WORCESTER POLYTECHNIC INSTITUTE

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1 How much it will cost WORCESTER POLYTECHNIC INSTITUTE All Employees Issued by The Prudential Insurance Company of America Effective: 01/01/2016 Employee - Optional Term Life Coverage is available in increments of $10,000 to a maximum of $500,000, not to exceed 5.0 times your covered annual earnings. Refer to the Optional Term Life section for evidence of insurability details. Initial rates based on age as of effective date of your coverage. Rates will change based on the following age schedule. $10,000 $20,000 $30,000 $40,000 $50,000 $60,000 $70,000 $80,000 $90,000 $100,000 $110,000 $120,000 $130,000 < 30 $0.80 $1.60 $2.40 $3.20 $4.00 $4.80 $5.60 $6.40 $7.20 $8.00 $8.80 $9.60 $ $0.90 $1.80 $2.70 $3.60 $4.50 $5.40 $6.30 $7.20 $8.10 $9.00 $9.90 $10.80 $ $1.20 $2.40 $3.60 $4.80 $6.00 $7.20 $8.40 $9.60 $10.80 $12.00 $13.20 $14.40 $ $1.70 $3.40 $5.10 $6.80 $8.50 $10.20 $11.90 $13.60 $15.30 $17.00 $18.70 $20.40 $ $2.70 $5.40 $8.10 $10.80 $13.50 $16.20 $18.90 $21.60 $24.30 $27.00 $29.70 $32.40 $ $4.30 $8.60 $12.90 $17.20 $21.50 $25.80 $30.10 $34.40 $38.70 $43.00 $47.30 $51.60 $ $6.70 $13.40 $20.10 $26.80 $33.50 $40.20 $46.90 $53.60 $60.30 $67.00 $73.70 $80.40 $ $12.90 $25.80 $38.70 $51.60 $64.50 $77.40 $90.30 $ $ $ $ $ $ $21.20 $42.40 $63.60 $84.80 $ $ $ $ $ $ $ $ $ $39.10 $78.20 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $1, $1, $1, $1, $1, $1, $140,000 $150,000 $160,000 $170,000 $180,000 $190,000 $200,000 $210,000 $220,000 $230,000 $240,000 $250,000 $260,000 < 30 $11.20 $12.00 $12.80 $13.60 $14.40 $15.20 $16.00 $16.80 $17.60 $18.40 $19.20 $20.00 $ $12.60 $13.50 $14.40 $15.30 $16.20 $17.10 $18.00 $18.90 $19.80 $20.70 $21.60 $22.50 $ $16.80 $18.00 $19.20 $20.40 $21.60 $22.80 $24.00 $25.20 $26.40 $27.60 $28.80 $30.00 $ $23.80 $25.50 $27.20 $28.90 $30.60 $32.30 $34.00 $35.70 $37.40 $39.10 $40.80 $42.50 $ $37.80 $40.50 $43.20 $45.90 $48.60 $51.30 $54.00 $56.70 $59.40 $62.10 $64.80 $67.50 $ $60.20 $64.50 $68.80 $73.10 $77.40 $81.70 $86.00 $90.30 $94.60 $98.90 $ $ $ $93.80 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $1, $1, $2, $2, $2, $2, $2, $2, $2, $2, $3, $3, $3, $3, Implementation of the insurance plan(s) will depend on having a specific percentage of all eligible employees enrolling in the plan(s). If this percentage of enrollment level is not met, these coverage(s) may not be effective

2 Employee - Optional Term Life Coverage is available in increments of $10,000 to a maximum of $500,000, not to exceed 5.0 times your covered annual earnings. Refer to the Optional Term Life section for evidence of insurability details. Initial rates based on age as of effective date of your coverage. Rates will change based on the following age schedule. $270,000 $280,000 $290,000 $300,000 $310,000 $320,000 $330,000 $340,000 $350,000 $360,000 $370,000 $380,000 < 30 $21.60 $22.40 $23.20 $24.00 $24.80 $25.60 $26.40 $27.20 $28.00 $28.80 $29.60 $ $24.30 $25.20 $26.10 $27.00 $27.90 $28.80 $29.70 $30.60 $31.50 $32.40 $33.30 $ $32.40 $33.60 $34.80 $36.00 $37.20 $38.40 $39.60 $40.80 $42.00 $43.20 $44.40 $ $45.90 $47.60 $49.30 $51.00 $52.70 $54.40 $56.10 $57.80 $59.50 $61.20 $62.90 $ $72.90 $75.60 $78.30 $81.00 $83.70 $86.40 $89.10 $91.80 $94.50 $97.20 $99.90 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $1, $1, $1, $1, $1, $1, $1, $1, $1, $1, $1, $1, $3, $3, $3, $4, $4, $4, $4, $4, $4, $4, $4, $5, $390,000 $400,000 $410,000 $420,000 $430,000 $440,000 $450,000 $460,000 $470,000 $480,000 $490,000 $500,000 < 30 $31.20 $32.00 $32.80 $33.60 $34.40 $35.20 $36.00 $36.80 $37.60 $38.40 $39.20 $ $35.10 $36.00 $36.90 $37.80 $38.70 $39.60 $40.50 $41.40 $42.30 $43.20 $44.10 $ $46.80 $48.00 $49.20 $50.40 $51.60 $52.80 $54.00 $55.20 $56.40 $57.60 $58.80 $ $66.30 $68.00 $69.70 $71.40 $73.10 $74.80 $76.50 $78.20 $79.90 $81.60 $83.30 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $1, $1, $1, $1, $1, $1, $1, $1, $1, $1, $1, $1, $1, $1, $1, $5, $5, $5, $5, $5, $5, $6, $6, $6, $6, $6, $6, Rates may change as the insured enters a higher age category. Also, rates may change if plan experience requires a change for all insureds. Spouse / Domestic Partner - Optional Dependent Term Life Coverage is available in increments of $5,000 to a maximum of $250,000, not to exceed 50% of your Optional Term Life coverage amount. Refer to the Optional Dependent Term Life section for evidence of insurability details. Initial rates based on age as of effective date of your coverage. Rates will change based on the following age schedule. $5,000 $10,000 $15,000 $20,000 $25,000 $30,000 $35,000 $40,000 $45,000 $50,000 $55,000 $60,000 $65,000 < 30 $0.40 $0.80 $1.20 $1.60 $2.00 $2.40 $2.80 $3.20 $3.60 $4.00 $4.40 $4.80 $ $0.45 $0.90 $1.35 $1.80 $2.25 $2.70 $3.15 $3.60 $4.05 $4.50 $4.95 $5.40 $ $0.60 $1.20 $1.80 $2.40 $3.00 $3.60 $4.20 $4.80 $5.40 $6.00 $6.60 $7.20 $ $0.85 $1.70 $2.55 $3.40 $4.25 $5.10 $5.95 $6.80 $7.65 $8.50 $9.35 $10.20 $ $1.35 $2.70 $4.05 $5.40 $6.75 $8.10 $9.45 $10.80 $12.15 $13.50 $14.85 $16.20 $ $2.15 $4.30 $6.45 $8.60 $10.75 $12.90 $15.05 $17.20 $19.35 $21.50 $23.65 $25.80 $ $3.35 $6.70 $10.05 $13.40 $16.75 $20.10 $23.45 $26.80 $30.15 $33.50 $36.85 $40.20 $ $6.45 $12.90 $19.35 $25.80 $32.25 $38.70 $45.15 $51.60 $58.05 $64.50 $70.95 $77.40 $ $10.60 $21.20 $31.80 $42.40 $53.00 $63.60 $74.20 $84.80 $95.40 $ $ $ $ $19.55 $39.10 $58.65 $78.20 $97.75 $ $ $ $ $ $ $ $ $67.15 $ $ $ $ $ $ $ $ $ $ $ $872.95

3 Spouse / Domestic Partner - Optional Dependent Term Life Coverage is available in increments of $5,000 to a maximum of $250,000, not to exceed 50% of your Optional Term Life coverage amount. Refer to the Optional Dependent Term Life section for evidence of insurability details. Initial rates based on age as of effective date of your coverage. Rates will change based on the following age schedule. $70,000 $75,000 $80,000 $85,000 $90,000 $95,000 $100,000 $105,000 $110,000 $115,000 $120,000 $125,000 $130,000 < 30 $5.60 $6.00 $6.40 $6.80 $7.20 $7.60 $8.00 $8.40 $8.80 $9.20 $9.60 $10.00 $ $6.30 $6.75 $7.20 $7.65 $8.10 $8.55 $9.00 $9.45 $9.90 $10.35 $10.80 $11.25 $ $8.40 $9.00 $9.60 $10.20 $10.80 $11.40 $12.00 $12.60 $13.20 $13.80 $14.40 $15.00 $ $11.90 $12.75 $13.60 $14.45 $15.30 $16.15 $17.00 $17.85 $18.70 $19.55 $20.40 $21.25 $ $18.90 $20.25 $21.60 $22.95 $24.30 $25.65 $27.00 $28.35 $29.70 $31.05 $32.40 $33.75 $ $30.10 $32.25 $34.40 $36.55 $38.70 $40.85 $43.00 $45.15 $47.30 $49.45 $51.60 $53.75 $ $46.90 $50.25 $53.60 $56.95 $60.30 $63.65 $67.00 $70.35 $73.70 $77.05 $80.40 $83.75 $ $90.30 $96.75 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $1, $1, $1, $1, $1, $1, $1, $1, $1, $1, $1, $1, $135,000 $140,000 $145,000 $150,000 $155,000 $160,000 $165,000 $170,000 $175,000 $180,000 $185,000 $190,000 < 30 $10.80 $11.20 $11.60 $12.00 $12.40 $12.80 $13.20 $13.60 $14.00 $14.40 $14.80 $ $12.15 $12.60 $13.05 $13.50 $13.95 $14.40 $14.85 $15.30 $15.75 $16.20 $16.65 $ $16.20 $16.80 $17.40 $18.00 $18.60 $19.20 $19.80 $20.40 $21.00 $21.60 $22.20 $ $22.95 $23.80 $24.65 $25.50 $26.35 $27.20 $28.05 $28.90 $29.75 $30.60 $31.45 $ $36.45 $37.80 $39.15 $40.50 $41.85 $43.20 $44.55 $45.90 $47.25 $48.60 $49.95 $ $58.05 $60.20 $62.35 $64.50 $66.65 $68.80 $70.95 $73.10 $75.25 $77.40 $79.55 $ $90.45 $93.80 $97.15 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $1, $1, $1, $2, $2, $2, $2, $2, $2, $2, $2, $2, $195,000 $200,000 $205,000 $210,000 $215,000 $220,000 $225,000 $230,000 $235,000 $240,000 $245,000 $250,000 < 30 $15.60 $16.00 $16.40 $16.80 $17.20 $17.60 $18.00 $18.40 $18.80 $19.20 $19.60 $ $17.55 $18.00 $18.45 $18.90 $19.35 $19.80 $20.25 $20.70 $21.15 $21.60 $22.05 $ $23.40 $24.00 $24.60 $25.20 $25.80 $26.40 $27.00 $27.60 $28.20 $28.80 $29.40 $ $33.15 $34.00 $34.85 $35.70 $36.55 $37.40 $38.25 $39.10 $39.95 $40.80 $41.65 $ $52.65 $54.00 $55.35 $56.70 $58.05 $59.40 $60.75 $62.10 $63.45 $64.80 $66.15 $ $83.85 $86.00 $88.15 $90.30 $92.45 $94.60 $96.75 $98.90 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $2, $2, $2, $2, $2, $2, $3, $3, $3, $3, $3, $3, Rates may change as the insured enters a higher age category. Also, rates may change if plan experience requires a change for all insureds. Spouse / Domestic Partner rate is based on employee's age.

4 Children - Optional Dependent Term Life One premium rate covers all eligible children Coverage is available for $10,000, not to exceed 100% of your Optional Term Life coverage amount. $10,000 $2.00 Rates may change if plan experience requires a change for all insureds. Employee - Optional Accidental Death & Dismemberment Coverage is available in increments of $10,000 to a maximum of $500,000, not to exceed 5.0 times your covered annual earnings. Refer to the Optional AD&D section for evidence of insurability details. $10,000 $20,000 $30,000 $40,000 $50,000 $60,000 $70,000 $80,000 $90,000 $100,000 $110,000 $120,000 $130,000 $0.25 $0.50 $0.75 $1.00 $1.25 $1.50 $1.75 $2.00 $2.25 $2.50 $2.75 $3.00 $3.25 $140,000 $150,000 $160,000 $170,000 $180,000 $190,000 $200,000 $210,000 $220,000 $230,000 $240,000 $250,000 $260,000 $3.50 $3.75 $4.00 $4.25 $4.50 $4.75 $5.00 $5.25 $5.50 $5.75 $6.00 $6.25 $6.50 $270,000 $280,000 $290,000 $300,000 $310,000 $320,000 $330,000 $340,000 $350,000 $360,000 $370,000 $380,000 $6.75 $7.00 $7.25 $7.50 $7.75 $8.00 $8.25 $8.50 $8.75 $9.00 $9.25 $9.50 $390,000 $400,000 $410,000 $420,000 $430,000 $440,000 $450,000 $460,000 $470,000 $480,000 $490,000 $500,000 $9.75 $10.00 $10.25 $10.50 $10.75 $11.00 $11.25 $11.50 $11.75 $12.00 $12.25 $12.50 Spouse - Optional Accidental Death & Dismemberment Coverage is available in increments of $5,000 to a maximum of $250,000. Refer to the Optional AD&D section for evidence of insurability details. $5,000 $10,000 $15,000 $20,000 $25,000 $30,000 $35,000 $40,000 $45,000 $50,000 $55,000 $60,000 $65,000 $0.13 $0.25 $0.38 $0.50 $0.63 $0.75 $0.88 $1.00 $1.13 $1.25 $1.38 $1.50 $1.63 $70,000 $75,000 $80,000 $85,000 $90,000 $95,000 $100,000 $105,000 $110,000 $115,000 $120,000 $125,000 $130,000 $1.75 $1.88 $2.00 $2.13 $2.25 $2.38 $2.50 $2.63 $2.75 $2.88 $3.00 $3.13 $3.25 $135,000 $140,000 $145,000 $150,000 $155,000 $160,000 $165,000 $170,000 $175,000 $180,000 $185,000 $190,000 $3.38 $3.50 $3.63 $3.75 $3.88 $4.00 $4.13 $4.25 $4.38 $4.50 $4.63 $4.75 $195,000 $200,000 $205,000 $210,000 $215,000 $220,000 $225,000 $230,000 $235,000 $240,000 $245,000 $250,000 $4.88 $5.00 $5.13 $5.25 $5.38 $5.50 $5.63 $5.75 $5.88 $6.00 $6.13 $6.25 Group Insurance coverages are issued by The Prudential Insurance Company of America, 751 Broad Street, Newark, NJ This policy provides ACCIDENT insurance only. It does NOT provide basic hospital, basic medical or major medical insurance as defined by the New York State Insurance Department. IMPORTANT NOTICE - THIS POLICY DOES NOT PROVIDE COVERAGE FOR SICKNESS. Implementation of the insurance plan(s) will depend on having a specific percentage of all eligible employees enrolling in the plan(s). If this percentage of enrollment level is not met, these coverage(s) may not be effective Prudential Financial, Inc. and its related entities. Prudential, the Prudential logo, and the Rock symbol are service marks of Prudential Financial, Inc. and its related entities, registered in many jurisdictions worldwide

5 Disclosure For Accelerated Benefits Return completed notice with your Enrollment Form Last Name First Name MI Social Security Number Limitations of the Accelerated Benefit Accelerated Death Benefit option is a feature that is made available to group life insurance participants. It is not a health, nursing home, or long-term care insurance benefit and is not designed to eliminate the need for those types of insurance coverage. The death benefit is reduced by the amount of the accelerated death benefit paid. There is no administrative fee to accelerate benefits. Receipt of accelerated death benefits may affect eligibility for public assistance and may be taxable. The federal income tax treatment of payments made under this rider depends upon whether the insured is the recipient of the benefits and is considered "terminally ill" or "chronically ill." You may wish to seek professional tax advice before exercising this option. A. Consequences of This Benefit Receipt of accelerated benefits MAY AFFECT MEDICAID and SUPPLEMENTAL SECURITY INCOME ("SSI") ELIGIBILITY. The mere fact that you own a policy with an accelerated benefit product may affect your eligibility for these government programs. In addition, exercising the option to accelerate death benefits and receiving those benefits before you apply for these programs, or while you are receiving government benefits, may affect your initial or continued eligibility. Contact the Medicaid Unit of your local Division of Medical Assistance and the Social Security Administration for more information. B. Medical Condition Enabling Accelerating of Life Benefit Terminal Illness means a condition that a physician certifies will reasonably be expected to result in death in 24 months or less. C. Options o Acceleration of 90% of the total death benefit, up to $500,000 as LUMP SUM. o Acceleration of 90% of the total death benefit, up to $500,000, in 24 equal monthly payments. Employee Signature (Sign in ink.) Date GRP Ed

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