$ per week. ternian. An Affordable Elective Benefits Program is Now Available for You! Enroll Now! Time is limited.

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1 An Affordable Elective Benefits Program is Now Available for You! HealthSelect Benefit Highlights Doctor Visit Pre-Pay * Inpatient Hospital Coverage Outpatient Accident Coverage Emergency Room Coverage Accidental Death & Dismemberment Coverage Prescription Drug Coverage Term Life Limited Medical Plans starting at only: $ per week Also Available Short-Term Disability Value-Added Services * Teladoc SupportLinc - EAP First Health PPO Network Discounts * This service is not insurance and is not provided by AXIS Insurance Company. Products offered by Midwest Heritage Insurance Services are not insured by the FDIC or any other Federal Government Agency, are not a deposit or obligation of, or guaranteed by Midwest Heritage Bank, may involve investment risks, including possible loss of principal amount invested, and may lose value. Enroll Now! Time is limited. EMPLOYER GROUP: Hy-Vee, Inc. and Subsidiaries WEB Enrollment: YOUR GROUP NUMBER IS: For questions BEFORE enrollment please call: For questions AFTER enrollment please call: Search First Health network providers at: or call (You do not need to use an in-network provider, however they provide discounts should you choose to visit them. You can visit a licensed non-network physician and present your insurance card- you may qualify for a discount. But regardless, you still have insurance coverage as outlined in this brochure.) Who can enroll? Part Time employees age 19 and above expecting to work an average of at least 15 hours per week. NOTICE: If you are over the age of 65 Medicare may be a better option. Please contact Midwest Heritage Insurance Services to learn more. When can I enroll? Within 60 days of the start of employment, or 19 th birthday, or 31 days of Qualified Event. When will coverage begin? On the 61st day of employment. When will coverage end? The earlier of: 1. The date the Policy terminates; 2. The date the employee s Active Service ends; or 3. The period ends for which premium has been paid. NOTICE: The Limited Medical Plans are a combination of limited scope, fixed indemnity, and accident insurance plans which do not provide Major Medical or Comprehensive Medical coverage. ternian

2 Value-Added Services, Savings, and Online Tools! All of Ternian s limited fixed indemnity plans include the following services* to enhance your plan value and provide increased savings: Medical PPO Network Office Visit Pre-pay, Service provides members affordable access to physicians by allowing them to pay a Office Visit Pre-pay before insurance benefits are applied. DataRx provides innovative Pharmacy Benefit Administration (PBA) solutions to organizations across the United States. DataRx partners with insurance carriers and other organizations to offer the highest quality, most cost-effective prescription services. Thanks to our relationship with this experienced PBA, members have access to unsurpassed service and superior savings on a wide variety of prescription drugs. Discount Prescription Drug Card With ScriptSave Savings average 22%, with potential savings of up to 50% on brand name and generic prescription drugs at over 62,000 participating pharmacies. Applies to the Basic Plan. Telemedicine 24/7 access to affordable care. Teladoc provides members with on-demand 24/7 phone, , and video access to U.S. based licensed physicians for information, advice, and treatment including prescription medication when appropriate. SupportLinc - Employee Assistance Program offers unlimited telephonic access to behavioral health professionals to help individuals with a variety of life and mental health issues, as well as three in-person counselor visits. *These services are not insurance and are not provided by AXIS Insurance Company. WEB Enrollment:

3 Benefits at a Glance This information is a brief description of the important features of the insurance plan. It is not a contract of insurance. The terms and conditions of coverage are set forth in the policies issued in the state in which policy is delivered. Complete details may be found in the policies on file at your employer s office. The policy is subject to the laws of the state in which it is issued. Coverage may not be available in all states or certain terms may be different if required by state law. Please keep this information as a reference. HealthSelect Indemnity plans Ternian HealthSelect Indemnity Plans WEEKLY RATES Employee Only Employee + Spouse Employee + Child(ren) Family INPATIENT (1) Hospital Confinement Day 1 benefit amount Days 2+ benefit amount per day - Maximum benefit Intensive Care Benefit (ICU) per day Surgery benefit amount (incl. maternity) per day Anesthesia benefit amount per day OUTPATIENT (1) Physician Office Visit Pre-pay (2) Benefit amount per day Annual Physical (Wellness) benefit amount per day Well Child Care (age 4 or below) daily benefit amount Accident maximum benefit amount per year up to: Benefit % payable Deductible per Accident Emergency Room (sickness) benefit amount per day Surgery benefit amount per day Anesthesia benefit amount per day Diagnostic, X-ray, lab benefit amount per day: Class I: Laboratory - blood work, CMP, Lipid Panel, ECG, Pap/PSA, urinalysis and all other laboratory tests Class II: Radiology, Ultrasound, Mammogram, Sonogram, Angiogram Class III: Imaging CT, PET Class IV: Other diagnostic test - Endoscopy, Bronchoscopy, Colonoscopy without Biopsy, MRI PRESCRIPTION (3) Retail - Generic RX co-pay Retail - Preferred brand RX co-pay Monthly benefit maximum - INDIVIDUAL/FAMILY AD&D / LIFE Accidental Death & Dismemberment (1) benefit amount* Term Life Insurance (4) benefit amount* BIOMETRIC SCREENING (5) OTHER SERVICES (5) Teladoc: Telephonic Doctor Office Visits SupportLinc-EAP First Health PPO Discounts Basic $500 per day x 1 day $500 thereafter 5 days per year $500 per day x 5 days $1,000 per day x 1 day $250 per day x 1 day $50 per day x 5 days 0 per day x 1 day 0 per day x 4 days $1,500 per year 80% U&C $0 0 per day x 2 days $500 per day x 1 day $125 per day x 1 day $35 per day x 4 days $50 per day x 4 days $150 per day x 2 days $200 per day x 2 days Discount Only (5) ScriptSave Card $5,000/5,000/1,000,000/5,000/2,000 Choice $1,000 per day x 1 day $1,000 thereafter 5 days per year $1,000 per day x 5 days $1,000 per day x 1 day $250 per day x 1 day $60 per day x 5 days 0 per day x 1 day 0 per day x 4 days $2,500 per year 80% U&C $0 $150 per day x 2 days $750 per day x 1 day $187 per day x 1 day $35 per day x 4 days $75 per day x 4 days $150 per day x 2 days $200 per day x 2 days Discount Only $200/$400,000/5,000/1,000,000/5,000/2,000 Max $3,000 per day x 1 day $2,000 thereafter 5 days per year $2,500 per day x 5 days $2,000 per day x 2 days $500 per day x 2 days $75 per day x 5 days 0 per day x 1 day 0 per day x 4 days $5,000 per year 80% U&C $0 $250 per day x 2 days $1,000 per day x 1 day $250 per day x 1 day $35 per day x 4 days 0 per day x 4 days $150 per day x 3 days $250 per day x 2 days $30 $200/$400,000/5,000/1,000,000/5,000/2,000 1 biometric screening performed by a Hy-Vee dietician is covered per year. (1) The Fixed Hospital Indemnity and Outpatient Accidental-Only Benefit Plans are underwritten by AXIS Insurance Company. (2) The office visit pre-pay is a service through the First Health PPO Network. (3) Prescription benefits are underwritten by participating nationally and regionally licensed insurance carriers. (4) Term Life is underwritten by Amalgamated Life. (5) These services are not insurance and are not provided by the underwriting companies shown here.

4 Short-Term Disability 7 day Accident / 7 day Sickness Elimination Period 60% of monthly earnings not to exceed $650 Monthly Benefit 13 week benefit duration Non-Occupation Coverage (off the job only) Not available to employees that reside in CA, HI, NJ, NY, RI and PR STD coverage is only available to eligible employees. There is no dependent coverage available. Short-Term Disability WEEKLY RATE - 100% Voluntary Employee The Short Term Disability Plans are underwritten by AXIS Insurance Company. This information is a brief description of the important features of the insurance plan. It is not a contract of insurance. The terms and conditions of coverage are set forth in the policies issued in the state in which the policy is delivered. The policy is subject to the laws of the state in which it is issued. Coverage may not be available in all states or certain terms may be different if required by state law. This insurance does not apply to the extent that trade or economic sanctions or regulations prohibit us from providing insurance, including, but not limited to, the payment of claims. $1.26 NOTICE The insurance described in this summary provides limited benefits. Limited benefits plans are insurance products with reduced benefits intended to supplement comprehensive health insurance plans. This insurance is not an alternative to comprehensive coverage. It does not provide major medical or comprehensive medical coverage and is not designed to replace major medical insurance. Further, this insurance is not minimum essential benefits as set forth under the Patient Protection and Affordable Care Act.

5 Frequently Asked Questions Is this plan a Major Medical Plan? No. Our Plans are not traditional comprehensive health insurance plans and should not be considered a substitute for this kind of coverage. They are fixed-indemnity medical plans that provide limited coverage for outpatient accidents, illness, and specified diseases to help cover basic, minor-medical expenses. What medical expenses are covered under my plan? Our plans provide coverage to help with expenses like doctor visits, hospital services, lab/x-ray and prescription drugs. Plans may include coverage for routine sickness, off-the-job accidents, hospital confinement or critical illness. Coverage varies based on the plan and level selected. Full details of the coverage, limitations and exclusions are contained in each policy. How do I enroll online? You can visit the Hy-Vee enrollment center at At the Hy-Vee enrollment center you can get a quick quote, plan details or enroll. When will I get my ID cards? Two ID cards will be mailed directly to your home address and should arrive within 5-10 business days after your approval date. If you need to see a doctor immediately or pick up a prescription, log on to to print a temporary ID card. What do I do if I am already enrolled in Medical or Short Term Disability and want to make changes? During annual open enrollment, changes can be made on Outside of open enrollment, call Midwest Heritage at or or csr@mhbankins.com. How do I find a doctor? The First Health Network gives you national access to 5,000 physicians and specialists and 15-50% discounts that help stretch your benefit dollars. With the First Health Network, you can find and choose a network doctor based on your review of price, quality, convenience and service measures. Search for providers online at: or call My doctor doesn t recognize Ternian as an insurance company. What do I need to tell them so they know I m covered? The insurance company that provides benefits through Ternian is AXIS Insurance Company. Give this company name to your doctor. You can also ask your doctor if they participate in the First Health Network which is the network of doctors that we offer our members. Will my medication be covered? Prescription coverage is subject to a formulary or a list of covered medications. For information on what is covered under the formulary of your plan, you can call our prescription vendor DataRx at Will my procedure be covered? For information on a specific procedure, you would need to speak to the claims department through Administrative Concepts, Inc. They will be able to give you a more detailed explanation. They can be reached at What are my out-of-pocket costs going to be? We pay a flat rate toward your services. You will be responsible for any remaining balance after your plan pays out for the coverage listed. Rates for services vary greatly depending on the doctor, procedure, and location of your provider. The best way to predict your out-of-pocket costs is to contact your provider and ask them for an estimate of your costs.

6 ternian Do I need to meet a deductible? Our plans are designed to start paying right away. In most cases, you do not need to meet a deductible. Will the doctor bill the Plan Provider or do I need to pay up front? By selecting a physician from the First Health Network you will be eligible for up front discounts, plus the doctor may bill the insurance company on your behalf. How long am I covered after I enroll in one of the plans? You are covered under the insurance plans for as long as you continue to pay premiums, or until you no longer meet the plan eligibility guidelines described in the insurance certificate. How does the DataRx prescription program work? DataRx is the pharmacy benefit manager for the HealthSelect plans which includes a pharmacy co-pay benefit. You can find a participating pharmacy at or by calling When can I make changes to my plan selections? You can make changes or drop coverage during the annual open enrollment period. This happens at a certain time every year set by your employer. Outside of that period, please verify with your employer to determine if you are able to make changes. How does the ScriptSave prescription savings program work? ScriptSave provides savings on both brand name and generic prescriptions for you and everyone in your household at over 62,000 participating pharmacies across the country. Savings average 22%, with potential savings of up to 50% (based on national program savings data). What is Teladoc? Teladoc allows you to address your routine medical issues on demand 24/7 from the convenience of your home or office. Call: TELADOC with additional questions. What is SupportLinc? SupportLinc is a 24/7/365 employee assistance program (EAP), which provides a variety of resources and referrals (includes 3 face-to-face counseling sessions for each covered family member) for issues related to work, family, caregiving, health and well-being. Call: LINC with additional questions. I still have questions. Who do I call? For eligibility, benefit, and claims questions, call Administrative Concepts, Inc. at:

7 What s Not Covered Under the Group Hospital Indemnity we will not pay for any loss, injury or sickness that is caused by, or results from: Intentionally self-inflicted injury, suicide or attempted suicide. War or any act of war, whether declared or not. Service in the military, naval or air service of any country or international organization. Piloting or serving as a crew member or riding in any aircraft except as a farepaying passenger on a regularly scheduled or charter airline. Commission of, or attempt to commit, a felony. Commission of or active participation in a riot, or insurrection. Bungee cord jumping, parachuting,skydiving, parasailing, hang-gliding. Flight in, boarding or alighting from any aircraft except as a fare-paying passenger on a regularly scheduled commercial airline. An accident if the Insured Person is the operator of a motor vehicle and does not possess a valid motor vehicle operator s license, except while participating in Driver s Education Program. Medical or surgical treatment, diagnostic procedure, administration anesthesia, or medical mishap or negligence, including malpractice. (This exclusion applies to the Accidental Death and Dismemberment benefit only.) Travel or activity outside the United States, Canada or Mexico, except for a Medical Emergency. Travel in any aircraft owned, leased or controlled by the Policyholder, or any of its subsidiaries or affiliates. An aircraft will be deemed to be controlled by the Policyholder if the aircraft may be used as the Policyholder wishes for more than 10 straight days, or more than 15 days in any year. Alcoholism, drug addiction or the use of any drug or narcotic except as prescribed by a Physician unless specifically provided herein. Repair or replacement of existing dentures, partial dentures, braces, fixed or removable bridges, or other artificial dental restoration. Repair, replacement, examinations for, prescriptions, or the fitting of eyeglasses or contact lenses. While the Insured Person is legally intoxicated (as determined by that state s laws) or while ministered under the influence of any drug unless administered under the advice and consent of a Physician. Elective Abortion. Elective Abortion means an abortion for any reason other than to preserve the life of the female upon whom the abortion is performed. Mental and Nervous Disorders. Cosmetic surgery, except for reconstruction surgery needed as the result of an injury or sickness. Experimental or Investigational drugs, services, supplies or any procedure held to be experimental or investigatory by Us at the time the procedure is done. Treatment for being overweight, gastric bypass or stapling, intestinal bypass, and any related procedures, including complications. Sexual reassignment surgery, sexual transformation surgery, sexual transgendering surgery. Services related to sterilization, reversal of vasectomy or tubal ligation; in vitro fertilization and diagnostic treatment of infertility or other problems related to the inability to conceive a child, unless such infertility is a result of a covered Injury or Sickness. Treatment or services provided by a private duty nurse, unless provided for in the Policy. Organ or tissue transplants and related services. Personal comfort or convenience items. Rest or custodial cures. Hearing aids. Radial keratotomy. Treatment by a family member or member of the Insured Person s household. Routine dental care and treatment, except for treatment of Injury as specified in the Policy. Under the Accident Medical Expense Policy we will not pay for loss, injury or sickness that is caused by, or results from: Suicide or attempted suicide, intentionally self-inflicted injury. War or any act of war, whether declared or not. A Covered Accident that occurs while on active duty service in the military, naval or air force of any country or international organization. Upon Our receipt of proof of service, We will refund any premium paid for this time. Reserve or National Guard active duty training is not excluded unless it extends beyond 31 days. Sickness, disease, or any bacterial infection, except one that results from an accidental cut or wound or pyogenic infections that result from accidental ingestion of contaminated substances. Piloting or serving as a crew member or riding in any aircraft except as a farepaying passenger on a regularly scheduled or charter airline. Injury that occurs while the Insured Person is legally intoxicated (as determined by that state s law) or while under the influence of any drug unless administered under the advice and consent of a Physician. Medical or surgical treatment, diagnostic procedure, administration of anesthesia, or medical mishap or negligence, including malpractice. Commission of, or attempt to commit, a felony. Aggravation or re-injury of a prior Injury the Insured Person suffered prior to his or her coverage effective date, unless We receive a written medical release from the Insured Person s Physician. In addition to the above Exclusions, under the Accident Medical Expense Policy, We will not pay for any loss, treatment or services resulting from or contributed to by: Treatment by persons employed or retained by the Policyholder, or by any Immediate Family or member of the Insured Person s household. Treatment of sickness, disease or infections except pyogenic infections or bacterial infections that result from the accidental ingestion of contaminated substances. Treatment of hernia, Osgood-Schlatter s Disease, osteochondritis, appendicitis, osteomyelitis, cardiac disease or conditions, pathological fractures, congenital weakness, detached retina unless caused by an Injury, or mental disorder or psychological or psychiatric care or treatment (except as provided in the Policy), whether or not caused by a Covered Accident. Pregnancy, childbirth, miscarriage, abortion or any complications of any of these conditions. Mental and nervous disorders (except as provided in the Policy). Injury covered by Workers Compensation, Employer s Liability Laws or similar occupational benefits, including any insurance policy that provides benefits to the Insured Person for injuries resulting from an occupational accident, or while engaging in activity for monetary gain from sources other than the Policyholder. Cosmetic surgery, except for reconstructive surgery needed as the result of an Injury. Any elective treatment, surgery, health treatment, or examination, including any service, treatment or supplies that: (a) are deemed by Us to be experimental; and (b) are not recognized and generally accepted medical practices in the United States. Eyeglasses, contact lenses, hearing aids, examinations or prescriptions for them, or repair or replacement of existing artificial limbs, orthopedic braces, or orthotic devices. Expenses payable by any automobile insurance Policy without regard to fault. (This exclusion does not apply in any state where prohibited.) Damage to or loss of dentures or bridges, or damage to existing orthodontic equipment (except as specifically covered by the Policy). Expenses incurred for treatment of temporomandibular or craniomandibular joint dysfunction and associated myofacial pain (except as provided by the Policy). Conditions that are not caused by a Covered Accident. Participation in any activity or hazard not specifically covered by the Policy. Any treatment, service or supply not specifically covered by the Policy. No Prescription Drug Benefits will be paid for: All over-the-counter products and medications unless shown in the definition of Prescription Drug. This includes, but is not limited to, electrolyte replacement, infant formulas, miscellaneous nutritional supplements, and all other over-thecounter products and medications. Blood glucose meters and insulin injecting devices. Depo-Provera; condoms, contraceptive sponges, and spermicides; sexual dysfunction drugs. Biologicals (including allergy tests); blood products; growth hormones; hemophiliac factors; MS injectables; immunizations; and all other injectables unless shown in the definition of Prescription Drug. Medical supplies and durable medical equipment. Liquid nutritional supplements; pediatric Legend Drug vitamins; prescribed versions of Vitamins A, D, K, B12, Folic Acid, and Niacin used in treatment verses as a dietary supplement; and all other Legend Drug vitamins and nutritional supplements. Anorexiants; any cosmetic drugs including, but not limited to, Renova and skin pigmentation preps; any drugs or products used for the treatment of baldness; and topical dental fluorides. Refills in excess of that specified by the prescribing Physician, or refills dispensed after one year from the original date of the prescription. Any drug labeled Caution limited by Federal Law for Investigational Use or experimental drugs. Any drug which the Food and Drug Administration has determined to be contraindicated for the specific treatment.

8 Drugs needed due to conditions caused, directly or indirectly, by a Insured Person taking part in a riot or other civil disorder; or the Insured Person taking part in the commission of a felony. Drugs needed due to conditions caused, directly or indirectly, by declared or undeclared war or any act of war; or drugs dispensed to a Insured Person while on active duty service in any armed forces. Any expenses related to the administration of any drug. Drugs or medicines taken while in or administered by a Hospital or any other health care facility or office. Drugs covered under Worker s Compensation, Medicare, Medicaid or other governmental program. Drugs, medicines or products which are not medically necessary. Diaphragms; erectile dysfunction Legend Drugs; and infertility Legend Drugs. Epi-Pen, Epi-Pen Jr., Ana-Kit, Ana-Guard; Glucagon-auto injection; and Imitrex-auto injection. Smoking deterrents, Legend or over-the-counter drugs. Replacement of stolen medication (except under circumstances approved by us), or lost, spilled, broken or dropped Prescription Drugs. Vacation supplies of Prescription Drugs (except under circumstances approved by us). All newly marketed pharmaceuticals or currently marketed pharmaceuticals with a new FDA approved indication for a period of one year from such FDA approval for its intended indication. The following applies to the Group Term Life Insurance benefit: SUICIDE EXCLUSION: We will not pay a death benefit if an insured person dies by suicide, while sane or insane, within two years of the date his/her insurance starts. If You or Your spouse dies by suicide, We will refund the premiums paid for Your insurance (if a dependent child dies by suicide, We will refund the premiums paid for the dependent children s insurance only if You have no surviving insured dependent children). If any death benefit is increased, this suicide exclusion starts anew, but will apply only to the amount of the increase. Pre-existing Condition Limitation The Insurance Company will not pay Disability Benefits for any period of Disability caused by or contributed to by, or resulting from, a Pre-existing Condition. A Pre-existing Condition means an Injury or Sickness for which the Employee incurred expenses, received medical treatment, care or services including diagnostic measures, took prescribed drugs or medicines, or for which a reasonable person would have consulted a physician within 12 months before his or her most recent effective date of insurance. The Preexisting Condition Limitation will apply to any added benefits or increase in benefits. It will not apply to a period of Disability that begins after an Employee is in Active Service for at least 12 months after his or her most recent effective date of insurance or the effective date of any added or increased benefits. The Pre-Existing Condition Limitation will not apply to an Employee covered under a Prior Plan who satisfied the Pre-existing Condition limitation, if any, under that plan. If an Employee, covered under a Prior Plan, did not fully satisfy the Pre-existing Condition limitation of that plan, credit will be given for any time that was satisfied. Time will not be credited for any day an Employee is not actively at work due to his or her Injury or Sickness. The Pre-existing Condition Limitation will be extended by the number of days the Employee is not actively at work due to his or her Injury or Sickness. IMPORTANT NOTICE: Insurance policies providing certain health insurance coverage issued or renewed on or after September 23, 2010 are required to comply with all applicable requirements of the Patient Protection and Affordable Care Act (PPACA). However, there are a number of insurance coverages that are specifically exempt from the requirements of PPACA (See 2791 of the Public Health Services Act). AXIS maintains that the Limited Accident and Sickness Plan presented In this brochure Is fixed Indemnity insurance, and is therefore, exempt from the requirements of PPACA. *Please note that certain exclusions and limitations listed in the What s Not Covered sections may vary by state law. The Insurance Company will not pay Disability Benefits for a Disability that results, directly or indirectly, from any of the following events: attempted suicide, or whenever an Employee injures himself or herself on purpose. war or any act of war, whether or not declared. serving on full-time active duty in any armed forces. If the Employee sends proof of military service, the Insurance Company will refund the portion of the premium paid to cover the Employee during a period of such service. active participation in a riot. commission of a felony. incarceration in a penal or corrections institution. participation in an activity or event while under the influence of a controlled substance (unless administered by a Physician or taken according to a Physician s instructions) or Intoxicated. Intoxicated means that condition as defined by the law of the jurisdiction in which the activity or event occurred. In addition, the Insurance Company will not pay Weekly Benefits for a Disability that results, directly or indirectly, from any of the following: any cosmetic surgery or surgical procedure that is not Medically Necessary; Medically Necessary means the surgical procedure is: (a) prescribed by a Physician as required treatment of the Injury or Sickness; and (b) appropriate according to conventional medical practice for the Injury or Sickness in the locality in which the surgery is performed. (The Insurance Company will pay benefits if the Disability is caused by the Employee donating an organ in a non-experimental organ transplant procedure.) an Injury or Sickness for which the Employee is entitled to benefits from Workers Compensation or occupational disease law. an Injury or Sickness that is work related. In addition, the Insurance Company will not pay Disability Benefits for any period of Disability during which the Employee does any of the following: refuses to participate in rehabilitation efforts as required by the Insurance Company. is not receiving Appropriate Care. fails to cooperate with the Insurance Company in the administration of the claim. Such cooperation includes, but is not limited to, providing any information or documents needed to determine whether benefits are payable or the actual benefit amount due. Claims Administered by: Administrative Concepts, Inc. (ACI) 994 Old Eagle School Road, Ste Wayne, PA

9 Important Notice Missed Premium Payments What is the purpose of this form? This form will allow you the option to make up a missed premium due to not working enough hours to cover the payroll deduction premium for Ternian. What if I do not have a payroll deduction for premium? If you do not work enough hours to cover your payroll deduction premium, your coverage will be placed in a suspended status until premium is paid current. Any claims filed for expenses or services incurred while your coverage is suspended will not be considered for payment. How can I make up a missed payroll deduction premium? You may pay a missed payroll deduction premium by mailing in your premium, along with a completed Missed Premium Deduction Form. Mail the completed form and a check, payable to Ternian Insurance Group, to: Midwest Heritage Insurance PO Box 737 Chariton, Iowa Can I pay just part of any missed premium? No, you must pay the full premium for all consecutive missed pay periods. Partial payments will not be accepted. How long do I have to pay a premium? Your check must be post-marked within 28 days after the date on the paycheck from which the first missed deduction would have been taken from your pay. If you miss any deduction, you must make up for all missed premiums once your payroll deductions resume within this 28 day period. Will my insurance be cancelled if I don t make up a missed premium? Your coverage will not be cancelled unless it remains suspended (unpaid) status for 28 consecutive days. If this happens, your coverage will be cancelled at the end of the period for which your last payroll deduction covered. If such cancellation occurs, you will not be eligible to enroll in the plan again until the next open enrollment period. Ternian Insurance Group Missed Premium Deduction Form Name: Social Security Number: List all payroll deduction dates that premium was not deducted: X = Number of missed Premium Periods Payroll Deduction Premium Amount Premium Amount Enclosed NOTE: No benefits will be considered for unpaid periods and your coverage will be subject to the Termination of Insurance provision of the Policy