as outlined in the policy. The company has the right to change premium rates by class. Currently participating in, or possibly moving to a High Deductible Health Plan? Health Savings Account (HSA) and qualified High Deductible Health Plan enrollments have quadrupled in the past six years and are on the rise 2. The Choice is Yours: Be prepared with either of American Fidelity s two plan options (Basic and Enhanced) that provide the benefit amounts you require. Plus, American Fidelity supplies the coverage you need with four choices of coverage including individual, individual and spouse, individual and child(ren), and family. Ready To Learn More? Contact your First Financial Account Representative for more details or to schedule an one-on-one appointment. [Account Rep Name Here First Financial Group of America N. Freeway, Suite 900 Houston, TX Local: (281) / Toll Free: (800) ] 2 AHIP: January 2012 Census Shows 13.5 Million People covered by HSA/High-Deductible Health Plans, May 2012, p.3. 71

75 3 Schedule of Benefits Emergency Accident Benefits Basic Enhanced Emergency Accident Treatment Emergency Accident Treatment $150 $200 Emergency Accident Follow-up Treatment (up to four visits) $50 $50 Accident Injury Benefits Benefit amounts for the following Benefits are the same for Basic and Enhanced Plans for all Persons: Primary, Spouse, and Child(ren). Basic / Enhanced Injury Treatment Fractures Benefit (Depending on open or closed reduction, bone involved, or chip fracture). $25 to $3,000 Lacerations Benefit Not requiring sutures Sutured lacerations up to two inches Sutured lacerations totaling two to six inches Sutured lacerations totaling over six inches $25 $100 $200 $400 Appliances Benefit (crutches, leg braces, etc.) $100 Torn Knee Cartilage or Ruptured Disc Benefit $500 Eye Injury Benefit Injury with surgical repair, for one or both eyes. Removal of foreign body by a Physician, for one or both eyes. Dislocations Benefit Depending on open or closed reduction, with or without anesthesia and joint involved. No other amount will be paid under this benefit. $250 $50 $25 to $3,000 Concussion Benefit $200 2nd & 3rd Degree Burns(Skin grafts are 25% of benefit) $100 to $10,000 Internal Injuries Benefit Resulting in open abdominal or thoracic surgery $1,000 Paralysis Benefit: Paraplegia / Quadriplegia $5,000 / $10,000 Tendons, Ligaments and Rotator Cuff Benefit One Tendon, Ligament or Rotator Cuff More than One Tendon, Ligament or Rotator Cuff $500 $750 Blood, Plasma and Platelets $250 Exploratory Surgery without Surgical Repair $250 Physical Therapy (per treatment up to eight treatments) $25 Prosthesis $500 Emergency Dental Work Broken teeth repaired with crown Extraction of broken teeth (regardless of number) Refer to Plan Benefit Highlights for complete Benefit Descriptions and limits on the Accident Only Insurance Plan. 72 $150 $50

76 A Highlight of Benefits Available Under The Plan Wellness Benefit Basic Enhanced Wellness Annual Routine Physical Exam (Requires a 12-month waiting period before use and one exam per policy per calendar year.) $50 $75 Accidental Death & Dismemberment Benefit Accidental Death & Dismemberment Basic Primary Spouse Child Common Carrier $50,000 $50,000 $25,000 Other Accident $15,000 $15,000 $7,500 Dismemberment $1,000 to $15,000 $1,000 to $15,000 $500 to $7,500 Enhanced Primary Spouse Child Common Carrier $100,000 $100,000 $50,000 Other Accident $30,000 $30,000 $15,000 Dismemberment $1,500 to $30,000 $1,500 to $30,000 $750 to $15,000 Additional Accident Benefits Basic Enhanced Non-Emergency Accident Treatment Non-Emergency Accident Treatment $75 $100 Non-Emergency Follow-up Treatment (up to two visits) $50 $50 Hospital Confinement Hospital Admission $500 $1,000 Intensive Care Unit (up to 15 days) $300 $600 Hospital Confinement (up to 365 days) $100 $200 Medical Imaging MRI, CT, CAT, PET, US $200 $200 X-Rays $50 $100 Ambulance Ground $300 $300 Air $1,500 $1,500 Treatment Outpatient Hospital or Ambulatory Surgical Center $150 $250 Anesthesia $150 $200 Transportation Benefits Transportation (Patient Only) (per round trip for up to three round trips per calendar year) Family Member Lodging and Meals (per day per Accident; up to 30 days per confinement) 73 $300 $300 $100 $100

77 Plan Benefit Highlights A Covered Person (thereafter referred to as Person ) under American Fidelity s Limited Benefit Accident Only Policy can expect the following benefits when a Covered Accident (thereafter referred to as Accident ) happens. All benefits are paid once per Person per Accident unless otherwise specified. All benefits are only paid as a result of Injuries received in an Accident that occurs while coverage is in force. Benefits are not be paid for loss from sickness. All treatment, procedures, and medical equipment must be diagnosed, recommended and treated by a Physician. These references are not intended to change or modify any definitions in the AO-03 policy series. Accident Emergency Treatment Benefit Payable for receiving emergency treatment in a Physician s office or emergency room within 72 hours, including physician fees and emergency services. Accident Follow-up Treatment Benefit Payable for necessary follow-up treatment of Injuries in addition to the emergency treatment administered within 72 hours for up to four treatments. Not payable for a visit in which a Physical Therapy Benefit or Non-Emergency Follow-Up Benefit is paid. Accidental Death and Dismemberment Benefit The applicable benefits apply when a Accidental Death or Dismemberment occurs within 90 days of an Accident. Or, if Accidental Death or Dismemberment occurs within one year from the date of the Covered Person s accident and during a period of continuous total disability resulting from the Accident and commencing within 30 days of the date of the Accident, we will pay the applicable benefit. Total Disability as used in this benefit means that the Person is: unable to work at any job for which (s)he is qualified by education, training or experience; and not working at any job for pay or benefits; and under the care of a Physician. Ambulance Benefit If air and ground transportation is required for the same Accident, only the highest benefit will be paid. Anesthesia Benefit Pays the amount shown in the Schedule of Benefits for the services of an anesthesiologist for a surgery performed due to an Accident. Hospital Confinement is not required to receive this benefit. We will only pay one Anesthesia Benefit per Person in a 24-hour period even if more than one surgical procedure is performed. This benefit is not payable for local anesthesia. Appliances Benefit Payable for one of the following: crutches, leg braces, back braces, walkers, or wheel chairs. Not payable for Prosthetic Devices. Blood, Plasma and Platelets Benefit Payable for blood, plasma and platelets. This benefit does not provide benefits for immunoglobulins. Burns Benefit Payable for burns when treated by a Physician within 72 hours. Concussion Benefit Payable for a Person who sustains a concussion and is diagnosed by a Physician within 72 hours using any type of medical imaging. Dislocations Benefit Amount payable varies by the joint involved, type of treatment, and type of anesthesia. If a Person receives more than one Dislocation in an Accident, we will pay for all Dislocations up to two times the amount shown in the Schedule of Benefits for the Dislocation involved that has the highest benefit amount. No other amount will be paid under this benefit. Benefits are payable only for the first dislocation of a joint which occurs while this policy is in force. Emergency Dental Work Benefit Payable for repair to natural teeth when treated by a Physician or dentist. Initial dental treatment must be received within 72 hours. Exploratory Surgery Benefit Payable when an exploratory surgical operation without surgical repair is performed. Eye Injury Benefit Payable for one or both eyes requiring treatment. Family Member Lodging and Meals Benefit Payable for lodging and meals for a family member to be near a Person who is Confined in a non-local Hospital. The Hospital must be at least 50 miles one way from the Person s residence or site of the Accident. Fractures Benefit Varies based on the bone involved, type of fracture and type of treatment. If the Person fractures more than one bone, payment is made for all fractures up to two times the amount for the bone involved that has the highest benefit amount. Hospital Admission Benefit Pays per admission for confinement to a Hospital. This benefit does not pay for outpatient treatment, emergency room treatment, or a stay of less than 18 hours in an observation unit. Hospital Confinement Benefit Payable for a one-time Hospital Admission Benefit due to accidental Injuries (does not include emergency room and outpatient treatment). You will also receive a daily benefit for a Hospital Confinement that is longer than 18 hours for up to 365 days and an additional daily benefit for Confinement in an Intensive Care Unit up to 15 days. Intensive Care Unit Benefit Payable for each day of confinement in an Intensive Care Unit, as defined in the policy, up to 15 days. This benefit is paid in addition to the Hospital Confinement Benefit amount. Internal Injuries Benefit Payable for an open abdominal or thoracic surgery performed within 72 hours. Lacerations Benefit This benefit varies based on the severity of the laceration. Medical Imaging Benefit Payable for a Magnetic Resonance Imaging (MRI), a Computed Tomography (CT) scan, a Computed Axial Tomography (CAT) scan, a Positron Emission Tomography (PET) scan or an ultrasound. 74

78 Non-Emergency Accident Initial Treatment Benefit Payable for initial medical treatment when treatment is received more than 72 hours after the Accident. Initial medical treatment must: (1) be received in a Physician s office or emergency room; and (2) be the first treatment; and (3) occur within 30 days. Non-Emergency Accident Follow-up Treatment Benefit Payable only if the Non-Emergency Accident Initial Treatment Benefit is payable and later requires additional treatment: we will pay over and above the initial medical treatment administered. We will pay for up to two treatments. Not payable for the same visit that the Physical Therapy Benefit or the Accident Follow-Up Benefit is paid. Outpatient Hospital or Ambulatory Surgical Center Benefit When a surgical procedure is performed on an outpatient basis in a Hospital or at an Ambulatory Surgical Center, we will pay the indemnity amount shown in the Schedule of Benefits for the facility fee charged by such Hospital or Ambulatory Surgical Center. We will only pay one Outpatient Hospital or Ambulatory Surgical Center Benefit in a 24-hour period even if more than one surgical procedure is performed. This benefit will not be paid for surgery performed in a Hospital emergency room or in a Physician s office. Paralysis Benefit The duration of the Paralysis must be a minimum of 3 consecutive months. Paid once per lifetime per Person. Physical Therapy Benefit Payable for one treatment per day for up to eight treatments by a caregiver licensed in physical therapy. This benefit is not payable for the same visit that the Accident Follow-up Treatment Benefit or Non- Emergency Follow-Up Benefit. Prosthesis Benefit Payable for the use of a Prosthesis. This benefit is not payable for hearing aids; dental aids; eyeglasses; false teeth; or for cosmetic aids such as wigs. Tendons, Ligaments and Rotator Cuff Benefit Payable for the repair of one or more tendons, ligaments, or rotator cuffs. The tendons, ligaments, or rotator cuff must be repaired through surgery. Torn Knee Cartilage or Ruptured Disc Benefit Payable for surgical repair. Transportation Benefit Payable for the transportation when specialized treatment and Hospital Confinement in a non-local Hospital is required. A non-local Hospital must be at least 50 miles away, one way, using the most direct route, from the closer of the Person s residence or site of the Accident. Travel must be by scheduled bus, plane, train, or by car. Ambulance service does not qualify for this benefit. The treatment must be prescribed by a Physician and not be available locally. Wellness Benefit After coverage is in force for the waiting period shown, you can receive a benefit for an annual routine physical exam, including immunizations and preventive testing. Services must be supervised by a Physician and a charge must be incurred for the service. The benefit does not apply to dental or eye exams and is payable once per policy per calendar year. Limitations and Exclusions Base Policy No benefits will be provided for an Accident that is caused by or occurs as a result of: (1) intentionally self-inflicted bodily injury, suicide or attempted suicide, whether sane or insane; (2) participation in any form of flight aviation other than as a farepaying passenger in a fully licensed/passenger-carrying aircraft; (3) any act that was caused by war, declared or undeclared, or service in any of the armed forces; (4) participation in any activity or event while under the influence of any narcotic unless administered by a Physician or taken according to the Physician s instructions; (5) participation in, or attempting to participate in, a felony, riot or insurrection. (A felony is as defined by the law of the jurisdiction in which the activity takes place.). Benefits will not be provided for medical treatment for an Accident received outside the United States or its territories. Benefits will not be paid for services rendered by a member of the immediate family of a Person. An Accident is defined as a sudden, unexpected and unintended event, which results in bodily injury, which is independent of disease or bodily infirmity or any other cause. The policy will not pay benefits for injuries received prior to the Effective Date of coverage that are aggravated or re-injured by any event that occurs after the Effective Date. A hospital is not an institution, or part thereof, used as: a hospice unit, including any bed designated as a hospice or a swing bed; a convalescent home; a rest or nursing facility; a rehabilitative facility; an extended-care facility; a skilled nursing facility; or a facility primarily affording custodial, educational care, or care or treatment for persons suffering from mental diseases or disorders, or care for the aged, or drug or alcohol addiction. You cannot be singled out for a rate increase for any reason. The Insurer has the right to increase premium rates only if rates for all policies in this class change. This is a brief description of the coverage. For actual benefits, limitations, exclusions and other provisions, please refer to the policy, AO-03, and Accident Only Benefit Enhancement Rider, AMDI-258 Series. This coverage does NOT replace Workers Compensation Insurance. This product is inappropriate for people who are eligible for Medicaid coverage. 75

79 Accident Only Insurance Premiums Monthly Premiums Basic Enhanced Individual $19.90 $26.10 Individual & Spouse $28.30 $34.90 Individual & Child(ren) $31.50 $41.00 Family $39.90 $ The premium and amount of benefits provided vary based upon the plan selected. Plan Options» Individual Plan The Insured, age 18 through 64, at the date of policy issue, is the only Person.» Individual and Lawful Spouse Plan Covers you and your Lawful Spouse (ages 18 to 64 at Policy Issue).» Individual and Child(ren) Plan Covers you (ages 18 to 64 at Policy Issue) and each Eligible Child, as defined in the policy, under the age of 21 or 25 if attending school full-time.» Family Plan Covers you, your Lawful Spouse (ages 18 to 64 at Policy Issue) and each Eligible Child, as defined in the policy, under the age of 21 or 25 if attending school full-time. Underwritten and administered by: 2000 N. Classen Boulevard Oklahoma City, Oklahoma SB-25787(VA)-0113 AO-03 Series and AMDI-258 Series 76

80 Portsmouth Public Schools Focus Eye Care Highlight Sheet Focus Plan Summary Comprehensive Plan VSP Network Out of Network Deductibles Exam $15 $15 Eye Glass Lenses See materials See materials Materials $15 $15 Annual Eye Exam Covered in full Up to $45 Lenses (per pair) Single Vision Covered in full Up to $35 Bifocal Covered in full Up to $50 Trifocal Covered in full Up to $70 Lenticular Covered in full Up to $90 Contacts Fit & Follow Up Exams 15% discount No benefit See Additional Focus Features. Elective Up to $105 Up to $105 Medically Necessary Covered in full Up to $210 Frames $120 Up to $50 Frequencies (months) Exam/Lens/Frame 12/12/24 12/12/24 Based on date of service Based on date of service Rates 20 Pay Employee Only (EE) $5.82 Family $14.26 Additional Focus Features Contact Lenses Elective Additional Glasses Laser VisionCare Low Vision Cost of the fitting and evaluation is deducted from the allowance and any amount left is deducted from the material allowance. Allowance can be applied to disposables, but the dollar amount must be used all at once (provider will order 3 or 6 month supply). Applies when contacts chosen in lieu of glasses. 20% discount off the retail price on additional pairs of prescription glasses (complete pair). VSP offers an average discount of 15% on LASIK and PRK. The maximum out-of-pocket per eye for members is $1,800 for LASIK and $2,300 for custom LASIK using Wavefront technology, and $1,500 for PRK. In order to receive the benefit, a VSP provider must coordinate the procedure. With prior authorization, 75% of approved amount (up to $1,000 is covered every two years). Eye Care Plan Member Service Focus eye care from Ameritas Group features the money-saving eye care network of VSP. Customer service is available to plan members through VSP's well-trained and helpful service representatives. Call or go online to locate the nearest VSP network provider, view plan benefit information and more. VSP Call Center: Service representative hours: 9 a.m. to 10 p.m. EST Monday through Friday Interactive Voice Response available 24/7 Locate a VSP provider at: ameritasgroup.com/provider View plan benefit information at: vsp.com If you would like a complete copy of your vision insurance certificate, please visit our website at This document is a highlight of plan benefits provided by Ameritas Life Insurance Corp. as selected by your employer. It is not a certificate of insurance and does not include exclusions and limitations. For exclusions and limitations, or a complete list of covered procedures, contact your benefits administrator. 77

81 RETIREMENT 101 LEARN MORE ABOUT YOUR 403(b) PLAN Questions and answers about 403(b) plans Q: What is a 403(b) plan? A: A section 403(b) plan is a deferred compensation program that is available to employees of a tax exempt organization under IRC 501(c)(3), and employees of certain educational organizations, such as K-12 public schools, community colleges and state-funded colleges and universities. Q: What advantages are there to participating in a 403(b) plan? A: Participating in a 403(b) plan is a good way to invest money for retirement. You can reduce your current income taxes and set aside money for your retirement at the same time. Most people pay taxes on their income first and use what is left over to put money into preparing for retirement. Since federal income taxes are calculated on your income after your retirement plan contribution has been deducted, you may pay less in federal income taxes. Thus, you may actually have more spendable income than you would if you were contributing a comparable amount to a savings account where contributions and earnings are subject to current income taxation. Q: How does a 403(b) plan work? A: You decide how much of your salary you want your employer to contribute to your account within the limits established by the federal government. You then complete a salary reduction agreement with your employer. Q: How much of my compensation can I contribute to a 403(b) plan? A: For the 2014 calendar year, you may contribute $17,500. This amount will be adjusted for inflation as needed in future years. Additional deferral amounts for participants 50 years and older and, in general, for participants who complete 15 years of service with a qualified organization are available through catch-up contributions. Check with your retirement plan representative to see if your plan allows catch-up contributions. Q: How can I change the amount that is contributed to my 403(b) account? A: Notify your employer that you would like to change your salary deferral amount. You may increase or decrease your contributions periodically according to your employer s plan. In some cases, changes may be done online at Q: When can I withdraw my 403(b) contributions? A: Like other retirement plans, a 403(b) plan is intended to be a long-term retirement investment vehicle. As permitted by your plan, withdrawals may be allowed when you reach age 59½, terminate employment, retire, die, become disabled or experience a financial hardship. Withdrawals, both contributions and earnings, will be subject to ordinary income taxes in the year in which you receive the money. Withdrawals prior to age 59½ may also be subject to a 10 percent IRS tax penalty OneAmerica Financial Partners, Inc. All rights reserved. PRODUCTS AND FINANCIAL SERVICES PROVIDED BY AMERICAN UNITED LIFE INSURANCE COMPANY, A ONEAMERICA COMPANY 1 of 2 78 R /24/13

82 Q: What options are available when I terminate employment or retire? A: When you terminate employment or retire, depending on your account balance, you may keep your money in the plan, transfer or roll it over to another eligible retirement plan or Individual Retirement Account (IRA), receive the money in a lump sum or select annuity payments (if allowed by your plan). Q: Can I roll over money from an existing IRA or retirement account into my 403(b) account? A: Regulations regarding rollovers may limit the ability to roll assets from one plan to another. However, tax law changes have made consolidating retirement assets easier than ever. Please check with your employer or call for more information. Q: How do I obtain information about my account? A: You will receive a personalized account statement each quarter. Additionally, you can check your account online at or by calling These services provide up-to-date information about your account balance, contributions, investment performance and other account data. One day you will have a better understanding of your 403(b) plan. One Day is Today! For more information on 403(b) plans, visit Note: Registered group variable annuity contracts, issued by AUL are distributed by OneAmerica Securities, Inc., Member FINRA, SIPC, a Registered Investment Advisor, 433 N. Capitol Ave., Indianapolis, IN 46204, , which is a wholly owned subsidiary of American United Life Insurance Company. Neither AUL, OneAmerica Securities, Inc. nor their representatives provide tax or legal advice. For answers to your specific questions please consult a qualified attorney or tax advisor OneAmerica Financial Partners, Inc. All rights reserved. PRODUCTS AND FINANCIAL SERVICES PROVIDED BY AMERICAN UNITED LIFE INSURANCE COMPANY, A ONEAMERICA COMPANY 2 of 2 79 R /24/13

83 RETIREMENT 101 LEARN MORE ABOUT YOUR 457(b) PLAN Questions and answers about 457(b) plans for governmental organizations Q: What is a 457(b) Deferred Compensation Plan (DCP)? A: A 457(b) plan is a retirement plan maintained by a governmental agency or certain non-governmental, tax exempt employers. Contributions are made on a pre-tax basis and accumulate tax-deferred until withdrawn. Upon distribution, withdrawal of both contributions and earnings will be subject to ordinary income tax. Q: How does a 457(b) DCP work? A: You decide how much of your salary you want to defer and complete a Deferred Compensation Agreement for your employer. Q: What advantages are there to participating in a 457(b) plan? A: When participating in a 457(b) plan, you can reduce your current income taxes and set aside money for your retirement at the same time. Some people pay taxes on their income first and use what is left over to put money into preparing for retirement. Since federal income taxes are calculated on your income after your retirement plan contribution has been deducted, you may pay less in current federal income taxes. Thus, you may actually have more spendable income than you would if you were contributing a comparable amount to an account where contributions and earnings are subject to current income tax rules. Q: How much can be contributed to a 457(b) plan? A: For the 2014 calendar year, the regular contribution limit (your contributions plus employer contributions) is $17,500. This amount will be subject to cost of living adjustments (COLAs) in future years. Deferrals to a 457(b) plan are not offset by employee elective deferrals to other retirement plans. Additionally, governmental 457(b) plans may provide for age 50 catch-up contributions and/or special 457(b) catch-up contributions. Q: What are age 50 catch-up contributions? A: Age 50 catch-up contributions are deferrals over the regular contribution limit that governmental 457(b) plans may allow participants age 50 years and older to make. For 2014, the age 50 catch-up contribution amount is $5,500. Like the regular 457(b) contribution limit, this amount is subject to future cost of living adjustments (COLAs). Check with your plan administrator to see if your plan allows age 50 catch-up contributions OneAmerica Financial Partners, Inc. All rights reserved. PRODUCTS AND FINANCIAL SERVICES PROVIDED BY AMERICAN UNITED LIFE INSURANCE COMPANY, A ONEAMERICA COMPANY 1 of 2 80 R /24/13

84 Q: What are special 457(b) catch-up contributions? A: Special 457(b) catch-up contributions are deferrals over the regular contribution limit that 457(b) plan participants may make if they are within three taxable years ending before their normal retirement age (as defined in the plan). Unlike age 50 catch-up contributions, which may be offered only by governmental 457(b) plans, any 457(b) plan may provide for this special catch-up contribution. If the plan allows special 457(b) catch-up contribution, the deferral amount is increased to the lesser of: Twice the dollar limit or Sum of current year limit plus unused portion of prior year limits The unused limit for a year is the difference between the regular contribution limit in effect for that year and the amount contributed for that year. Important: If a governmental 457(b) plan allows both special 457(b) catch-up contributions and age 50 catch-up contributions, a participant wishing to make catch-up contributions must make the greater of the two. Q: Can I roll over my account when I terminate my employment? A: You may roll over your account balance to another eligible retirement plan (for example, an Individual Retirement Account (IRA) or a profit-sharing, 401(k), 403(b), or governmental 457(b) plan). Q: When can I withdraw my 457(b) deferrals? A: Like other retirement plans, a 457(b) plan is intended to be a long-term investment for your retirement. As a result, a 457(b) plan can permit distributions only in the event of death, severance from employment (termination of employment or retirement at any age), an unforeseeable emergency or attainment of age 70½. Additionally, the plan may allow a one-time withdrawal if your account value is $5,000 or less, there have been no contributions to your account for the two-year period ending on the date of the distribution and no prior withdrawals of this type have been made. Check with your plan administrator for the plan s distribution rules. Q: How can I change the amount of my deferral? A: You can increase or decrease the amount of compensation you defer according to your employer s plan specifics. Generally, changes are allowed at least once a year. Q: Will I pay taxes when I withdraw my 457(b) account? A: All distributions paid to you will be subject to ordinary income tax in the taxable year the distribution is paid from the plan. Q: Can I roll over money from an existing IRA or my account in another retirement plan into my 457(b) account? A: A 457(b) plan sponsored by a governmental employer may accept rollovers in from an IRA (except Roth IRAs, other after-tax and Coverdale Education Savings Accounts) or another retirement plan. Check with your employer or call for more information. Q: How are my 457(b) deferrals invested? A: You may choose from a variety of investment options in the AUL Group Annuity contract. One day you will have a better understanding of your 457(b) plan. One Day is Today! For more information on 457(b) plans, visit Note: Registered group variable annuity contracts, issued by AUL are distributed by OneAmerica Securities, Inc., Member FINRA, SIPC, a Registered Investment Advisor, 433 N. Capitol Ave., Indianapolis, IN 46204, , which is a wholly owned subsidiary of American United Life Insurance Company. Neither AUL, OneAmerica Securities, Inc. nor their representatives provide tax or legal advice. For answers to your specific questions please consult a qualified attorney or tax advisor OneAmerica Financial Partners, Inc. All rights reserved. PRODUCTS AND FINANCIAL SERVICES PROVIDED BY AMERICAN UNITED LIFE INSURANCE COMPANY, A ONEAMERICA COMPANY 2 of 2 81 R /24/13

85 Department of Finance PO Box 998 Portsmouth, Virginia Tax Sheltered Annuity Companies Eligible to solicit new enrollments from Portsmouth Public Schools Employees As of July 1, 2015 Carrier Agents Business Address Phone Number American Funds Jacques Cureton, PhD, MBA Capital Concepts, LLC Managing Director 5741 Cleveland St, Suite 140 fax Va Beach VA American Funds W. Xavier Randall Investors Security Financial Advisor 291 Independence Blvd, Pembroke 4 fax Suite 420 mobile Virginia Beach VA wxrandall@investorssecurity.net AXA Equitable Lori Preston - Lori.Preston@axa-advisors.com Leonard Mochi - Leonard.Mochi@axa-advisors.com Mark Johnson - mjohnson9@farmersagent.com First Investors Corporation Katherine Taylor First Investors Corporation , Ext East Shore Dr, Ste 105 (800) , Ext 315 Glen Allen VA Fax katherine.taylor@firstinvestors.com First Investors Corporation Corey Creech First Investors Corporation , Ext East Shore Dr, Ste 105 (800) , Ext 308 Glen Allen VA Fax (804) Corey.creech@firstinvestors.com Lincoln Financial Group William F. Sherrill Lincoln Financial Advisors Corp Registered Representative PO Box 3228 cell Portsmouth VA fax wfsherrill@lnc.com Lincoln Financial Group Wardell M. Nottingham, LUTCF Lincoln Financial Advisors Corp Investment Advisor Representative 400 North Center Drive, Suite 205 fax Norfolk VA Wardell.Nottingham@LFG.com Lincoln Financial Group Matthew Hedley Lincoln Financial Advisors Corp. (757) Direct Financial Planner One Columbus Center (757) Fax Suite 800 Matthew.Hedley@lfg.com Virginia Beach, VA MetLife Resources Vickie Pulley, CLTC Metlife Resources Direct Financial Services Representative 283 Constitution Dr., Ste. 525 Office Virginia Beach, VA Fax: vpulley@metlife.com MetLife Resources Andre Dawkins Metlife Resources Financial Services Representative MetLife Resources Kyle R. Arcand MetLife ext 4129 Financial Services Representative 505 Independence Pkwy, Suite 101 Fax Chesapeake, VA karcand@metlife.com Security Benefit Ed Fissinger Securites America Financial Advisor Fissinger Investment Services Becton Place fax Va Beach VA ed.fissenger@securitiesamerica.com Security Benefit Jason Dodzik Security Benefit Crawford Street Suite 802 jason@fcva.net Portsmouth, VA Security Benefit Rich Thiesfeld Brecek & Young Advisors, Inc Financial Advisor 412 Becton Place fax Va Beach VA VALIC A. Dean Anninos, LUTCF VALIC Financial Advisors, Inc ext Investment Advisor Rep Midlothian Turnpike, Suite 200 cell Richmond VA fax dean.anninos@valic.com VALIC.com VALIC Tim Hewitt VALIC Financial Advisors, Inc Financial Advisor Tim.hewitt@valic.com VALIC.com 82