Legal Name: Brown County. Type of Corporation: Government Organization. Address: 305 East Walnut Street Suite 591. Green Bay WI 54301

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1 Enter Customer Name Legal Name: Brown County Type of Corporation: Government Organization Address: 305 East Walnut Street Suite 591 Green Bay WI Effective: January 1,2019 Situs/Employer Location: WI Product Policy #/Ext. Finalized Date SI STD /FT25/2019 Enter Date 2/25/19

2 SI STD Service Eligible Group(s) Self Insured STD Plan Provisions Policy Number Advice to Pay Service All full-time employees in active employment in the United States with the Employer. Group 1: Sheriff Non-Supervisory Union Members and Sheriff Supervisory Members Group 2: ADRC Members Group 3: All other Members For all Groups above: in active employment in the United States with the Employer Foreign Nationals Note: for Puerto Rico employees, PR maternity law requires the employer to pay 100% benefit for 8 weeks (No mimimum benefit payable). Minimum Hours No Note: list policy they are covered under The following information will be needed for the administrative letter to extend coverage. Last name, First initial Type of employee (i.e. Expatriates) Country of work location Gender Occupation Country of citizenship Date of birth Salary (US $) Working at least.5 FTE hours per week. Waiting Period Present Employees: 6 months First of the month following date the waiting period is met New Employees: 6 months First of the month following date the waiting period is met Rehire 12 months (standard) Waiver of Waiting Period OR Credit Prior Service Elimination Period Credit Prior Service Illness: Group 001 0/3 Injury: Hospital/Surgery: 2

3 Sick Leave and Salary Continuation Group 002& 003 0/7 p Are Employees required to Exhaust the following programs before the elimination period is complete and benefits become payable or will Unum offset benefits? i.e. EP: the greater of 180 days or the end of your salary continuation or accumulated sick leave program or STD Program Salary Continuation: Do Not Extend Elimination Period or Offset Accumulated Sick Leave: Do Not Extend Elimination Period or Offset Max Period of Payment (Benefit Duration) When benefits are paid (must match Report Frequency) Benefit Payment Basis Definition of Disability 26 weeks (calendar or work days also available) From Date of Disability (Includes EP) Bi-Weekly (14 calendar days) 1/7th Calendar Day Plan STD: Residual Maternity SI STD Ante-Partum: Medically managed until delivery date After Delivery: 6 Weeks Vaginal and 8 weeks C-Section Delivery Benefit End date Exclusions Continuity of Coverage Coverage during Non Medical Leave of Absence Do benefits end upon termination of employment? Yes The plan does not cover any disabilities caused by, contributed to by, or resulting from your: - occupational sickness or injury - intentionally self-inflicted injuries - active participation in riot - loss of a professional license, occupational license or certification - commission of a crime for which you have been convicted - war, declared or undeclared - any period for which the claimant is incarcerated N/A End of the month following the month the LOA begins (subject to premium payment) 3

4 (LOA) Coverage during Temporary Layoff Recurrent Disability Delayed Effective Date Unum Claim Fiduciary SI STD Service Review report samples for type of service being considered or requested RMS Job Aid End of the month following the month the Layoff begins (subject to premium payment) 14 consecutive days or less from the end of the prior claim for same or related For Employee: If you are absent from work due to injury, sickness, temporary layoff or leave of absence on the date your coverage would normally begin or increase, your coverage will begin or increase on the date you return to active employment. No Advice to Pay Service NOTE: An RMS form needs to be completed and submitted for all services and each recipient. RMS Form: Please list the recipient(s) name, phone and and all applicable Options to be visible on your SI STD Reports: For ATP or ATP Ben% only Options: Delivery Date (maternity) Missing Information Work related disability Job Title Part-time return to work Not Approved (non-payable period) Diagnosis code & description Current Age Gender Reporting sorting/view options: SSN: None Claim Sorting: Alpha Listing Note: For multiple users please attach separate spreadsheet with all users and options SI STD Reporting Frequency Frequency must match when benefits are paid SI STD Report Delivery Select appropriate choice and remove all others Bi-Weekly (14 calendar days) Biweekly Day of the week want report to run: Monday before Friday payroll (Example: Should you choose to receive the bi-weekly report on a Monday: Report will cover will 4

5 Sunday through Saturday claims information on a bi-weekly basis) or; If matching payroll calendar, what day of week within the payroll period do you want report to run: Date Payroll calendar received: (Example: Payroll runs Friday: report runs Thursday and covers Friday through Thursday data) Monthly: Date to receive report: Mondays Monday before Friday pay day (9/14 8/27-9/10) Who should receive the reports? Will need contact information (name, phone, address) Jill.bomkamp@co.brown.wi.us : (920) Ranee.keomanyvong@co.brown.wi.us Denise.buhler@co.brown.wi.us Client Approval (Name/Date/Comments) Underwriter Approval (Name/Date/Comments) Jill Bomkamp Emily Cothran 5

6 Billing/Claims Divisions NOTES: If Policyholder needs loss ratio experience (premium vs. claims) for any group it will need to be identified through separate billing and claim divisions Division Structure Billing Method: Self Accounting Self-Insured Billed: Current (standard) If multiple divisions, is the contact the same for each division? Billing: No Claims: No. Policy #/Product Claim Division #/Name Pegs Billing Division #/Name SI STD Brown County Brown County FI LTD Brown County Brown County FMLA Decision Maker Contacts Name/Title Address Phone/Fax/ Correspondence/ Method Troy Streckenback 305 East Walnut Street Suite 591 Green Bay WI Div. Products Disability Only 6

7 Billing Jill Bomkamp 305 East Walnut Street Suite 591 Green Bay WI Disability Only Claims Jill Bomkamp 305 East Walnut Street Suite 591 Green Bay WI Are you willing to accommodate a Return to Work situation: Y/N If Yes, provide contact information Y Correspondence: All Letters Method: Disability Only RATES Product Policy # Eligible Lives Rates SI STD Monthly Fees: 2.11 PEPM Per Employee Per Month $ 2.11 Fee Guarantee: 3 years FMLA Standard Services: $2.30 PEPM Rate Guarantee:3 years Sales/Service Office: Milwaukee Sales Rep: Nicholas Verhayan CM: Jamie Runde Disability Underwriter: Emily Cothran Unum Information Benefits OC: Justin Riley Benefits Location: Portland Implementation Resource: Susan Leahy 7

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