Social Security # City. or D I currently have an eligible Domestic Partner -----

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1 INSURANCE ENROLLMENT FORM Please use this form to apply for coverage. Simply fill in any missing information below. Don't forget to include your Social Security Number, Birthdate, sign your name and enter today's date. Return completed form to Human Resources Employer: Kyrene Elementary School ~,.w:, ~r~ Cigna. Life Insurance Company of North America Your Name Address Work Phone Social Security # City State Birthdate Zip Gender: D I am currently married and my date of marriage is: or D I currently have an eligible Domestic Partner My Spouse/ Name Social Security# Domestic Partner's Information Birthdate Gender *To be eligible for Domestic Partner coverage, you must have a state-registered Domestic Partnership or Affidavit on file with your employer, and accepted by the Insurance company. If not, an Affidavit should be requested from your employer. Emplo ee-paid (Voluntar ) Critical Illness Insurance - Polic # Cl Choose both an Amount below and who you would like to include in your coverage. See the enclosed Summa of Benefits for Monthl costs. Who You Want to Cover D Employee Only D Employee+ Spouse D Employee+ Child(ren) 0 Employee+ Family How many children are you covering? Covera e Amount D $10,000 Acee tance D Accept Coverage I understand that I am required to complete an Evidence of lnsurabi/iry form if/ elect coverage above the Guaranteed Coverage amount of$ 10,000*. D Decline Covera e Employee-Paid {Voluntary) Accidental Injury Insurance - Policy# Al Choose both a Plan below and who you would like to include in your coverage. See the enclosed Summary of Benefits for Monthly cost s. Who You Want to Cover Dependents Plan Acceptance 0 Employee Only How many children are D Accept Coverage D Employee+ Spouse you covering? D Low Plan D Employee + Children D Decline Coverage 0 Employee + Family *This is the Guaranteed Coverage amount. You may choose this amount, or less, without answering medical questions during this open enrollment. All coverage elected during this enrollment period will take effect on the latter of 10/ 01/2016 or the date the insurance company approves your application. Form #TL Cigna Please turn to other side to complete enrollment process. Be sure to make a copy for your records.

2 Employee Name Social Security# I accept the insurance options chosen above. If premiums are to be paid by payroll, I authorize my employer to deduct the necessary amounts from my paycheck. If I did not choose coverage now, and I decii::le I want coverage at a later date, I may be required to provide evidence of insurability af my own expense. I understand that coverage is subject to Cigna's approval and that my insurance will not go into effect unless I am actively at work on the effective date.l also understand that coverage for each of my dependents will go into effect only if the person is not confined in a hosp,ital or institution, or receiving certain medical treatment. I understand my information is protected by privacy laws and will be released only in accordance with these laws. Additional information about the rules and conditions around the requested insurance is described in the policy and certificate. Insurance coverage is underwritten by Life Insurance Company of North America. Pre-Existi Condition Limitation a lies to critical llness insurance onl : e w1 not_pay ene its or a overe oss cause or contri ute to Y., or resu ting from, a Pre-existing Condition. The term "Pre-existin_g Condition" means any Sickness or Injury for whicll a Covered Person received medical treatment, advice, care or services including diagnostic measures, took prescribed drugs or medicines or for which a reasonable person would have consultea a Physician within 12 months before the Covered Person's most recent effective date of insurance, and the most recent effective date of any added or increased amount of insurance. The Pre-Existing Condition Limitation will apply to any added benefits or increases in benefits. This Limitation will not apgly to a Covered Loss for which the Date of Diagnosis occurs after the Covered Person is insured under this Policy for at least 12 months after the Covered Person's most recent effective date of insurance, and effective date of any added or increased amount of insurance. Please Sign Here (.. Signature Date Caution: Any person who, knowingly and with intent to defraud any insurance company or other person: (1) files an ai:iplication for insurance or statement of claim containing any materially false information; or (2) conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act. "Cigna" and the ''Tree of Life" logo are registered service marks of Cigna Intellectual Property, Inc., licensed for use by Cigna Corporation and its operating subsidiaries. All products and services are provided by or through such operating subsidiaries, including Life Insurance Company of North America, and not by Cigna Corporation. Form #TL Cigna

3 CRITICAL ILLNESS INSURANCE APPLICATION FORM Life Insurance Company of North America (LINA) a Cigna Company (referred to as We or Us) For information and customer service for Critical Illness Insurance, call The applicant, and spouse if coverage is requested, must sign and date th is form. This form cannot be considered unless received within 30 days of the date it is dated. We must approve your request for coverage bef ore it becomes effective. All information must be completed by the applicant and spouse. Important: Please enter all dates in mmlddlyyyy format. Please print (preferably in black ink). EMPLOYER NAME: KYRENE ELEMENTARY SCHOOL DISTRICT NO. 28 POLICY# CI EMPLOYER USE (MANDATORY DATA NEEDED): In order for us to process this form, the employer must complete this information. Return comoleted form to: Cigna Grouo insurance P.O. Box Lehigh Vallev, PA '}24 Fax: D New Hire D Initial Enrollment D Late Entrant D Life Status Change D Enrollment Event D Reinstatement Class 001 Occupation Location Date of Hire Base Annual Salary EMPLOYEE INFORMATION D Mr. D Mrs. D Ms. (Check one) Name: (First) (Last) (M I) Address. Apt. # City State Zip. Day Phone Evening Phone Social Security# COMPLETE IF ELECTING SPOUSE COVERAGE 0 I am currently married and my date of marriage is Date of Birt h * DFor employers who offer Domestic Partnership coverage: I am currently in a Domestic Partnership and the date of formation of my Domestic Partnership is _ Name: (First) (Last) (MI) Social Security # Date of Birth *Domestic Partner is defined in the Group Policy. For purposes of this f orm, wherever the tenn Spouse appears, it shall also include Domestic Partner and Domestic Partners registered under any state which legally recognizes Domestic Partnerships or Civil Unions. Additional information is available from your Benefit Services Representative. Spouse includes Partners in Civil Union relationships fo r residents of Vermont and State registered D omestic Partners for residents of California, Oregon and Washington. CRITICAL ILLNESS INSURANCE ELIGIBILITY Have you smoked or used any form of tobacco in the last 12 mo nths? Employee D Y D N Spouse D Y D N FOR CALIFORNIA RESIDENTS ONLY Are the proposed insured(s): Currently covered for comprehensive health benefits from an insurance policy, an HMO plan, or an employer health benefit plan? D Y D N Anyone for whom the answer is NO is not eligible for this coverage. I am electing the following Voluntarv Employee Paid Critical Illness Coverage: Accept Coverage: DI wish to enro ll in Critical Til ness Coverage Amount Requested (indicate the amount requested below) Employee 0$10,000 Spouse DBenefit amount is 50% of issued employee-paid benefit amount Child(ren) DBenefit amount is 25 % of issued employee-paid benefit amount Number of children: D One or DTwo or more Decline Coverage: D I do not wish to enroll in Critical Illness Coverage Guarantee Issue Amount* $ $ 5000 All Guarantee Issue for Child(ren) * Guaranteed Issue Amount is only available during Initial Enrollment and at such other times as identified and outlined in offering materials. Amounts o insurance ma be limited b state law. GCI

4 Applicant's Name Social Security# ID# ACCEPTANCE/ DECLINATION I enroll and authorize my Employer to deduct the premiums from my earnings. I understand that the coverage selected up to the Guaranteed Issue Amount will begin on the effective date as described in the brochure. If I am not actively at work, or my enrolled family member is an inpatient in a hospital or confined at home under the care of a licensed healthcare professional or is totall y disabled or is receiving disability benefits or is unable to engage in all the usual duties of a person of like age and sex, the effective date of coverage will be delayed until the individual returns to work, or the fami ly member resumes usual duties. Pre-Existing Condition Limitation We will not pay benefits for a Covered Loss caused or contributed to by, or resulting from, a Pre-existing Condition. The term "Preexisting Condition" means any Sickness or Injury for which a Covered Person received medical treatment, advice, 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 the Covered Person's most recent effective date of coverage, and the most recent effective date of any added or increased amount of coverage. The Pre-Existing Condition Limitation will apply to any added benefits or increases in benefits. This Limitation will not apply to a Covered Loss for which the Date of Diagnosis occurs after the Covered Person is insured under this Policy for at least 12 months after the Covered Person's most recent effective date of coverage, and effective date of any added or increased amount of coverage. By signing below, I certify that I have obtained, or will obtain, as of the effective date of this coverage, health care (or major medical) insurance that meets the requirements of the Individual Mandate under the Affordable Care Act (ACA). For Residents of Connecticut: PLEASE NOTE: If you are already covered by Medicaid, you are not eli gible for this coverage, and cannot be included in the group. Signature. Date **If you are applying for coverage above the Guaranteed Issue amount, please complete the "Evidence of lnsurability" Section** GCI

5 Applicant's Name Social Security# JD# IMPORTANT Please see the Instructions immediately below and complete the following section if needed. After you complete this Section, please read the Agreements and Authorization at the end of this Form. Please be sure to sign and date the form in the space provided. Evidence of Insurability Section Instructions: Complete the employee in formation in each section if you (i.e., the Employee) are: applying for coverage fo r yourself that is greater than the Guaranteed Issue Amount, or applying for coverage for yourself more than 31 days after you were eligible for coverage. Complete the spouse information in this section if: applying for coverage for your spouse that is greater than the Guaranteed Issue Amount, or applying for coverage for your spouse more than 3 1 days after the spouse is eligible for coverage. Height and Weight Information Employee Soouse Name: Name: Height ft m Height _ ft - in Weigh t lbs Weight lbs Please indicate your answers for each question in this section by checking the Yes or No box. Within the last 5 years has the proposed insured been: diagnosed with any of the conditions shown below; told by a medical professional he/she has or may have any of the conditions shown below; or been treated by a medical professional for any of the conditions shown below? a. Cancer or any malignancy including: carcinoma, sarcoma, blood cancer (leukemia, lymphoma (Hodgkin's disease), myeloma, myelodysplasia syndromes), malignant tumor (except for basal cell or squamous cell skin cancer), or a benign brain tumor(s)? b. Heart attack, stroke, transient ischemic attack, or any disease or disorder of the heart, moderate to severe (Stages 3-5) chronic kidney disease, systemic lupus or major organ failure (liver, kidney, heart, lung or pancreas)? C. Emphysema (excluding asthma) or Chronic Obstructive Pulmonary Disease (COPD)? d. Chronic Hepatitis (B or C) or cirrhosis, or any disease of the liver? e. Insulin dependent diabetes (excluding gestational diabetes) or high blood pressure requiring three or more high blood pressure medications? Has any proposed insured(s) ever been treated or diagnosed by a medical professional for: For all residents except Vermont and Connecticut: Acquired Immune Deficiency Syndrome (AIDS), AIDS Related Complex (ARC) or tested positive for the Human Immunodeficiency Virus (HN)? For Vermont residents: Acquired Immune Deficiency Syndrome (AIDS), AIDS Related Complex (ARC)? In the past 6 months has any proposed insured: Been recommended to have a diagnostic test related to cancer or suspected cancer that has not been taken or for which results have not been received, or had a diagnostic or screening test related to cancer for which follow-up was recommended other than routine screening? Em11Ioyee 0 YON S11ouse For Arkansas Residents: Fraud Warning: Any person who knowingly presenls a false or fraudulenl claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. For Maryland Residents: Caution: Any person who knowingly or willfully presents a false or fraudulent claim for payment of a loss or benefit, or who knowingly or willfully presents false information in an application for insurance, is guilty of a crime and may be subject to fines and confinement in prison. For North Carolina Residents: Caution: Any person who, knowingly and with intent to defraud any insurance company or other person: ( 1) files an application for insurance or statement of claim containing any materially false information; or (2) conceals for the purpose of misleading, information concerning any fact material thereto; may subject the individual to criminal and civil penallies. For Oregon Residents: Caution : Any person who, knowingly and with intent to defraud any insurance company or other person: ( 1) files an application for insurance or statement of claim containing any materially false information; or (2) conceals for the purpose of misleading, information concerning any fact material thereto; commits a fraudulent insurance act may be guilty of fraud and may be subject to civil or criminal penalties if intentional and material to the risk. For Vermont Residents: Any person who knowingly presents a false slatement in an application for insurance may be guilty of a criminal offense and subject to penallies under state law. Caution: Any person who, knowingly and wilh intenl to defraud any insurance company or other person: ( 1) files an application for insurance or statement of claim containing any materially false informalion; or (2) conceals for the purpose of misleading, informalion concerning any fact malerial thereto; commits afraudulenl insurance acl. GCI

6 Applicant's Name Social Security# ID# AGREEMENTS To the best of my knowledge and belief all written, telephonic and electronic information I gave is true and complete. I also understand that my insurance will not go into effect unless I am actively at work on the effective date. I also understand that coverage for each of my dependents will not go into effect unless the person is not confined in a hospital, or institution, or at home under the direction of a physician. The conditions for the requested insurance to be effective are described in the policy and certificate. The approval of this request by the Insurance Company is one of those conditions. I understand and agree that: (1) This request will be a part of the policy that provides the insurance. (2) I may need to provide more medical information. (3) I must report any change in my health that happens before the insurance is effective. (4) I must report any change in the health of my spouse for whom coverage is requested that happens before the insurance is effective. (5) Requested insurance above any Guaranteed Coverage Amount will not be effective for a person if the person does not meet the underwriting requirements on the date insurance is to be effective. Authorization. I hereby authorize any physician, medical professional, hospital or other medical facility, pharmacy, employee assistance plan, insurance company, health maintenance organization or similar entity, or any other person or organization to provide access to or copies of any medical records or other information, relating to me, to my employer' s Plan Administrator and to their authorized representatives including Life Insurance Company of North America. I understand that this information may include, but is not limited to, information concerning: mental illness, psychiatric, substance abuse or use, disability, HIV testing and illness, Acquired Immune Deficiency Syndrome, and genetic testing, but does not include psychotherapy notes. If my employer sponsors any other plans, whether or not underwritten or administered by Life Insurance Company of North America, or its affiliates, the information and/or records obtained may also be shared with the underwriting company insurer or administrators of those other plans, including their internal or external health management, disease management, wellness, employee/member assistance program or other similar programs, for the purpose of administering any service, benefit or feature described in those plans. I understand that the information will be used to assess my request for insurance. It may only be used for the purposes stated above if the information is re-disclosed. Any information provided to a third-party as permitted by this Authorization may not be re-disclosed by that third-party without your Authorization or unless allowed or required by law. This authorization will remain in effect for a period of 24 months from the date signed. If I wish to obtain a copy of this Authorization, I and/or my authorized agent may receive a copy upon request. I am aware that I may cancel this authorization at any time by written notice to the Insurance Company at the address at the top of this Application form. If I cancel this Authorization, it will not: (1) change any action taken in reliance on the Authorization up to that date; or (2) change the Insurance Company's right to use the Authorization for contest of a claim or policy in accordance with applicable law. I understand that information disclosed under this authorization by the recipient is no longer subject to the protections of the Health Insurance Portability and Accountability Act (HIPAA). The Insurance Company is subject to the Grarnm-Leach-Bliley Act and state privacy laws. The Insurance Company may not disclose protected information except as permitted by those laws or as authorized by you. Pre-Existing Condition Limitation We will not pay benefits for a Covered Loss caused or contributed to by, or resulting from, a Pre-existing Condition. The term "Pre-existing Condition" means any Sickness or Injury for which a Covered Person received medical treatment, advice, 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 the Covered Person's most recent effective date of coverage, and the most recent effective date of any added or increased amount of coverage. The Pre-Existing Condition Limitation will apply to any added benefits or increases in benefits. This Limitation will not apply to a Covered Loss for which the Date of Diagnosis occurs after the Covered Person is insured under this Policy for at least 12 months after the Covered Person's most recent effective date of coverage, and effective date of any added or increased amount of coverage. Sign Here Empl oyee 's Signatur e or Domestic Part ner's Signatur e Month/Day/Year Month/Day/Year (If applying f or insurance f or your sp ous e/domes tic partner) Spouse Notice: Personal information may be collected from persons other than those proposed for coverage. Information may be disclosed to third parties without your authorization as permitted by law. You have the right to access and correct all personal information collected. Additional information about Our privacy practices is available upon request. GCI