Table of Contents. Pre-Tax Benefits Superior Vision...3 Aflac Dental Plan...7 Aflac Cancer Care Plan...9 Aflac Accident Indemnity Advantage Plan...

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1 Table of Contents Pre-Tax Benefits Superior Vision Aflac Dental Plan Aflac Cancer Care Plan Aflac Accident Indemnity Advantage Plan After-Tax Benefits AUL Short Term Disability Plan Dearborn National Term Life For Your Reference Continuations of Benefits Vender Contact Information

2 * * * * * * * * NOTICE * * * * * * * * The Towns County Government is offering all full-time employees a comprehensive Cafeteria Benefits program. The Cafeteria Benefits program is being arranged by Mark III Brokerage, an employee benefits firm that has worked in the public sector for more than 33 years. The Cafeteria Benefits program allows you to pay for certain insurance premiums before taxes are taken out of your paycheck. (Paying for these benefits in this method may reduce your taxes and may increase your take home pay.) The Cafeteria Benefits program includes pre-tax and after tax products. The plan year is July 1, 2014 through June 30, All products described in this booklet are pre-taxed EXCEPT: AUL Short Term Disability Dearborn National Group Term Life Insurance If you wish to add or make changes to your insurance coverage(s), please consult a Benefits Representative during your scheduled enrollment period. You will not be able to make any changes once the enrollment period is over unless you experience a qualified event (i.e., marriage, divorce, birth of a child, etc.) All information in this booklet is a brief description of your coverage and is not a contract. Refer to your policy or certificate for each product for the exact terms and conditions.

3 Effective Date: July 1, 2014 Superior Vision Plan Outline of Benefits Gold Preferred Plan with Materials Discount Vision Plan Preferred Provider (PPO / Indemnity) Copayment: $10.00 Exam $15.00 Materials 1 $35.00 Contact Lens Fitting Fee benefits Frequency In-network Non-Network Comprehensive Exam 12 Months Covered in Full Up to $42.00 (by an Ophthalmologist) Comprehensive Exam 12 Months Covered in Full Up to $37.00 (by an Optometrist) Lenses (Standard) per Pair Single Vision 12 Months Covered in Full Up to $32.00 Bifocal 12 Months Covered in Full Up to $46.00 Trifocal 12 Months Covered in Full Up to $61.00 Lenticular 12 Months Covered in Full Up to $84.00 Contact Lenses (Per Pair) 2 Medically Necessary 12 Months Covered in Full Up to $ Cosmetic (Elective) 3 12 Months Up to $ Up to $ Standard Contact 12 Months Covered in Full Not Covered Lens Fitting Fee 4 Specialty Contact 12 Months Up to $50.00 Not Covered Lens Fitting Fee 4 Frames (Standard) 3 24 Months Up to $ Up to $48.00 Items or Services Not Covered While Superior Vision offer a variety of vision benefits, there are a few materials, services and treatments that are generally not covered, or have limitations to their coverage. We do offer discounts on many of these items, as outlined in our discount plan coverage information. YOUR specific Superior Vision Plan may differ, so confirm the details of your employer s plan prior to seeking services. Items or Services Not Covered or Have Limited Coverage* non-prescription (plano) lenses of any kind, sunglasses, or contact lenses any coating applied to lenses such as anti-reflective, scratch, UV, lamination, tints (except pink tint #1 and #2), and sunglass coloring any lens materials other than standard plastic or glass such as polycarbonate, hi-index, polaroid, and photochromic any special lens features or treatment such as prisms, slab off, faceted, oversize lens greater than 61mm, polished bevel, groove, drill mount, notch, roll and polish, and blended bifocal 1. All in-network and out-of-network allowances are at the retail value. 2. Contact lenses are in lieu of eyeglass lenses and frames benefits. 3. The insured is responsible for paying any charges in excess of this amount. 4. Standard contact lens fitting applies to an existing contact lens user who wears disposable, daily wear or extended wear lenses only. The specialty contact lens fitting fee applies to new contact lens wearers and/or a member who wears toric, gas permeable, or multifocal lenses. Page 3

4 progressive lenses (Though progressive lenses are not a covered benefit, the provider will apply the retail charge for standard trifocal lenses against the retail charges for the progressive lenses you selected. You are responsible for paying the provider the difference) replacement of broken, lost, or damaged frames and/or lenses orthoptics, vision training, and developmental vision procedures experimental or non-conventional treatment or device medical or surgical treatment of the eyes post-cataract lenses (intra-ocular) subnormal or low vision aids safety eyewear eye examinations or corrective eyewear required by an employer as a condition of employment services or materials when covered under workers compensation or similar third party coverage services or materials rendered by a provider other than an ophthalmologist, optometrist, or optician acting within the scope of his or her license any additional services or procedures outside of a routine eye exam and contact lens fitting services or materials rendered after the date a member ceases to be covered by the benefits plan except when vision materials ordered before coverage ended are delivered AND the corresponding services are provided to the member within 31 days of the initial order Regardless of optical necessity, benefits are not available more frequently than that which is specified in the Outline of Benefits. * Plans vary, so please refer to your own employer s specific coverage. How to Use the Plan Welcome to Superior Vision s vision plan. Superior Vision provides primary vision care benefits including eye examinations, prescription eyewear, and contact lenses through a broad-based provider network consisting of ophthalmologist, optometrist, and opticians. The plan also contracts with a large number of national and regional optometric chain locations Your first step should be to choose an eye care provider, or ensure that your current provider is part of the Superior Vision network. Go to and click on Locate a Provider for an updated list. You will learn about in-network and out-of-network providers - it is an important distinction when receiving your benefits. You will also learn more about how to use your benefits, as well as the discounts that are available to you. Remember that a routine eye exam is important not only for correcting vision problems, but for maintaining healthy eyes and overall health wellness. Superior Vision eye care providers are trained to test for and diagnose a variety of health issues - not just eye problems Take the time to get to know your vision plan, and start experiencing healthy eyes and healthy living. Page 4

5 Discounts on Additional Purchases Prescription eyeglass lenses Eyeframes Add-on charges to basic lenses Everyday frame and lens package pricing Contact lenses, standard hard or soft Disposable contact lenses All other prescription materials 30% off retail prices 30% off retail prices 20% off retail prices 20% off retail prices 20% off retail prices 10% off retail prices 20% off retail prices Discount SVP8-20 Frames - 20% off the difference between the covered frame Allowance and the retail price of the selected frame Add-on charges to covered Member pays 20% off retail up to: pair of lenses Factory Scratch Coat $13 (Single Vision & Standard Multifocal lenses) Ultraviolet Coat $15 (Single Vision & Standard Multifocal lenses) Standard Anti-Reflective coat* $50 (Single Vision & Standard Multifocal lenses) High Index 1.6* $55 (Single Vision lenses only) Polycarbonate $40 (Single Vision lenses only) Standard Photochromic $80 (Single Vision lenses only) Glass coloring $35 (Any Type lenses) Plastic Tints solid or gradient $25 (Any Type lenses) Member pays: Power over 4.00 Sphere, 2.00D Cylinder & 5.00 Prism 20% off retail prices (any type lenses) Cosmetic finishing, Beveling, Edging, and Mounting 20% off retail prices (any type lenses) Miscellaneous Options 20% off retail prices (any type lenses) * Higher end or brand name lens upgrades are at an additional expense to the member. Apply maximum out of pocket expense toward upgraded lens retail cost and member is responsible for the difference less 20%. Refractive Surgery Discounts Superior Vision Services has contracted a network of over 500 refractive surgeons nationwide who specialize in the popular elective procedures of radial keratotomy (RK), photo-refractive keratotomy, (PRK), and LASIK. These providers offer Superior Vision Plan members a 20% discount off their usual and customary surgical fees for these procedures. Ophthalmic plastic surgeons are also contracted to provide the procedure of blepharoplasty (cosmetic eyelid surgery) to Superior Vision Plan members on the same discount basis. Note: This is only a summary of the benefit plan. You may review and/or obtain a copy of the Master Policy and Certificate of Coverage by contacting your Human Resources/Employee Benefit Office. Page 5

6 semi-monthly COST Employee Only $ 4.87 Employee + 1 Dependent $ 9.45 Employee + Family $ Customer Service fax Authorization numbers (out-of-network) Explanation of benefits Provider locator; provider nomination Claims inquiries Grievance issues Customer Service/Corporate Office White Rock Rd., Rancho Cordova, CA Claims Administration P.O. Box 967 Rancho Cordova, CA Disclaimer: All final determinations of benefits, administrative duties, and definitions are governed by the Certificate of Insurance Coverage for you vision plan. Please check with your Benefits Administrator or Human Resources department if you have any questions. The Superior Vision Plan is under written by National Guardian Life Insurance Company. National Guardian Life Insurance Company is not affiliated with The Guardian Life Insurance Company of America, a/k/a The Guardian or Guardian Life Page 6

7 Aflac Dental Plan Dental Insurance - Level 1 Smile Millions of people believe a smile is the most important physical attribute more so than hair, eyes, or figure. 1 The best way to maintain or improve your smile is to brush and floss your teeth daily, visit your dentist, and apply for an Aflac Dental insurance policy. Aflac Dental provides benefits for periodic checkups and cleanings, X-rays, fillings, crowns, and much more. It s your smile and your policy; Aflac Dental gives your control. You choose your dentist. Because Aflac doesn t use a network of dentists, you can go to any dentist you choose. You and your dentist choose the best treatment for you. Aflac Dental doesn t have pre certification requirements. If the treatment is covered by your policy, you don t need Aflac s permission to receive it. 2 Aflac Dental is different from many other dental plans you may have seen. You know what you re getting with Aflac Dental. The plan spells out the benefits for both wellness and other diagnostic/treatment services. There are no gray areas. Each covered procedure has a specific benefit amount. Aflac Dental doesn t have an annual deductible. Other dental plans may require you to meet an annual deductible before benefits are payable. Aflac Dental pays benefits regardless of any other plan. Even if you have other coverage, you ll receive your full Aflac benefit amount. 3 With Aflac Dental s Annual Maximum Building Benefit, you can receive even more benefits. Aflac will increase each Covered Person s Policy Year Maximum by $100 after each 12 consecutive months the policy is in force up to a maximum of $500 per Covered Person. 1 The public Speaks Up on Oral Health Care: An ADA and Crest/Oral-B Survey, American Dental Association, October Subject to applicable Waiting Periods. 3 If the applicant retains existing dental coverage with another company, only the Essentials plan can be offered. MMC /14 Page 7

8 Aflac Dental pays benefits for seven categories of dental treatments and hundreds of procedures. The benefit amounts within each category vary based on the procedure received and are subject to a Policy Year Maximum. Benefit amounts and the Policy Year Maximum are per Covered Person. BENEFIT CATEGORIES WAITING PERIODS BENEFIT AMOUNTS Preventive (Wellness and None $35 $50 X-Ray) Fillings and Basic Services 3 months $15 $250 Pain Management and Adjunctive 3 months $30 $130 Services Other Preventive Services 6 months $20 $110 Oral Surgery, Gum Treatments, 6 months $30 $850 and Prosthetic Repair Crowns and Major Services 12 months $15 $375 Major Prosthetic Services 24 months $45 $550 POLICY YEAR MAXIMUM $1,400 This is a brief overview only. Please refer to the policy for complete definitions, details, limitations, and exclusions. For more information about the benefits available, please see the schedule of dental procedures. Underwritten by: American Family Life Assurance Company of Columbus Page 8

9 Aflac s Cancer Care Plan Cancer Indemnity Insurance Classic Plan Added Protection for You and Your Family Chances are you know someone who s been affected, directly or indirectly, by cancer. You also know the toll it s taken on them physically, emotionally, and financially. That s why we ve developed the Aflac Cancer Care insurance policy. The plan pays a cash benefit upon initial diagnosis of a covered cancer, with a variety of other benefits payable throughout cancer treatment. You can use these cash benefits to help pay deductibles and copayments, the rent or mortgage, groceries, or utility bills the choice is yours. And while you can t always predict the future, here at Aflac we believe it s good to be prepared. The Aflac Cancer Care plan is here to help you and your family better cope financially and emotionally if a positive diagnosis of cancer ever occurs. That way you can worry less about what may be lying ahead. The facts say you need the protection of Aflac s Cancer Care Plan: In the United States, men have slightly less than a 1-in-2 lifetime risk of developing cancer. 1 In the United States, women have slightly more than a 1-in-3 lifetime risk of developing cancer. 1 Policy Benefits Include: Cancer Wellness Benefit Initial Diagnosis Benefit Chemotherapy and Radiation Benefits Hospital Confinement Benefit Plus much more 1 Cancer Facts & Figures 2012, American Cancer Society. This is a brief overview only. Please refer to the policy for complete definitions, details, limitations, and exclusions. Underwritten by: American Family Life Assurance Company of Columbus Page 9

10 Aflac Accident Indemnity Advantage Plan 24-Hour Accident-Only Insurance - Plan 2 The Need Accidents happen to all kinds of people every day. In 2009, 38.9 million people about 1 out of 8 sought medical attention for an injury. 1 What would the financial impact of an injury mean to your security? Are you prepared for medical debts in addition to everyday household expenditures and lost wages? Out-of-pocket expenses associated with an accident are unexpected and often burdensome; perhaps the accident itself could not have been prevented, but its impact on your fiances and your well-being certainly can be reduced. Aflac pays cash benefits directly to you, unless you choose otherwise. This means that you will have added financial resources to help with expenses incurred due to an injury, to help with ongoing living expenses, or to help with any purpose you choose. Aflac Accident Indemnity Advantage is designed to provide you with cash benefits throughout the different stages of care, regardless of the severity of the injury. Aflac enables you to take charge and to help provide for an unpredictable future by paying cash benefits for accidental injuries. Your own peace of mind and the assurance that your family will have help financially are powerful reasons to consider Aflac. The Accident Indemnity Advantage Insurance Policy has: 1. No deductibles and no copayments. 2. No lifetime limit policy won t terminate based on number or dollar amount of claims paid. 3. No network restrictions you choose your own medical treatment provider. 4. No coordination of benefits we pay regardless of any other insurance. Policy Benefits Include: Wellness Benefit Emergency Treatment Benefit Specific-Sum Injuries Benefits Hospital Confinement Benefit Plus much more 1 Injury Facts, 2011 Edition, National Safety Council. This is a brief overview only. Please refer to the policy for complete definitions, details, limitations, and exclusions. Underwritten by: American Family Life Assurance Company of Columbus Page 10

11 AUL Short-Term Disability Plan Effective Date: July 1, 2014 Why do you need Disability Insurance? Consider this... Statistics show you are much more likely to be injured in an accident than to die from one. A fatal injury occurs every 5 minutes, and a disabling injury occurs every 1.5 seconds. 1 There is a death caused by a motor vehicle crash every 12 minutes; there is a disabling injury every 14 seconds. 1 In the home, there is a fatal injury every 16 minutes and a disabling injury every 4 seconds. 1 While many people survive accidental injuries, many others live with serious illnesses. In the United States, men have a little less than a 1-in-2 lifetime risk of developing cancer; for women the risk is a little more than 1-in-3. The five-year relative survival rate for all cancers combined is 63%. 2 One in five males and females has some form of cardiovascular disease. High blood pressure is the most common form of cardiovascular disease. 3 More than 35 million Americans are now living with chronic lung diseases, such as asthma, emphysema, and chronic bronchitis. 4 Advances in medicine are allowing us to live longer. However, recovery from a serious illness or injury often requires time away from work. In the last 20 years, deaths due to the big three (cancer, heart attack, and stroke) have gone down significantly. But disabilities due to those same three are up dramatically! Things that use to kill now disable. 5 You have life insurance, home insurance, and automobile insurance. But is your income insured? Page 11

12 Class Description All Full-Time Eligible Employees working a minimum of 30 hours per week, electing to participate in the Voluntary Short Term Disability Insurance. Disability You are considered disabled if, because of injury or sickness, you cannot perform the material and substantial duties of your regular occupation. You are not working in any occupation and are under the regular attendance of a Physician for that injury or sickness. Monthly Benefit You can choose a benefit in $100 increments up to 70% of an Employee s covered basic monthly earnings to a maximum monthly benefit of $2,000. The minimum monthly benefit is $500. Elimination Period This means a period of time a disabled Employee must be out of work and totally disabled before weekly benefits begin; seven (7) consecutive days for a sickness and zero (0) days for injury. Benefit Duration This is the period of time that benefits will be payable for disability. The benefit duration is 13, 26, or 52 weeks. Basis of Coverage 24 Hour Coverage, on or off the job. Maternity Coverage Benefits will be paid the same as any other qualifying disability, subject to any applicable pre-existing condition exclusion. Annual Enrollment Employees who did not elect coverage during their initial enrollment period are eligible to sign up for $500 to $1000 monthly benefit without medical questions, subject to pre-existing exclusion. Employees may increase their coverage up to $500 monthly benefit without medical questions. The maximum benefit cannot exceed 70% of basic monthly earnings and must be in $100 increments. Employees that elect to increase their Benefit Duration may do so only during the annual enrollment period subject to the pre-existing exclusion. The pre-existing exclusion will apply to the increased benefit duration. STD Pre-Existing Condition Exclusion 3/12, If a person receives medical treatment, or service or incurs expenses as a result of an Injury or Sickness within 3 months prior to the Individual Effective Date, then the Group Policy will not cover any Disability which is caused by, contributed to by, or resulting from that Injury or Sickness; and begins during the first 12 months after the Person s Individual Effective Date. However, Continuity of Coverage may apply if the employee was insured under the employers prior group Page 12

13 plan on the effective date of coverage. This means the benefit payable will be the lesser of the prior plan s or AUL s benefit. Recurrent Disability If you resume Active Work for 30 consecutive workdays following a period of Disability for which the Weekly Benefit was paid, any recurrent Disability will be considered a new period of Disability. A new Elimination Period must be completed before the Weekly Benefit is payable. Portability Once an employee is on the AUL disability plan for 3 consecutive months, you may be eligible to port your coverage for one year at the same rate without evidence of insurability. You have 31 days from your date of termination to submit an application to port your coverage. The Portability Privilege is not available to any Person that retires (when the Person receives payment from any Employer s Retirement Plan as recognition of past services or has concluded his/her working career) Exclusions and Limitations This plan will not cover any disability resulting from war, declared or undeclared or any act of war; active participation in a riot; intentionally self-inflicted injuries; commission of an assault or felony; or a pre-existing condition for a specified time period. This information is provided as a summary of the product. It is not a part of the insurance contract and does not change or extend AUL s liability under the group policy. If there are any discrepancies between this information and the group policy, the group policy will prevail. Customer Service Disability Claims Fax: Disability Claims claims@disabilityrms.com Please refer to the Mark III website for a copy of your certificate, a claim form or application to port coverage form. Page 13

14 AUL Life Short-Term Disability Semi-Monthly Rates Benefit Duration: 13 weeks Monthly Benefit Semi- Monthly Premium Benefit Duration: 26 weeks Monthly Benefit Semi- Monthly Premium Benefit Duration: 52 weeks Monthly Benefit Semi- Monthly Premium $500 $5.18 $500 $7.50 $500 $9.86 $600 $6.21 $600 $9.00 $600 $11.83 $700 $7.25 $700 $10.50 $700 $13.80 $800 $8.28 $800 $12.00 $800 $15.77 $900 $9.32 $900 $13.50 $900 $17.74 $1,000 $10.36 $1,000 $15.00 $1,000 $19.72 $1,100 $11.39 $1,100 $16.50 $1,100 $21.69 $1,200 $12.43 $1,200 $18.00 $1,200 $23.66 $1,300 $13.46 $1,300 $19.50 $1,300 $25.63 $1,400 $14.50 $1,400 $21.00 $1,400 $27.60 $1,500 $15.53 $1,500 $22.50 $1,500 $29.57 $1,600 $16.57 $1,600 $24.00 $1,600 $31.54 $1,700 $17.60 $1,700 $25.50 $1,700 $33.52 $1,800 $18.64 $1,800 $27.00 $1,800 $35.49 $1,900 $19.67 $1,900 $28.50 $1,900 $37.46 $2,000 $20.71 $2,000 $30.00 $2,000 $39.43 Page 14

15 Dearborn National Life Term Life BASIC EMPLOYEE LIFE INSURANCE This insurance is payable for death from any cause to any person you name as beneficiary. VOLUNTARY EMPLOYEE LIFE INSURANCE Your employer-sponsored basic life coverage provides important protection for you, but you may need to add to that protection. Now you can...at low group rates and through convenient payroll deductions. To help meet this need, you have the opportunity to elect additional group life insurance under the voluntary portion of your program to go along with any personal insurance coverage you may have. VOLUNTARY DEPENDENT LIFE INSURANCE Provides coverage on: Your Spouse Unmarried child(ren) between the ages of 15 days and 18 years (up to age 23 if wholly dependent upon you for maintenance and support and if enrolled as a full time student in an accredited school or college). Handicapped children can continue to be covered with no age limit. Children can only be covered by one parent. It is your responsibility to notify Human Resources when a spouse or dependent child is no longer eligible for coverage. (i.e. divorce, child no longer full-time college student, etc.) FLEXIBILITY Simply choose the amount of coverage that suits your needs from the selection provided, as outlined on the back of this folder. FEATURES The plan features easy eligibility and simple enrollment procedures. Furthermore, automatic payroll deductions simplify paperwork. This means less bookkeeping for you and no worries about a lapse in coverage due to missed payments. LOW COST Your cost is lower than for comparable insurance on an individual basis due to the wholesale economies inherent in group insurance. Additionally, the County absorbs the cost of administering the program which is underwritten by Dearborn National - a leader in the field of group coverage. ELIGIBILITY You will be eligible for this program if you are a full-time active employee. Page 15

16 ENROLLMENT Enrollment is simple -- just fill out the enrollment form provided by your employer. Make sure you supply all the required information and return the form where you work. That s all. You will be notified as to when coverage starts. BENEFICIARY You have the right to designate the beneficiary of your choice under employee coverage. You are automatically the beneficiary under Dependent Life. WHEN YOUR INSURANCE STARTS If you enroll on or before the day you become eligible, your employer provided insurance becomes effective on the date of your eligibility if you are then actively at work; otherwise, on the day you return to active work. If you have elected Voluntary Employee or Dependent Life Insurance, you will be notified as to when that coverage begins. Anyone electing not to enroll when first eligible or within three months thereafter can enroll later only if evidence of insurability satisfactory to the Insurance Company is provided. TERMINATION OF COVERAGE All insurance under the plan will terminate upon the earlier of retirement, termination of employment, when the plan ceases or when you withdraw from the plan. Nevertheless, if you should die within 31 days thereafter, and you are eligible for conversion or portability, your life insurance will still be paid to your beneficiary. If any of your covered dependents should die within such 31 day period, the amount of Life Insurance on account will be paid to you. REDUCTIONS AT AGES 65 & OVER If you remain in active service beyond age 65 your amount of Basic Employee Life Insurance will be as follows: Attained Age Percent of Original Amount 65 65% 70 50% (The above age reduction also applies to dependent spouse.) FAMILY STATUS CHANGE This provision allows you to increase your coverage by one times your basic annual salary without evidence of insurability within 31 days of the following: Marriage or divorce Death of a spouse or dependent child Birth or adoption of a dependent child Change in employment status for you or your spouse waiver of premium Your Basic and Voluntary Life coverages include a wavier of premium provision. If an employee is unable to engage in any occupation as a result of injury or sickness for a minimum of 6 months, prior to age 60, premium will be waived for the employee's life insurance benefit until the employee is no longer disabled or reaches age 65, whichever occurs first. Your Voluntary Dependent Life Insurance may be continued provided you remit the applicable premium to your employer. Page 16

17 CONVERSION If your employment terminates while you are covered under the plan, you may purchase without medical evidence of insurability, any individual insurance policy, except a term policy, issued by Dearborn National Life Insurance Company, in any amount up to the amount of your life coverage in effect on your date of termination. You must apply for this policy within 31 days after the date your coverage terminates. This privilege applies to Supplemental Life Insurance and Supplemental Dependent Life Insurance as well as to Basic Life Insurance. PORTABILITY Voluntary Life benefits are portable upon retirement or termination for the employee and/or his insured spouse. If an insured employee or spouse elects portability, he may also elect to continue Dependent Child(ren)'s coverage. Ported coverage terminates at age 70. ACCELERATED BENEFITS OPTION Dearborn National Life Insurance Company has included an Accelerated Benefit Option (ABO) as part of your group life benefits. Under this option, if you are diagnosed as having a terminal illness, you may be eligible to receive a portion of your group life benefits at such a difficult time. Please refer to your Group Certificate for details. GROUP POLICY AND CERTIFICATE The insurance briefly described in this folder is subject to the terms and conditions of the Group Policy issued by Dearborn National Life Insurance Company. If you become insured, you will receive a certificate outlining your benefits under the policy. CLAIMS PROCEDURE Claim forms needed to file for benefits under the group insurance program can be obtained from your employer who will also be ready to answer questions about the insurance benefits and to assist in filing claims. The instructions on the claim form should be followed carefully. This will expedite the processing of the claim. Be sure all questions are answered fully. If there is any question about a claim payment, an explanation can be requested from your employer, who is usually able to provide the necessary information. This is only a brief summary of the life insurance benefits available. Some restrictions may apply. For more specific information about the coverage details, including limitations, exclusions and other requirements, please refer to your certificate booklet or contact Human Resources. This coverage is underwritten by Dearborn National Life Insurance Company. Page 17

18 SCHEDULE OF BENEFITS BASIC LIFE and ad&d INSURANCE In the amount of $10,000 at no cost to you; paid by the County VOLUNTARY GROUP LIFE INSURANCE You choose the following amounts on yourself and your spouse: $10,000, $20,000, $30,000, $40,000, $50,000, $60,000, $70,000, $80,000, $90,000, $100,000, $150,000, $200,000, $250,000, $300,000, $400,000, or $500,000 YOUR MONTHLY COST FOR EMPLOYEE AND SPOUSE VOLUNTARY GROUP LIFE INSURANCE (Spouse coverage based on spouse's age) Age Rate Per $1,000 Less than voluntary DEPENDENT LIFE INSURANCE $10,000 on each of your eligible children - $1.00/semi-month $ 5,000 on each of your eligible children - $.50/semi-month Employees under age 60 must furnish evidence of insurability for amounts over $100,000. Employees age must furnish evidence of insurability for amounts over $20,000. Employees age 70 and over must furnish evidence of insurability for all amounts of coverages. To be eligible for $20,000 or more, your spouse must furnish medical evidence of insurability. Page 18

19 Continuing Your Benefits SUPERIOR VISION PLAN Under the Superior Vision plan, you and your covered dependents are eligible to continue vision coverage through COBRA according to the following qualifying events. If you and your dependents are enrolled in the vision plan, you will be eligible to continue coverage through COBRA after you leave your employment for a specified period. In addition, while covered under the plan, if you should die, become divorced or legally separated, or become eligible for Medicare, your covered dependents may be eligible to continue vision coverage through COBRA. Also while you are covered under the plan, your covered children who no longer qualify as an eligible dependent may continue coverage through COBRA. Examples of an ineligible dependent would be when your child graduates from college or turns 24 years old. You will receive notification from Interactive Medical Systems with premium and continuation options shortly following your termination of employment. For further information, call Interactive Medical Systems (IMS) at (800) AFLAC PLANS You may continue your Aflac policies by having the premiums currently being deducted from your paycheck either drafted from your bank account or billed directly to your home. Contact Aflac at for more information. DEARBORN NATIONAL OPTIONAL TERM LIFE Portability: If you terminate employment, the portability provision allows you to take your optional life coverage with you, subject to the following provisions: You must apply for coverage with 31 days from the date your life coverage terminates. You must be ACTIVELY at work prior to employment termination. You may only port up to your current coverage amount. You cannot increase the amount of your coverage. The portability provision applies to Employee Optional Term Life only. To get information and rates for coverage, please contact Dearborn National Life at (800) to answer any questions and obtain the necessary forms for conversion/ portability. AUL SHORT TERM DISABILITY You may continue your AUL Short-Term Disability policie by having the premiums currently deducted from your paycheck drafted from you bank account or billed to your home. For portability please refer to page 13 of the benefits booklet. For more information, contact AUL at Page 19

20 Contact Information for Questions and Claims Superior Vision Services White Rock Road Rancho Cordova, CA Non-Network Claims Submission: P.O. Box 967 Rancho Cordova, CA Aflac (800) Gloria Camp (Aflac Agent) (770) , Fax: (770) (claims) American United Life (AUL) Claims Toll-Free Number Customer Service Dearborn National Insurance Company (800) Mark III Brokerage 114 E Unaka Ave. Johnson City, TN ext Page 20