KEARNEY Trailers, LLC.

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1 KEARNEY Trailers, LLC. Minimum Essential Coverage & Limited Medical Benefit Program Enrollment Guide Minimum Essential Coverage Offered in tandem with Voluntary Limited Benefit Health Insurance Vision Prescription Drugs Life No Deductibles No Co-pays First Dollar Coverage For more information about your plan, Call the Enrollment IMPORTANT Crescent Limited Medical programs are not comprehensive major medical insurance plans. Policy forms are intended to comply fully with all applicable state insurance statutes and regulations. Because of differing state requirements, benefits, terms and conditions may vary by state from the description according to the approved plan sponsor location and/or the insured s state of residence. Plan are underwritten by Companion 1 P a g e Life Insurance Company of SC. Claims are administered by TCC of South Carolina.

2 PART 1 MINIMUM ESSENTIAL COVERAGE Covered 100% by Employer Patient Protection and Affordable Care Act ( PPACA ) compliance: The plan will at all times be in compliance with PPACA rules and regulations. Notes regarding the plan: This plan provides coverage for Preventive Services. Claims will be processed based upon the Billing practices of your healthcare provider. Services that are not Preventive Services as Defined by the Patient Protection and Affordable Care Act ( PPACA ) will not be covered By the plan. Network provider service payments will be based on the applicable network access agreement and non-network provider services will be paid based on the reasonable and customary amount. SCHEDULE OF BENEFITS MEC PLAN Minimum Essential Coverage Benefits Network Non-network 15 Preventive Services For Adults 100% 40% 22 Preventive Services For Women 100% 40% 26 Preventive Services For Children 100% 40% PPO Network FIRST HEALTH DEDUCTIBLES COINSURANCE NETWORK NON-NETWORK Individual None None Family None None NETWORK NON-NETWORK Plan Pays 100% Plan Pays 40% LIFETIME MAXIMUM None ANNUAL MAXIMUM None PLEASE NOTE: Office exams billed with the below services or with a covered preventive diagnosis is Covered under the plan. GENERAL EXCLUSIONS TO THE PLAN Covered expenses do not include and no benefits are payable for the following: 1. Charges that the participant is not legally required to pay for or charges which would not have been made if this coverage had not existed. 2. Non-network charges that are in excess of the reasonable and customary rates for the services as determined by the plan. 3. Charges for a covered person that are reimbursed, that could be reimbursed, or that could have been reimbursed as part of a clinical trial, by any public program, Such as Medicare or Medicaid, even if the person could have, but does not, elect To be covered by that public program. 4. Treatment or services provided by anyone other than a healthcare provider as Defined herein unless specifically stated in the plan. 5. Services that are not preventive services will not be covered by the plan. 6. Investigatory and experimental treatment, services, and supplies, unless provided for herein. 7. Services for the treatment of an illness or injury shall not be covered by the plan. 2 P a g e

3 Abdominal Aortic Aneurysm - One-time screening for men of ages65-75 who have ever smoked Alcohol Misuse - Screening and counseling Aspirin - Use for men and women of certain ages Blood Pressure - Screening for all adults Cholesterol - Screening for adults of certain ages or at higher risk Colorectal Cancer - Screening for adults over 50 Depression - Screening for adults Type 2 Diabetes - Screening for adults with high blood pressure Diet - Counseling for adults at higher risk for chronic disease HIV - Screening for all adults at higher risk COVERED PREVENTIVE SERVICES FOR ADULTS Immunization - Vaccines for adults--doses, recommended ages, and recommended populations vary: Hepatitis A, Hepatitis B, Herpes Zoster, Human Papillomavirus, Influenza (Flu Shot), Measles, Mumps, Rubella, Meningococcal, Pneumococcal, Tetanus, Diphtheria, Pertussis and Varicella Obesity - Screening and counseling for all adults Sexually Transmitted Infection (STI) - Prevention counseling for adults at higher risk Tobacco Use - Screening for all adults and cessation interventions for tobacco users Syphilis - Screening for all adults at higher risk COVERED PREVENTIVE SERVICES FOR WOMEN, INCLUDING PREGNANT WOMEN Anemia - Screening on a routine basis for pregnant women Bacteriuria - Urinary tract or other infection screening for pregnant women BRCA - Counseling about genetic testing for women at higher risk Breast Cancer Mammography - Screenings every 1 to 2 years for women over 40 Breast Cancer Chemoprevention - Counseling for women at higher risk Breastfeeding - Comprehensive support and counseling from trained providers, as well as access to breastfeeding supplies, for pregnant and nursing women Cervical Cancer - Screening for sexually active women Chlamydia Infection - Screening for younger women and other women at higher risk Contraception - Food and Drug Administration-approved contraceptive methods, sterilization procedures, and patient education and counseling, not including abortifacient drugs Domestic and interpersonal violence - Screening and counseling for all women Folic Acid - Supplements for women who may become pregnant Alcohol and Drug Use - Assessments for adolescents Autism - Screening for children at 18 and 24 months Behavioral - Assessments for children of all ages Ages: 0 to 11 months, 1 to 4 years, 5 to 10 years, 11 to 14 years, 15 to 17 years limited to 5 assessments Blood Pressure - Screening for children Ages: 0 to 11 months, 1 to 4 years, 5 to 10 years, 11 to 14 years, 15 to 17 years Cervical Dysplasia- screening Congenital Hypothyroidism- screening for newborns Depression - screening for adolescents age 12 and older Developmental - screening for children under age 3, and surveillance throughout childhood Dyslipidemia - Screening for children at higher risk of lipid disorders Ages: 1 to 4 years, 5 to 10 years, 11 to 14 years, 15 to 17 years Fluoride Chemoprevention - Supplements for children without fluoride in their water source Gonorrhea - Preventive medication for the eyes of all newborns Hearing - Screening for all newborns Height, Weight and Body Mass Index - Measurements for children Ages: 0 to 11 months, 1 to 4 years, 5 to 10 years, 11 to 14 years, 15 to 17 years Hematocrit or Hemoglobin - Screening for children Hemoglobinopathies or Sickle Cell - Screening for newborns HIV- Screening for adolescents at higher risk COVERED PREVENTIVE SERVICES FOR CHILDREN Gestational diabetes - Screening for women 24 to 28 weeks pregnant and those at high risk of developing gestational diabetes Gonorrhea - Screening for all women at higher risk Hepatitis B - Screening for pregnant women at their first prenatal visit Human Immunodeficiency Virus (HIV) - Screening and counseling for sexually active women Human Papillomavirus (HPV) DNA Test - High risk HPV DNA testing every three years for women with normal cytology results who are 30 or older Osteoporosis - Screening for women over age 60 depending on risk factors Rh Incompatibility - Screening for all pregnant women and followup testing for women at higher risk Tobacco Use - Screening and interventions for all women, and expanded counseling for pregnant tobacco users Sexually Transmitted Infections (STI) - Counseling for sexually active women Syphilis - Screening for all pregnant women or other women at increased risk Well-woman - Visits to obtain recommended preventive services Immunization - Vaccines for children from birth to age 18 doses, recommended ages, and recommended populations vary: Diphtheria, Tetanus, Pertussis, Haemophilus influenza type b, Hepatitis A, Hepatitis B, Human Papillomavirus, Inactivated Poliovirus, Influenza (Flu Shot), Measles, Mumps, Rubella, Meningococcal, Pneumococcal, Rotavirus and Varicella Iron - Supplements for children ages 6 to 12 months at risk for anemia Lead - Screening for children at risk of exposure Medical History - For all children throughout development Ages: 0 to 11 months, 1 to 4 years, 5 to 10 years, 11 to 14 years, 15 to 17 years Obesity - Screening and counseling Oral Health - Risk assessment for young children Ages: 0 to 11 months, 1 to 4 years, 5 to 10 years Phenylketonuria (PKU) - Screening for this genetic disorder in newborns Sexually Transmitted Infection (STI) - Prevention counseling and screening for adolescents at higher risk Tuberculin - Testing for children at higher risk of tuberculosis Ages: 0 to 11 months, 1 to 4 years, 5 to 10 years, 11 to 14 years, 15 to 17 years Vision - Screening for all children 3 P a g e

4 PART 2 INDEMNITY MEDICAL COVERAGE Voluntary BENEFIT DESCRIPTIONS Plan 1 NATIONAL PPO NETWORK First Health Hospital Indemnity Benefit Paid per Day of Confinement $250 Number of Days allowed per Calendar Year 150 In Patient Surgical (Flat Surgical Benefit) $200 Number of times paid per Calendar Year 1 Anesthesia Benefit Per Day $50 Physician Office Visit $50 Number of Visits per Covered Person Per Calendar Year 5 Wellness Benefit $100 Number of Visits per Calendar Year 2 Outpatient Surgical Benefit - Indemnity $100 Anesthesia (25%) $25 Outpatient Surgical Facility Benefit Paid per day $100 Number of days allowed in Calendar Year 1 LIFE INSURANCE Life Insurance^ $10,000 Dependent Spouse Life $1,000 Dependent Child Life - 14 days or older $1,000 MMP 2050 Form number for Companion s Employer Indemnity Benefit Health Insurance Policy ADDITIONAL BENEFITS Plan 1 Insured Rx Program EyeMed Standard Vision Program Lab, CT Scans and MRI Imaging Discount Program Patient Advocacy $10 Generic $30 Brand Name $1,200 Annual Limit $2,400 Family Limit $10 Co-pay Eye Exam Every 12 months Included Included The premium rates include a charge for the Value Added Benefit Programs, Pharmacy Benefits, PPO fee and administrative services provided by ADMU Benefits. * The Value Added Benefits, except for pharmacy and vision programs, is neither underwritten nor insured by Companion Life Insurance Company. **Accident Medical coverage is underwritten by Zurich America Insurance Company and not available in all states; Consumer Alliance USA is the policy holder for this coverage. 4 P a g e

5 BENEFIT DESCRIPTIONS Daily In-Hospital Indemnity Benefit - If a Covered Person, while insured, is Confined in a Hospital as a result of Accident or Sickness, the Company will pay the Daily In-Hospital Indemnity Benefit amount, as shown in the Schedule, for each day of Confinement, for up to the Maximum Number of Days of Confinement, as shown in the Schedule. No benefit will be paid during any period the Covered Person is not under the regular care and attendance of a Physician. Surgical Indemnity Benefit - If a Covered Person has a covered surgery performed, the Company will pay the Surgical Indemnity Benefit amount. This amount is based on the Payment Factor amount, as shown in the Schedule of Surgical Indemnity Benefits, times the number of Surgical Procedure Units, as shown in the Schedule. If two or more procedures are performed through the same incision or operative field, payment will be made only for the procedure of the larger benefit. If more than one procedure is performed but each through separate incisions or in a separate operative field, the amount payable shall be the specified amount for the primary procedure plus 50% of the amount payable for all other surgical procedures performed. Unlisted Procedures: In addition to the procedures listed in the Schedule of Surgical Indemnity Benefits, amounts shall be payable for any other covered operations. The amounts for such procedures shall be determined by the Company in amounts consistent with those listed in the Schedule of Surgical Benefits. Anesthesia Indemnity Benefit - If the Surgical Indemnity Benefit is payable, the Company will pay the Anesthesia Indemnity Benefit amount, as shown in the Schedule, for the administration of anesthesia. Outpatient Physician Office Visit Indemnity Benefit - The Company will pay the Outpatient Physician Office Visit Indemnity Benefit, as shown in the Schedule, for a Physician office visit as a result of Sickness or Accident, not to exceed the Maximum Number of Office Visits per Calendar Year, as shown in the Schedule. Wellness Benefit - A. The company will pay the indemnity benefit shown in the schedule of benefits for an annual physical examination for the insured and his covered dependents up to the calendar year maximum shown on the schedule of benefits. These services will only be covered to the extent that the services are provided by, or under the supervision of, a single physician during the course of one (1) visit. Services include: 1. A history; 2. Physical examination; 3. X-rays; 4. Laboratory services including, but not limited to, a pap test, colorectal screening and prostate cancer screening. Outpatient Surgical Facility Indemnity Benefit - The Company will pay the Outpatient Surgical Facility Indemnity Benefit for charges made by an Outpatient Surgical facility, including a hospital ambulatory surgery center, provided the Covered Person is not admitted to the hospital, in connection with a covered outpatient surgical procedure performed on a Covered Person. Benefits will be paid for services and supplies such as the cost of the operating room, laboratory tests and X-ray examinations, including professional fees, drugs or medicines, and supplies. Life Insurance - If a Covered Person dies, the Company will pay the Death Benefit, subject to the provisions of the Policy. This benefit is shown in the Schedule. Payment will be made in one lump sum to the Beneficiary (or to the Insured in the event of a covered Dependent s death). WEEKLY RATES WEEKLY RATES MEC Plan Kearny 250 Weekly Total Individual $0.00 $25.15 $25.15 Individual + Spouse $3.82 $43.15 $46.97 Individual + Child(ren) $19.47 $41.54 $61.01 Family $23.29 $58.85 $ P a g e

6 CRESCENT INDEMNITY BENEFIT HEALTH PLAN LIMITATION AND EXCLUSIONS With respect to all of the benefits provided under the policy, no benefits will be payable as the result of: (a) suicide or any attempt thereat, while sane or insane. [if any covered person, sane or insane, should die by suicide within two years (one year in Colorado and North Dakota) of his or her effective date of coverage, life insurance benefits will not be payable; (in Missouri, the reference to insanity does not apply and suicide is no defense to payment under this policy where the covered person is a Missouri citizen unless the company can show that the covered person intended suicide when he or she applied for coverage, regardless of any language to the contrary in the policy.)] (b) any intentionally self-inflicted injury or sickness; (c) rest care or rehabilitative care and treatment; (d) cosmetic surgery or care or treatment solely for cosmetic purposes, or complications therefrom. This exclusion does not apply to cosmetic surgery resulting from a covered accident if initial treatment of the covered person is begun within 12 months of the date of the accident; (e)immunization shots and routine examinations such as: health exams; periodic check-ups; pre-marital exams; and routine physicals; (f) routine newborn care, including routine nursery charges; (g) voluntary abortion, except with respect to the insured or covered dependent spouse: (1)where such person s life would be endangered if the fetus were carried to term; or (2)where medical complications have arisen from an abortion; (h) pregnancy of a dependent child, unless required by law; (i) the treatment of: (1)mental illness; (2)functional or organic nervous disorder, regardless of cause; (3)alcohol abuse; (4)drug use, unless such drugs were taken on the advice of a physician and taken as prescribed, for more than 10 days in any calendar year, with respect to payment of the daily in-hospital indemnity benefit; (j) participation in a riot, civil commotion, civil disobedience, or unlawful assembly. This does not include a loss which occurs while acting in a lawful manner within the scope of authority; (k) committing, attempting to commit, or taking part in a felony or assault, or engaging in an illegal occupation; (l) participation in a contest of speed in power driven vehicles, parachuting, parasailing, bungee-jumping, or hang gliding; (m) air travel, except: (1)as a fare-paying passenger on a commercial airline on a regularly scheduled route; or (2)as a passenger for transportation only and not as a pilot or crew member; (n) any accident occurring as a result of the covered person being intoxicated (where the blood alcohol content meets the legal presumption of intoxication under the law of the state where the accident took place); (o) sex changes; (p) experimental treatments or surgery; (q) the reversal of tubal ligation and vasectomies; (r)artificial insemination, in vitro fertilization, and test tube fertilization, including any related testing, medications, or physician s services, unless required by law; (s) treatment of exogenous obesity or weight control; (t)an act of war, whether declared or undeclared, or while performing police duty as a member of any military or naval organization. This exclusion includes accident sustained or sickness contracted while in the service of any military, naval or air force of any country engaged in war. The company will refund the pro rata unearned premium for any such period the covered person is not covered; (u) accident or sickness arising out of and in the course of any occupation for compensation, wage or profit. Expenses which are payable under occupational disease law or similar law, whether or not application for such benefits has been made; (v) pre-existing conditions, except as described in the schedule; or (w)air or ground ambulance service. (x) for loss incurred, care or treatment received, or hospital confinement occurring outside of the United States or its possessions. In addition to the exclusions and limitations for all coverages, the following are not covered under the out-patient physician office visit indemnity benefit and the outpatient diagnostic x-ray and laboratory indemnity benefit: (a) visits made, examinations given, or x-rays or laboratory tests performed as an in-patient while confined to a hospital; (b) routine eye examinations or fitting of glasses; (c) fitting of hearing aids; (d) dental examinations or dental care other than expenses resulting from accidental injury; and (e)benefits which are provided under any other part of the policy. 6 P a g e

7 VALUE ADDED BENEFIT PROGRAMS The Value Added Benefit Programs is neither underwritten nor insured by Companion Life Insurance Company. Companion assumes no responsibility or liability for any of the listed services, the providers of the services, the quality of the services, the delivery of the services or the outcomes of the services. Questions or concerns about the services should be addressed directly to the providers. PRESCRIPTION DRUG COVERAGE ADVANTAGE RX 10/30 PLAN $10 Co-pay for Preferred Generic drugs $30 Co-pay for Preferred Brand Name $200 individual monthly - $400 family monthly max. VISION BY DESIGN Vision Essentials ($10 Co-pay Eye Exam + Discount). Provides a paid in full exam and substantial point of sale discounts for frames, lenses and contact lenses. Discount applies when a complete pair of eyeglasses ** is purchased; otherwise the discount is 20% off the retail price. Members also receive a 40% discount off complete pair of eyeglass purchases (frames, lenses, and lens options purchased in the same transaction) and a 15% discount off conventional contact lenses once the funded benefits have been used. After initial purchase, replacement contact lenses may be obtained via the Internet at substantial savings and mailed directly to the member. Details are available at The contact lens benefit allowance is not applicable to this service. Laser vision correction (Lasik or PRK) savings of 15%off retail or 5%off promotional price nationwide.* ACCIDENT MEDICAL INSURANCE, ACCIDENTAL DEATH & DISMEMBERMENT (AD&D) INSURANCE - If you are injured in a covered accident and receive treatment from a physician, you are eligible for benefits during the benefit period of 52 weeks; you will be paid up to $2,500 for X-rays, Physician Services, Emergency Room Services, Supplies and Appliances. This benefit is available on a per occurrence basis with a $100 deductible per event. This is secondary coverage. ACCIDENTAL DEATH AND DISMEMBERMENT These plans also include $5,000 of AD&D coverage. See certificate for breakdown of benefits. Group Accident Medical is NOT available in all states. This item is underwritten by Caitlin Insurance Company with membership into Consumer Alliance USA. LAB & IMAGING PROGRAM The Lab and Imaging program provides unlimited access to significant savings. Saving average between 40%-70% of the usual price. The vast nationwide access, network of lab & diagnostics centers contains over 8,000 accredited laboratory sites and over 1,200 imaging facilities across the country. All major laboratory and diagnostic regional chains are represented in our network. Anytime your doctor orders a test, you simply call the ADMU Customer Service department and they will advise you of the most convenient location and ensure that you only pay the heavily reduced member s only rate. PATIENT ADVOCACY Your medical program includes a service called Patient Advocacy provided by The Karis Group, which can provide tremendous help and reassurance when members faced with large medical bills. This service links members to negotiating professionals who help them resolve their bills with medical providers, whether in or outside of the network or whether it s after one has been scheduled for admission or once a member has a bill in hand. NOT AN INSURANCE PRODUCT. 7 P a g e

8 MEC FREQUENTLY ASKED QUESTIONS Q: New MEC plans, why have I not heard about this before. A: HHS just released the regulations in late 2012, thus it took time to review the regulations. Q. If I receive my coverage from my spouse s employer, will I have minimum essential coverage? A: Yes. Employer-sponsored coverage is generally minimum essential coverage. If an employee enrolls in employersponsored coverage for himself and his family, the employee and all of the covered family members have minimum essential coverage. Q. Do my spouse and dependent children have to be covered under the same policy or plan that covers me? A: No. You, your spouse and your dependent children do not have to be covered under the same policy or plan. However, you, your spouse and each dependent child for whom you may claim a personal exemption on your federal income tax return must have minimum essential coverage or qualify for an exemption, or you will owe a payment when you file. Q: What happens if I do not have minimum essential coverage, and I cannot afford to make the payment with my tax return? A: The IRS routinely works with taxpayers who owe amounts they cannot afford to pay. The law prohibits the IRS from using liens or levies to collect any payment you owe related to the individual responsibility provision, if you, your spouse or a dependent included on your tax return does not have minimum essential coverage. INDEMNITY MEDICAL FREQUENTLY ASKED QUESTIONS Q: Are pre-existing conditions covered by the Limited Benefit Health Insurance? A: Yes, pre-existing conditions are covered. Q: How does my medical plan work? A: The plan you have been issued is called a Limited Benefit Health Insurance plan. This is not NOT MAJOR MEDICAL INSURANCE; nor is it intended to replace major medical insurance. The limited benefit health insurance plan pays a scheduled amount for various medical services. When a claim is filed, 100% of the indemnity amount for the medical service provided is paid based upon the schedule of benefits of your plan. For example, if your plan specifies an indemnity amount of $75 for a doctor s office visit, your benefits plan will pay the service provider $75 toward the billed amount (or you will be reimbursed $75 if you file your own claim). Your plan also has the benefit of a Preferred Provider Organization (PPO). Q: Is this Major Medical Insurance? A: No. Limited Benefit Health Insurance plans offer limited benefit medical reimbursement coverage for basic medical expenses at an affordable cost. Unlike major medical, these plans do not coordinate benefits, so it pays regardless of any other coverage the covered person may have. Q: If my doctor is not listed as a PPO provider, will that change the benefit I will receive? A: No. the plan will pay the same benefits in your schedule of benefits whether you go to a PPO provider or a Non-PPO provider. You are free to use any licensed provider or hospital of your choice. If you go to a participating PPO provider, chances are your benefits will go further and cover more of the bill. Q: Why should I use a PPO Provider? A: By utilizing an in-network provider, you may reduce your out-of-pocket expense because the PPO provider will charge a negotiated reduced fee for his / her service. Q: Do these plans cover Maternity? A: Yes. Maternity is covered the same as any other sickness benefit and will pay subject to the limits of the plan chosen. Q: What is my co-payment amount? Is there a deductible? A: One of the great features of your limited benefit health insurance plan is that there are NO deductibles or co-payments. 8 P a g e

9 Minimum Essential Coverage and Crescent Limited Benefit Health Underwritten by: COMPANION LIFE INSURANCE COMPANY EMPLOYEE APPLICATION FOR INSURANCE (FILL OUT COMPLETELY) / / Requested Effective Date New Enrollment Change Termination (see other side) Employer Name Location EMPLOYEE INFORMATION Employee Name Social Security Number Home Address Street City, State Zip Home Telephone Gender: Male Female Date of Birth Date of Hire # Hours Worked PLAN SELECTION: MEC (ONLY) KEARNEY 250 (ONLY) MEC + KERNEY 250 MEDICAL COVERAGE: $ IND $ IND $ IND PER PAY (52) RATES ILLUSTRATED $ IND+SP $ IND+SP $ IND+SP $ IND+CH $ IND+CH $ IND+CH $ FAMILY $ FAMILY $ FAMILY Are you covered by Medicare? YES NO Marital Status Single Married Divorced Life Insurance Beneficiary Relationship Dependent Name Date of Birth DEPENDENT INFORMATION Sex (M/F) Relationship Spouse Full-Time Student (Yes/No) student verification letter must be attached N/A Social Security No. Use an Additional Form if more space is needed EMPLOYEE AUTHORIZATION I ELECT TO PARTICIPATE IN THE PLAN AND AUTHORIZE MY EMPLOYER TO MAKE DEDUCTIONS FROM MY PAYCHECK, IF APPLICABLE. I HAVE BEEN GIVEN THE OPPORTUNITY TO PARTICIPATE, BUT I ELECT NOT TO PARTICIPATE IN THIS PLAN. Answer only if your employer has a GROUP MAJOR MEDICAL plan: I am participating in the Group Major Medical Plan I am NOT participating in the Group Major Medical Plan Employee Signature MME 2070 Date 9 P a g e

10 FULL DECLINATION WAIVER: I certify that I have been given the opportunity to apply for group health insurance (Minimum Essential Coverage) and decline to enroll as indicated, on behalf of myself, my spouse and/or my dependent child(ren). I understand that by signing this waiver, I, my spouse and/or my dependent child(ren) forfeit the right to coverage. I was not pressured, forced or unfairly induced by my employer, the agent or the insurer(s) into waiving or declining the group health insurance. If in the future I apply for coverage, I, my spouse or any of my dependent child(ren) may be treated as a late enrollee and subject to postponement or an exclusion of coverage for preexisting conditions for a period of up to 18 months. This period may be offset by the time I, my spouse or my dependent child(ren) was covered under a qualified health plan. Initials: COVERAGE ALREADY IN PLACE I understand that if I am declining enrollment for myself, my spouse or my dependent child(ren) because of other health insurance, I may in the future be able to enroll myself, my spouse or my dependent child(ren) in this plan, provided that I request enrollment within 30 days after my other health coverage ends. In addition, if I gain a dependent spouse or child(ren) as a result of marriage, birth, adoption or placement for adoption, I understand that I may be able to enroll myself, my spouse and/or my dependent child(ren), provided that I request enrollment within 30 days after the marriage, birth, adoption or placement for adoption. I understand that I can obtain enrollment information from my employer or group health insurance carrier. Initials: POSSIBLE TAX PENALTIES All employees can prevent being taxed the greater of the $95 penalty of 1% of adjusted household income by purchasing the MEC only plan. The employee penalty progresses over a three year period. In 2015, it is the greater of 1% of adjusted household income or $95 per adult plus $47.50 per child; in 2016, it is the greater of 2% of adjusted household income or $325 per adult plus $ per child therefore the greater of 2.5% of adjusted household income or $695 per adult plus $ per child. Initials: 10 P a g e