NEW YORK DISABILITY BENEFITS LAW (DBL) State-mandated, non-occupational disability coverage for your employees

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1 NEW YORK DISABILITY BENEFITS LAW (DBL) State-mandated, non-occupational disability coverage for your employees WHILE EMPLOYEES RECOvER PROvIDE THEM PEACE OF MIND RATES EFFECTIvE 07/01/2012 GRoUPROTECTOR SM

2 Illness and injuries will happen. BUT THEY DON T HAvE TO PUT EMPLOYEES ON THE SPOT. Let Nationwide Specialty Insurance SM help. When an injury or illness prevents an employee from working for a while, our non-occupational disability insurance provides much-needed benefits so they can focus on recuperation. While New York law requires you to have disability coverage, you can choose your provider. Nationwide Specialty Insurance offers unique options and benefits that make our coverage an easy choice. The New York State Disability Benefits Law (DBL) This law is designed to provide a weekly cash benefit to your employees for disabilities caused by non-occupational illness or injury. Statutory benefits are equal to 50% of your insured employee s average weekly wage up to a maximum of $170 per week. Statutory benefits are payable starting at the eighth day of disability for non-occupational illness or injury. Benefits are payable for up to 26 weeks during a 52 week period that starts with the first week of benefits. An employer is allowed by law to deduct one half of one percent (0.5%) of an employee s weekly wage not to exceed sixty cents per week towards the cost of this coverage. The employer pays the balance of the premium. Nationwide Specialty Insurance s program is designed for employer groups with fewer than 50 eligible employees. For groups with 50 or more eligible employees, please see page 5 for the information needed. Call us at for assistance. Important Notice Coverage is provided under policy form No. DBL-GR-5990-D. Certain provisions of the policy and the Disability Benefits Law are summarized in this brochure. All benefits are subject to the terms of the policy and the law. 2

3 New York State Group Disability Benefits Application Which upon acceptance and approval by Nationwide Life Insurance Company, will become a part of New York State Group Disability Benefits Policy Number. 1. Legal Name of Employer (per filing receipt) Doing Business as Contact Address Mailing Address (if different from above) Nature of business Phone Unemployment Insurance Registration Number - REQUIRED (provided to employers by the Dept of Labor) Federal Employer Identification Number - REQUIRED 2. List other employers whose employees will be insured under the policy (if additional space is needed, please use a separate sheet) Legal Company Name Address Nature of business Phone Unemployment Insurance Registration Number - REQUIRED (provided to employers by the Dept. of Labor) Federal Employer Identification Number - REQUIRED 3. The policy covers all employer s Employees as defined in and subject to the law, except (check box if applicable); Executive Corporate Officers (if excluded, do not count in premium calculation). Name(s) Other (please describe) 4. General information (Please answer all questions) (a) Will the employee contribute to the cost of his/her insurance? No Yes If yes, how much weekly $ (b) Total # of employees # Males # Females # Part Time # Students (c) Is this business seasonal? No Yes Number of months in operation during calendar year? (d) Is this insurance going to replace any insurance now or previously in effect? No Yes If yes, name of Carrier Date such coverage will change Reason for Change (e) Are employees covered by Workers Compensation? No Yes If yes, name of Carrier 5. It is understood and agreed that: (a) All renewal premium will be paid quarterly or annually in advance. (The minimum premium is $16 per quarter or $64 per year) (b) Are there multiple locations to be billed separately? No Yes If yes, number of locations. Bill to individual locations or Plan Sponsor 6. Effective date: The policy term starts at 12:01 a.m. on which is the effective date. By the signature below of its duly authorized representative, the proposed Plan Sponsor hereby applies for the Nationwide Life Insurance Company Policy and the proposed Plan Sponsor understands and agrees that it shall be subject to the provisions set forth herein. It is understood and agreed that the first advance premium is based on a monthly rate as specified in the brochure. The minimum premium is $16 per quarter or $64 per year. Benefits shall be those which covered employees are entitled to receive under Section 204 of the Disability Benefits Law of the State of New York because of employment with the above named Employer(s). NEW YORK REQUIRED STATEMENT Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty not to exceed $5,000 and the stated value of the claim for each such violation. Previous policy number Agent s signature and number Signature and title of applicant Date application signed Agent s telephone number Print name of applicant DBL GR 5993-F 3 Agent s (877) insure@barricksinsurance.com Applicant s

4 First Advance Premium Calculation Number of employees to be covered (excluding partners and proprietors) A B C D E F Number of Corporate Officer Employees 1 Number of Regular Employees 2 Total Number of Employees Advance Premium Factor (see chart below) Rate per Employee per Month Males + = x x$ 2.59 $ Females + = x x$ 5.52 $ Total Quarterly Advance Premium Due 3 $ 1 Complete column A for Corporations only. 2 Please see page 5 for information on pricing for 50 or more employees. 3 The minimum advance premium is $16 for quarterly or $64 annually. First Advance Premium 3 Advance Premium Factor Chart Policy Effective Date Advance Premium Next Premium Due Date Advance Premium Factor-Annual Next Premum Due Date 1/11 to 1/15 3 April 1 12 January 1 1/16 to 1/31 2 April 1 11 January 1 2/1 to 2/15 2 April 1 11 January 1 2/16 to 2/29 4 July 1 10 January 1 3/1 to 3/15 4 July 1 10 January 1 3/16 to 3/31 3 July 1 12 April 1 4/1 to 4/15 3 July 1 12 April 1 4/16 to 4/30 2 July 1 11 April 1 5/1 to 5/15 2 July 1 11 April 1 5/16 to 5/31 4 October 1 10 April 1 6/1 to 6/15 4 October 1 10 April 1 6/16 to 6/30 3 October 1 12 July 1 7/1 to 7/15 3 October 1 12 July 1 7/16 to 7/31 2 October 1 11 July 1 8/1 to 8/15 2 October 1 11 July 1 8/16 to 8/31 4 January 1 10 July 1 9/1 to 9/15 4 January 1 10 July 1 9/16 to 9/30 3 January 1 12 October 1 10/1 to 10/15 3 January 1 12 October 1 10/16 to 10/31 2 January 1 11 October 1 11/1 to 11/15 2 January 1 11 October 1 11/16 to 11/30 4 April 1 10 October 1 12/1 to 12/15 4 April 1 10 October 1 12/16 to 12/31 3 April 1 12 January 1 4 Use this chart when applying for coverage. Select the correct advance premium factor, and write it into column D of the First Advance Premium Calculation section. Also, make note of the next premium due date. We will send you a bill prior to that date.

5 To obtain a quote for coverage on groups of 50+ employees... The following information for employees who work in New York must be provided. The legal name and address of all entities (employers) including a brief description of the business and the SIC code, if available. A census list with gender, date of birth and weekly salary for all full-time and eligible part-time employees. For hourly employees, average weekly wages should be provided. The original effective date of the current carrier s New York DBL policy. If two years or fewer from the requested effective date with Nationwide, the effective date and carrier of the previous plan will also be needed. A copy of the current carrier s Schedule of Benefits or complete policy. Premium, claims, in-force rates, and rate histories from the current carrier(s) for at least two years, if available. Experience may not always be available on groups of less than 100 employees but should be available on groups of 100 or more employees. A copy of the current carrier s renewal letter, if available. The amount of contribution an employee will contribute toward the insurance premium, if any. Additional information may be required by our underwriters for groups of 250 or more employees. If the quote is accepted, a fully completed and signed NYDBL application along with a check for premium, will be required before the policy can be issued. The applicant should not cancel their in-force policy until final approval is received from Nationwide. To receive a quote for a group of 50 or more lives, please fax information requested above to Nationwide Specialty Insurance,

6 How do you apply for coverage? 1. Complete ALL fields on the application. Be sure to sign and date where indicated. 2. Complete first advanced premium report on page 4 to calculate amount due. 3. Mail the application with a check made payable to Nationwide Insurance to the address listed below. Be sure to mail before the desired policy effective date. 4. Upon approval of received completed application and premium payment, we will send your policy, claim forms and instructions. How do you contact us? (8:00 a.m. 5:00 p.m. ET, M-F) Nationwide Specialty Insurance, P.O. Box 1970, Springfield, MA grouprotector@ consolidatedhealthplan.com nationwide.com/grouprotector BARRICKS INSURANCE SERVICES 276 N El Camino Real #6 Oceanside, CA Phone: (877) CA License: Submitting the application There are 3 ways to submit an application for coverage. Fax: Fax the completed application and automated clearing house (ACH) form found at nationwide.com/ach to: Nationwide Specialty Insurance Phone: Call You will be asked to fax your application to and submit payment by check, Visa or MasterCard. Mail: (8:00 a.m. 5:00 p.m. ET, M-F) Mail the completed application, Premium Report and premium payment to: Nationwide Specialty Insurance PO Box 1970 Springfield, MA Fraud Warnings (NY) Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation. Note: This product is ONLY available in NY Please read these important notices and warnings This sales literature contains only general descriptions of coverages and is not intended to be a statement of contract. All coverages are subject to the deductibles, exclusions and conditions in the actual policy. Underwritten by Nationwide Life Insurance Company. Nationwide, Nationwide Specialty Insurance, the Nationwide framemark and On Your Side are federally registered service marks of Nationwide Mutual Insurance Company. Nationwide Insurance is a federally registered service mark of Nationwide Mutual Insurance Company. GrouProtector is a service mark of Nationwide Mutual Insurance Company. 6