TABLE OF CONTENTS DESCRIPTION. Website and Contacts 2

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1 TABLE OF CONTENTS DESCRIPTION PAGE Website and Contacts 2 Health Insurance Health Insurance Rates 4-5 Health Insurance Calculations 6 Benefit Comparison 7 Optima Vantage 2250/70 Benefit Details 8-9 Optima Vantage 1500/20/80 Benefit Details Dental Insurance Dental Rates 13 Dental Benefit Details Vision Insurance Vision Rates 18 Vision Benefit Details Life Insurance Voluntary Life Benefit Details Choctaw Pension Actuaries, LLC

2 WEBSITE AND CONTACTS To view this booklet as well as claim forms and provider lookups, go to We have also created a new ticket system, allowing you to create a support ticket on our website. This system can be used for things like claims problems, provider directories, address changes, etc. Once the ticket is created, you will automatically be assigned a ticket number and login credentials to view the status of your ticket 24 hours a day. This system is SSL secured and allows for documents to be scanned and uploaded. To create a support ticket, go to CONTACTS National Headquarters PO Box 1472 Virginia Beach, VA Ph F Vice President W. Brandon Beavers Cell: Office: Extension 110 brandon@cpactuaries.com Director of Benefits Amy Thompson Direct: Office: Extension 112 amy@cpactuaries.com For a complete list of Limitations and Exclusions, as well as the ACA Mandated Summary of Coverage and Benefits go to: Page Choctaw Pension Actuaries, LLC Chix Cafe Employee Benefits

3 HEALTH INSURANCE HEALTH BENEFIT COMPARISON HEALTH BENEFIT DETAILS

4 HEALTH INSURANCE RATES Employee Bi-Weekly Rates Contract - Optima Vantage 2250/70% Rx Low AGE NON TOBACCO TOBACCO < 20 $12.48 $ $49.50 $ $49.50 $ $49.50 $ $49.50 $ $49.91 $ $51.93 $ $54.37 $ $58.32 $ $61.57 $ $63.19 $ $65.63 $ $68.06 $ $69.58 $ $71.21 $ $72.02 $ $72.83 $ $73.64 $ $74.45 $ $76.08 $ $77.70 $ $80.13 $ $82.47 $ $85.71 $ $89.77 $ $94.54 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ Small Group Pharmacy Benefit: AD 10%/30%/40%/50% Dependent Bi-Weekly Rates Contract - Optima Vantage 2250/70% Rx Low AGE NON TOBACCO TOBACCO < 20 $64.41 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ Small Group Pharmacy Benefit: AD 10%/30%/40%/50% Page Choctaw Pension Actuaries, LLC Chix Cafe Employee Benefits

5 HEALTH INSURANCE RATES Employee Bi-Weekly Rates Contract - Optima Vantage 1500/20/80% Rx Low AGE NON TOBACCO TOBACCO > 20 $36.67 $ $87.60 $ $87.60 $ $87.60 $ $87.60 $ $88.16 $ $90.95 $ $94.30 $ $99.74 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ Small Group Pharmacy Benefit: RX DED $100; $10/$30/$50/$75 Dependent Bi-Weekly Rates Contract - Optima Vantage 1500/20/80% Rx Low AGE NON TOBACCO TOBACCO > 20 $88.60 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ Small Group Pharmacy Benefit: RX DED $100; $10/$30/$50/$75 Chix Cafe Employee Benefits 2014 Choctaw Pension Actuaries, LLC Page 5

6 CALCULATING YOUR PAYROLL DEDUCTION Each person in the family has their own rate. Due to ACA, you have to find each person s age in your family and add them up to find your total bi-weekly deduction. Please use the calculator below as a guide: Employee Rate: Spouse Rate: Child 1 Rate: Child 2 Rate: Child 3 Rate: = Total Bi-Weekly Rate: **All rates shown are bi-weekly. Optima charges for the first three children ONLY. Any additional children have no cost. If your deduction is $0 or less, there will be no deduction from payroll. Page Choctaw Pension Actuaries, LLC Chix Cafe Employee Benefits

7 HEALTH BENEFIT COMPARISON BENEFITS AND FEATURES Chix Health Benefits Overview Buy Up Base Optima BENEFITS AND FEATURES Vantage HMO Vantage 1500/20/80% $2250/70% Annual deductibles (indiv/family) In-network $1,500 / $3,000 $2,250 / $4,500 Out-of-network N/A N/A Coinsurance (plan pays) In-network Covered at 80% (AD) Covered at 70% (AD) Out-of-network N/A Out of pocket maximum (indiv/family) In-network $3,000 / $6,000 $6,250 / $12,500 Out-of-network N/A N/A Physician Services Primary Care Visit $20 Copay Covered at 70% (AD) N/A Specialist Visit $40 Copay Covered at 70% (AD) Hospital Services Inpatient hospitalization Covered at 80% (AD) Covered at 70% (AD) Outpatient Surgery Covered at 80% (AD) Covered at 70% (AD) Emergency/Urgent Care Svcs. Emergency care (true emergency) Covered at 80% (AD) Covered at 70% (AD) Urgent care centers (non-er level of $40 Copay Covered at 70% (AD) care) Prescription Coverage Retail Pharmacy $10/30/50/75 or 20% 10/30/40/50% ($250 max per RX) 90-day Mail Order $25/75/150/225 or 20% 10/30/40/50% ($750 max per RX) Preventive Vision (AD) = After Deductible 1 exam every 12 months: no cost 1 exam every 12 months: no cost For a complete list of Limitations and Exclusions, as well as the ACA Mandated Summary of Coverage and Benefits go to: Chix Cafe Employee Benefits 2014 Choctaw Pension Actuaries, LLC Page 7

8 OPTIMA VANTAGE 2250/70 BENEFIT DETAILS Page Choctaw Pension Actuaries, LLC Chix Cafe Employee Benefits

9 OPTIMA VANTAGE 2250/70 BENEFIT DETAILS Chix Cafe Employee Benefits 2014 Choctaw Pension Actuaries, LLC Page 9

10 OPTIMA VANTAGE 1500/20/80 BENEFIT DETAILS Page Choctaw Pension Actuaries, LLC Chix Cafe Employee Benefits

11 OPTIMA VANTAGE 1500/20/80 BENEFIT DETAILS Page Choctaw Pension Actuaries, LLC Chix Cafe Employee Benefits

12 DENTAL INSURANCE DENTAL RATES DENTAL BENEFIT PLAN

13 DENTAL INSURANCE RATES DENTAL RATES Effective December 1, 2014 Bi-Weekly Payroll Deduction Guardian PPO Guardian DHMO Employee Only $14.23 $8.76 Employee + Spouse $27.02 $16.20 Employee + Child(ren) $31.86 $18.97 Family $44.65 $24.11 Page Choctaw Pension Actuaries, LLC Chix Cafe Employee Benefits

14 DENTAL PPO BENEFIT DETAIL Contribution/Participation Deductible Annual Maximum Maximum Rollover Period Family Limit Waived For Threshold Rollover Amount In-Network only Rollover In-Network Preventive BENEFITS All Eligible Employees Voluntary, assumes 40% of eligible employees. Out-of-Network Chix Cafe Employee Benefits 2014 Choctaw Pension Actuaries, LLC Page 14 $50 Calendar Year 3 per family $1,000 plus Maximum Rollover Preventive Account Limit $1,000 Claim Payment Basis Negotiated Fee Schedule Negotiated Fee Schedule Network DentalGuard Preferred Coinsurance - Preventive 100% 80% Oral Exams (once/6 mos.) Cleanings (once/6 mos.) X-Rays (Full-mouth series once/60 mos.) Coinsurance - Basic 80% 70% Fillings Simple Extractions Periodontal Services (eg Scaling and Root Planing) Endodontic Services (eg. Root Canal) Coinsurance - Major 50% 40% Bridges & Dentures Single Crowns Complex Extractions Dependent Age Limits To Age 26 Plan Type & Code Split Value Plan (M7) PLAN HIGHLIGHTS Strong Network Coverage Nationwide Guardian's DentalGuard Preferred network is the #2 network nationally and we're growing fast. In many parts of the country, Guardian offers more providers than any other network (Netminder, 3/12). Guardian has over 87,000 dentists at more than 200,000 locations. Network dentists charge discounted fees - savings average 30%. Guardian has an easy to use provider online search. Just visit GuardianLife.com and select 'Find a Provider'. Dental Split Value Plan With Split Value Plan, employees have a great incentive to use in-network dentists. Both in-network and out-of-network benefits are paid based on the PPO fee schedule, and in-network benefits are paid at a higher coinsurance percentage than out-of-network benefits. So, when employees seek in-network care, they receive our regular PPO savings. If they choose to seek out-of-network care, they'll still receive substantial benefits, although the dentist may charge them up to their regular fee. International Dental Travel Assistance While traveling internationally, Guardian members can get a referral to a local dentist for immediate dental care through the International Dental Travel Assistance Program. This service is available 24/7, in over 200 countries. Coverage will be considered under the out-of-network benefits. International Dental Travel Assistance services are administered by AXA Assistance USA, Inc. AXA Assistance is not affiliated with Guardian Life Insurance, and the services they provide are separate and apart from the benefits provided by Guardian Life Insurance. $500 $250 $350 SUMMARY OF PLAN LIMITATIONS AND EXCLUSIONS Coverage is limited to charges that are necessary to prevent, diagnose or treat dental disease, defect or injury. Depending on plan type, deductibles, waiting periods, per service frequency limitations, and payment limits may apply. The list of dental services shown is not exhaustive. This coverage will not be effective until approved by a Guardian underwriter. Please refer to certificate of coverage for full plan description. This plan does not pay for: Any restoration procedure, appliance or dental prosthesis used solely to: a) alter vertical dimension; b) restore or maintain occlusion, except to the extent that this plan covers orthodontic treatment; c) splint or stabilize teeth for periodontal reasons; or d) treat a condition caused by abrasion or attrition. Cosmetic or experimental treatments, unless specifically listed in the BENEFIT DETAIL section of this proposal as a covered cosmetic service. Replacing a lost, stolen or missing appliance or prosthetic device; or making a spare appliance or device. Treatment needed due to: a) an on-the-job or job-related injury; or b) a condition for which benefits are payable by Workers' Compensation or similar laws. Replacing an appliance or prosthetic device with a like appliance or device, unless: a) it is damaged while in the covered person's mouth in an injury suffered while insured, and can't be fixed; or b) can't be made usable and meets the replacement age criteria selected by the employer. Treatment for which no charge is made. The replacement of extracted or missing third molars/wisdom teeth. Treatment of congenital or developmental malformations, or the replacement of congenitally missing teeth. Evaluations and consultations for non-covered services; detailed and extensive oral evaluations. Any procedure performed in conjunction with, as part of, or related to a non-covered procedure. Any procedure not specifically listed as a covered benefit. GP-1-DG2000 et al. Guardian Dental is underwritten by The Guardian Life Insurance Company of America, New York, NY. Products are not available in all states. Policy limitations and exclusions apply. Optional riders and/or features may incur additional costs. Plan documents are the final arbiter of coverage.

15 DENTAL DHMO BENEFIT DETAILS Contribution/Participation Contributory Dependent Age Limits 19(23 if a full-time student) Office Visit Copay $10 Annual Maximum Unlimited Claim Payment Basis No Claims - Member Copay Only Plan Type & Code Select/Pre-Paid (703) Network Dominion Select Plan/Pre-Paid BENEFITS All Eligible SERVICES & PATIENT CHARGES Services Your Coverage Oral Exams % Preventive Cleanings % Preventive X-Rays % Preventive Fillings 60-70% Basic Endodontic (Root Canal) 50-60% Major Periodontal (Scaling & Root 50-60% Major Planing) Simple Extractions 60-70% Basic Complex Extractions 50-60% Major Bridges & Dentures 50-60% Major Single Crowns 50-60% Major Orthodontia 40%-45% Bleaching Not Covered Per Arch Approximate coverage based on the Captiva context fee schedule's 80th percentile. Select members receive copayment schedules fees (if any) for services rendered at time of treatment. Select plan is same as a DHMO option PLAN HIGHLIGHTS No annual maximums No deductibles No claim forms Specialty services available by referral Member always knows out-of-pocket costs No exclusions for pre-existing conditions No participation requirements No employer contribution required Select/Pre-paid* Guardian Life Insurance Company of America and Dominion Dental Services (Dominion) 1 have committed to offer high value dental benefits. Dominion's Select Plan (same as a DHMO) network - one of the largest in the Mid-Atlantic region. 2. Extensive coverage on 250 dental services. Quality dental care at predetermined fees. Your choice of convenient private offices - for a list of dentists: DominionDental.com/find-a-dentist An emphasis on prevention and early treatment of dental problems. (continued) Page Choctaw Pension Actuaries, LLC Chix Cafe Employee Benefits

16 DENTAL DHMO BENEFIT DETAILS PLAN HIGHLIGHTS (continued) Orthodontic benefits for adults and children. Continuous coverage on a direct-billing basis for ex-employees and retirees who have been previously enrolled. A guarantee that members will like their dentist. Dominion will pay Select Plan members approximately two times their monthly premium if they transfer to another participating dentist due to office dissatisfaction after their first visit. No prior condition exclusions. No waiting periods. No claim forms 3 No deductibles. No pre-authorizations. No annual maximums. *Same as a DHMO with fixed member copayments, no annual maximum dollar limits, no waiting periods, no deductibles, no pre-authorization paperwork or re-treatment estimates and no claim forms (except in the case of out-of-area emergencies). 1 Dominion Dental Services, Inc. is a licensed as a Dental Plan Organization in Virginia, Maryland and Delaware, a Risk Assuming PPO in Pennsylvania and an Accident and Health Insurer in D.C. 2 Based on a Dominion competitive network survey,4 th Quarter Participating dentists are subject to change. Mid-Atlantic includes D.C., Delaware, Maryland, Pennsylvania and Virginia. 3 Out-of-area emergency care reimbursement requires a receipt or other proof of loss International Dental Travel Assistance While traveling internationally, Guardian members can get a referral to a local dentist for immediate dental care through the International Dental Travel Assistance Program. This service is available 24/7, in over 200 countries. Coverage will be considered under the out-of-network benefits. International Dental Travel Assistance services are administered by AXA Assistance USA, Inc. AXA Assistance is not affiliated with Guardian Life Insurance, and the services they provide are separate and apart from the benefits provided by Guardian Life Insurance. SUMMARY OF PLAN LIMITATIONS AND EXCLUSIONS The list of dental services shown is not exhaustive. This coverage will not be effective until approved by a Guardian underwriter. Please refer to certificate of coverage for full plan description. Select/Pre-Paid Dental Plans For Plan types with no suffix, ending with X or beginning with U, all covered services must be provided by the member's Primary Care Dentist. Copayments do not apply when performed by a Plan Specialist (with the exception of orthodontics). Plan Specialist, if available will reduce fees 25% from Usual, Customary, Reasonable (UCR) fees, except in the State of Delaware. In Delaware, Plan Specialists will provide a reduction from their UCR that will vary between specialists. Except for limited emergency services, benefits will be provided for services provided by the primary care dentist selected by the member. The member must pay the primary care dentist a patient charge for most covered services. Only those services listed in the Description of Benefits & Member Copayments are covered. Fixed member copayments, no annual maximum dollar limits, no waiting periods, no deductibles, no pre-authorization paperwork or pretreatment estimates and no claim forms or proof of loss (except in the case of out-of-area emergencies). For full details of the coverages, limitations and exclusions, please read the enclosed Description of Benefits & Member Copayments 703X Select/pre-paid dental coverage provided by Dominion Dental Services, Inc. Except for limited emergency services, benefits will be provided for services provided by the primary care dentist selected by the member. The member must pay the primary care dentist a patient charge for most covered services. No benefits will be paid for treatment by a specialist unless the patient is referred by his or her primary care dentist and the referral is approved by the plan. Underwritten by: (IL) - First Commonwealth Insurance Company, (MO) - First Commonwealth of Missouri, (IN) - First Commonwealth Limited Health Services Corporation, (MI) - First Commonwealth Inc., (CA) - Managed Dental Care, (TX) - Managed DentalGuard, Inc. (DHMO), (NJ) - Managed DentalGuard, Inc., (FL, NY) - The Guardian Life Insurance Company of America. All First Commonwealth, Managed DentalGuard, Inc. and Managed Dental Care entities referenced are wholly-owned subsidiaries of The Guardian Life Insurance Company of America, New York, NY. Products may not available in all states. Limitations and exclusions apply. Please refer to certificate of coverage for full plan description. Chix Cafe Employee Benefits 2014 Choctaw Pension Actuaries, LLC Page 16

17 Vision Insurance Vision Rates Vision Benefits

18 VISION RATES VISION INSURANCE RATES Effective December 1, 2014 Bi-Weekly premium deduction from paycheck Bi-Weekly Employee Only $2.74 Employee + Spouse $4.62 Employee + Child(ren) $4.71 Family $7.45 Page Choctaw Pension Actuaries, LLC Chix Cafe Employee Benefits

19 VISION BENEFIT DETAILS BENEFITS All Eligible Employees Contribution/Participation Voluntary, Assumes 25% of eligible employees. Vision is sold with Dental. Dependent Age Limits To Age 26 Network/Plan Davis/Full Feature - Designer B Copay Split(Exams/Materials) $10/$25 Eye Exams Lenses Benefit Contact Lenses Frames SERVICE FREQUENCIES Once Every: Calendar Year Calendar Year Calendar Year Other Calendar Year REIMBURSEMENT SCHEDULE In Network (Copay) Out Network (After Copay) Eye Exams Benefit $10 $50 max Lenses Benefit Single Vision $25 $48 max Bifocal $25 $67 max Trifocal $25 $86 max Lenticular $25 $126 max Contact Lenses Benefit** Medically Necessary Covered after copay $210 max Elective $130 max (Copay waived) $105 max (Copay waived) Frames Benefit $130 retail max + 20% off balance $48 max **In lieu of complete set of glasses PLAN HIGHLIGHTS Guardian's affiliation with Davis Vision offers access to over 43,000 provider locations nationwide, including private practice providers and many convenient retailers such as Wal-Mart, Sam's Club,Target, Sears, JC Penney and Pearle locations. On average 95% of members use an in network provider. Just visit GuardianLife.com and select 'Find a Provider'. All plan eyeglasses at national retailers come with a breakage warranty for repair or replacement of the frame and/or lenses for a period of one year from the date of delivery. At private practice providers the warranty would cover all lenses and frames from the Davis Vision Collection only. For calendar year plans, this plan allows for frames every two calendar years, regardless of whether the member obtained elective contact lenses the previous year. With our Designer plans, members will receive significant discounts on lens options, discounts will range from 20-60% off the U&C. For example, standard progressive lenses will cost $50 and scratch resistant coating will cost $20. Oversized lenses and fashion or gradient tinting of plastic lenses are covered in full. (continued) Chix Cafe Employee Benefits 2014 Choctaw Pension Actuaries, LLC Page 19

20 VISION BENEFIT DETAILS Vision Chix Cafe W Brandon Beavers PLAN HIGHLIGHTS (continued) Full Feature plans receive a 20% discount off the amount exceeding the copay and allowance on non-collection frames and 15% off the amount exceeding the copay and allowance on non-collection contact lenses purchased from a participating provider. These discounts are not available at Wal-Mart and Sam's Club locations. With our Designer plans, frames from Davis' Fashion or Designer collections are covered in full in excess of the plan's materials copay. Frames from Davis' Premier collection are covered in full in excess of a $25 copay applied in addition to the plan's materials copay. Frames not in the collections are covered up to the plan's retail allowance in excess of the plan's materials copay. The Collections are available at most participating independent provider offices but not in retail locations. Contact lenses purchased from the Davis Collection are covered in full after the copay, if any, and the contact lens fitting and evaluations are included at no additional charge. The Collection is available at most participating independent provider offices but not in retail locations. SUMMARY OF PLAN LIMITATIONS AND EXCLUSIONS Coverage is limited to those charges that are necessary to prevent, diagnose and treat a vision condition. Members cannot bank unused allowance amounts for future use, they must use their allowance during the same office visit. Members cannot split their benefits, they must purchase frames and lenses during the same office visit The plan does not pay for: Orthoptics or vision training and any associated supplemental testing. Medical or surgical treatment of the eye. Eye examination or corrective eyewear required by an employer as a condition of employment. Lenses and frames furnished under this plan, which are lost or broken (except when services are otherwise available). Our Designer plans limit benefits for most optional cosmetic lens processes and treatments. Our Premier Platinum plans cover a wide range of cosmetic lens processes and treatments. Medically necessary contact lenses are covered only if needed: (1) after cataract surgery; (2) to correct extreme visual acuity problems that cannot be corrected with eyeglasses; (3) for certain conditions of Anisometropia; or (4) for Keratoconus. The services, exclusions and limitations listed above do not constitute a contract and are a summary only. GP-1-Davis-1 et al. Page Choctaw Pension Actuaries, LLC Chix Cafe Employee Benefits

21 Life Insurance VOLUNTARY TERM LIFE

22 VOLUNTARY TERM LIFE BENEFIT DETAILS Voluntary Term Life RATES per $1,000 Age < Rates $0.106 $0.114 $0.158 $0.257 $0.405 $0.613 $0.997 $1.667 $2.652 $4.364 Rate Guarantee Minimum Participation Re-enrollment Underwriting Requirements Census Child 17 $ Year Voluntary, Greater of 25% or 10 enrolled employees. Annual Election Option: allows an employee to annually enroll for an increase of coverage, by an electable amount up to $50,000, not to exceed the case Conditional Issue. Employee <65 Spouse <65 Child Employee 65<70 Spouse 65<70 Employee 70+ Spouse 70+ Conditional Issue $50,000 $50,000 $10,000 $50,000 $10,000 $10,000 $0 Employee Benefit Spouse Benefit Child Benefit BENEFITS $10,000 to $500,000 in $10,000 increments $5,000 to $250,000 in $5,000 increments, not to exceed 50% of Employee's amount $1,000 to $10,000 in $1,000 increments, not to exceed 10% of Employee's amount Dependent Age Limits 14 days to 23 years (25 if full time student). Spouse terminates at 70. Accelerated Life 50% of the death benefit, Minimum: $10,000, Maximum: $250,000 Waiver of Premium Portability Conversion If disabled, insurance will continue until age 65 or no longer disabled Included, without Evidence of Insurability Included Refer to your enrollment Worksheet for calcualted rates. Seatbelt/Airbag Employee: $10,000/$15,000, Dependent: $5,000/$7,500 Benefit Reduction (of Age Reduction original amount) 65 35% 70 60% 75 75% 80 85% PLAN HIGHLIGHTS W Brandon Beavers Will Prep Services: Provides resources to prepare wills and other planning documents. Will Prep Services include: free Estate Planning documents, access to Estate Planners and Resource Library. For a small fee, Attorney Assisted Will Preparation is also available. SUMMARY OF PLAN LIMITATIONS AND EXCLUSIONS Life Plan In order to be eligible for coverage: Employees must be legally working (a) in the United States or (b) outside the United States, for a US based employer, in a country or region approved by Guardian. We pay no benefits if the insured s death is due to suicide within two years from the insured s original effective date. This two year limitation also applies to any increase in benefit. This exclusion may vary according to state law. GP-1-A-GP-90-1-et al. Employees must be working full-time on the effective date of your coverage; otherwise, coverage becomes effective after the completion of the specific waiting period. (continued) Voluntary Term Life W Brandon Beavers SUMMARY OF PLAN LIMITATIONS AND EXCLUSIONS (continued) Evidence of Insurability is required for all late enrollees. Benefit increases may require underwriting. Guardian Voluntary Term Life Insurance is underwritten by The Guardian Life Insurance Company of America, New York, NY and will not be effective until approved by a Guardian underwriter. This proposal is subject to satisfactory financial evaluation. Please refer to certificate of coverage for full plan description; plan documents are the final arbiter of coverage. Chix Cafe Employee Benefits 2014 Choctaw Pension Actuaries, LLC Page 22