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1 The Guardian Life Insurance Company of America And its Affiiates and Subsidiaries Enroment/Change Form Page 1 of 6 Guardian Life, P.O. Box 14319, Lexington, KY Pease print ceary and mark carefuy. Empoyer Name: Technoogy Integration Group Group Pan Number: Benefits Effective: PLEASE CHECK APPROPRIATE BOX q Initia Enroment q Re-Enroment q Add Empoyee/Dependents q Drop/Refuse Coverage q Information Change q Increase Amount q Famiy Status Change Cass: NON-CA Empoyee Division: Subtota Code: (Pease obtain this from your Empoyer) About You: First, MI, Last Name: Socia Security Number - - Address City State Zip Gender: Date of Birth(mm-dd-yy): - - Phone:( ) - Emai Address: Are you married or do you have a spouse/domestic partner? q Yes q No Date of marriage/union:_ Do you have chidren or other dependents? q Yes q No Pacement date of adopted chid:_ About Your Job: Hours worked per week: Job Tite: Work Status: q Active q Retired q Cobra/State Continuation Date of fu time hire: Annua Saary: $ About Your Famiy: Pease incude the names of the dependents you wish to enro for coverage. A dependent is a person that you, as a taxpayer, caim; who reies on you for financia support; and for whom you quaify for a dependency tax exception. Dependency tax exemptions are subject to IRS rues and reguations. Additiona information may be required for non-standard dependents such as a grandchid, a niece or a nephew. Spouse/Domestic Partner (First, MI, Last Name) Chid/Dependent 1: Chid/Dependent 2: Chid/Dependent 3: Chid/Dependent 4: Gender q Add q Drop Gender q Add q Drop Gender q Add q Drop Gender q Add q Drop Gender Status (check a that appy) q Student (post high schoo) q Disabed q Non standard dependent State of Residence: Status (check a that appy) q Student (post high schoo) q Disabed q Non standard dependent State of Residence: Status (check a that appy) q Student (post high schoo) q Disabed q Non standard dependent State of Residence: Status (check a that appy) q Student (post high schoo) q Disabed q Non standard dependent State of Residence: CEF2012-CA DETACH ENTIRE FORM AND RETURN TO YOUR EMPLOYER DATE FORM PUBLISHED: Jun 06,

2 Drop Coverage: q Drop Empoyee q Drop Dependents The date of withdrawa cannot be prior to the date this form is competed and signed. Last Day of Coverage: - - q Termination of Empoyment q Retirement Last Day Worked: - - q Other Event: Date of Event: - - Loss Of Other Coverage: I and/or my dependents were previousy covered under another insurance pan. Loss of coverage was due to: q Termination of Empoyment: - - q Divorce - - q Death of Spouse/Domestic Partner - - q Termination/Expiration of Coverage - - Coverage Lost q Denta q Vision Coverage Being Dropped: q Denta q Empoyee q Spouse/Domestic Partner q Chid(ren) q Vision q Empoyee q Spouse/Domestic Partner q Chid(ren) q Basic Life q Vountary Life q Empoyee q Spouse/Domestic Partner q Chid(ren) q Long Term Disabiity q Short Term Disabiity I have been offered the above coverage(s) and wish to drop enroment for the foowing reasons: q Covered under another insurance pan q Other (additiona information may be required) Denta Coverage: You must be enroed to cover your dependents. Check ony one box. Empoyee Ony EE & Spouse EE & /Domestic Partner Dependent/Chid(ren) Option 1: Low PPO q q q q Option 2: High PPO q q q q q I do not want this coverage. If you do not want this Denta Coverage, pease mark a that appy: q I am covered under another Denta pan q My spouse/domestic Partner is covered under another Denta pan q My dependents are covered under another Denta pan EE, Spouse/Domestic Partner & Dependent/Chid(ren) Vision Coverage: You must be enroed to cover your dependents. Check ony one box. Empoyee Ony Empoyee and 1 EE, Spouse/Domestic Partner Dependent & Dependent/Chid(ren) Fu Feature q q q q I do not want this coverage. If you do not want this Vision Coverage, pease mark a that appy: q I am covered under another Vision pan q My spouse/domestic Partner is covered under another Vision pan q My dependents are covered under another Vision pan Basic Life Coverage with Accidenta Death and Dismemberment (AD&D): Benefit reductions appy. Pease see pan administrator. Poicy Amount Empoyee Ony R $15,000 NAME YOUR BENEFICIARIES (primary beneficiaries must tota 100%) Primary Beneficiary: Name % Reationship to empoyee: Name % Reationship to empoyee: Contingent Beneficiary: Reationship to empoyee: (In the event the designated primary beneficiaries are deceased, the contingent beneficiary wi receive the benefit. Empoyer maintains beneficiary information.) If this Basic Life poicy wi repace your existing ife insurance poicy under your current empoyer, provide the amount of the previous poicy $ Important Notes: Based on your pan benefits and age, you may be required to compete an evidence of insurabiity form for Basic Life. 2 DETACH ENTIRE FORM AND RETURN TO YOUR EMPLOYER

3 Guardian Group Pan Number: Pease print empoyee name: Vountary Term Life Coverage: Empoyee You must be enroed to cover your dependents. Benefit reductions appy. Pease see pan administrator. Poicy Amount Check one box ony q $10,000 q $20,000 q $30,000 q $40,000 q $50,000 q $60,000 q $70,000 q $80,000 q $90,000 q $100,000 q $150,000* q $200,000 q $250,000** q $300,000 q $350,000 q $400,000 q $450,000 q $500,000 $ *Guarantee Issue Amount **Guarantee Issue Amount pus Additiona Amount q I do not want this coverage Add Vountary Life for Spouse/Domestic Partner q 50% of empoyee's amount to maximum $250,000 The Guarantee Issue Amount is $50,000. The Guarantee Issue with Additiona Amount is $50,000. *The amount may not be more than 50% of the empoyee amount for Vountary Life. q I do not want this coverage Add Vountary Life for Dependent/Chid(ren) Poicy Amount q $2,000 q $3,000 q $4,000 q $5,000 q $6,000 q $7,000 q $8,000 q $9,000 q $10,000* *Guarantee Issue Amount *The amount may not be more than 10% of the empoyee amount for Vountary Life. q I do not want this coverage Important Notes: Based on your pan benefits and age, you may be required to compete an evidence of insurabiity form for Vountary Life. Name your beneficiaries: (primary beneficiaries must tota 100%) If eecting different beneficiaries that are not the same as those named for Basic Life, pease name beow. Primary Beneficiaries: Name: % Reationship to empoyee: Name: % Reationship to empoyee: Contingency Beneficiary: Reationship to empoyee: (In the event the designated beneficiaries are deceased, the contingent beneficiary wi receive the benefit. Empoyer maintains beneficiary information.) Short-Term Disabiity (STD) Coverage: Weeky Benefit q 60% of saary to a maximum of $1,250 q I do not want this coverage. Long-Term Disabiity (LTD) Coverage: Monthy Benefit R 60% of saary to a maximum of $5,000 DETACH ENTIRE FORM AND RETURN TO YOUR EMPLOYER 3

4 Heath History Compete the foowing question(s) if you are enroing for one or more of the foowing benefits isted beow. NOTE: Additiona information may be required. Vountary Life To the best of your knowedge, in the ast 6 months have you or any of your dependents been diagnosed with or treated by a medica professiona for or had a study done for which medica resuts are pending for; or taken prescribed drugs for: Cancer, (except ocaized non meanoma skin cancer), Heart disease, or Diabetes? q Yes, I have. q No, I haven't. q Yes, my spouse/domestic Partner has. q No, my spouse/domestic Partner hasn't. q Yes, my dependent chid(ren) have. q No, my dependent chid(ren) haven't. To the best of your knowedge, have you or any of your dependents been treated for or diagnosed by a medica professiona as having AIDS Reated Compex (ARC) or AIDS? q Yes, I have. q No I haven't. q Yes, my spouse/domestic Partner has. q No, my spouse/domestic Partner hasn't. q Yes, my dependent chid(ren) have. q No, my chid(ren) haven't. An Evidence of Insurabiity form must be competed for any person with a "Yes" answer to the question(s) above. Signature An empoyee's decision to eect Vision or not eect Vision must be retained unti the next pan's Open Enroment period. If the empoyee eects not to enro in vision coverage, they are not eigibe to enro unti the pan's next Open Enroment period. I understand that ife insurance coverage for a dependent, other than a newborn chid, wi not take effect if that dependent is confined to a hospita or other heath care faciity, or is home confined, or is unabe to perform the norma activities of someone of ike age and sex. I understand that my dependent(s) cannot be enroed for a coverage if I am not enroed for that coverage. I understand that the premium amounts shown above are estimations and are for iustrative purposes ony. Submission of this form does not guarantee coverage. Among other things, coverage is contingent upon underwriting approva and meeting the appicabe eigibiity requirements as set forth in the appicabe benefit booket. If coverage is waived and you ater decide to enro, ate entrant penaties may appy. You may aso have to provide, at your own expense, proof of each person's insurabiity. Guardian or its designee has the right to reject your request. I understand that I must be activey at work or my eected coverage wi not take effect unti I have met the eigibiity requirements (as defined in the benefit booket.) This does not appy to eigibe retirees. Pan design imitations and excusions may appy. For compete detais of coverage, pease refer to your benefit booket. State imitations may appy. Your coverage wi not be effective unti approved by a Guardian or its designated underwriter. I hereby appy for the group benefit(s) that I have chosen above. I understand that I must meet eigibiity requirements for a coverages that I have chosen above. I agree that my empoyer may deduct premiums from my pay if they are required for the coverage I have chosen above. I attest that the information provided above is true and correct to the best of my knowedge. "Caifornia aw prohibits an HIV test from being required or used by heath insurance companies as a condition of obtaining heath insurance coverage." For your protection Caifornia aw requires the foowing to appear on this form: The fasity of any statement in the appication sha not bar the right to recovery under the poicy uness such fase statement was made with actua intent to deceive or uness it materiay affected either the acceptance of the risk or the hazard assumed by the insurer. The state in which you reside may have a specific state fraud warning. Pease refer to the attached Fraud Warning Statements page. SIGNATURE OF EMPLOYEE X DATE Enroment Kit , 0002, EN 4

5 Guardian Group Pan Number: Pease print empoyee name: Fraud Warning Statements The aws of severa states require the foowing statements to appear on the enroment form: Aabama: Any person who knowingy presents a fase or frauduent caim for payment of a oss or benefit or who knowingy presents fase information in an appication for insurance is guity of a crime and may be subject to restitution fines or confinement in prison, or any combination thereof. Arizona: For your protection Arizona aw requires the foowing statement to appear on this form. Any person who knowingy presents a fase or frauduent caim for payment of a oss is subject to crimina and civi penaties. Caifornia: For your protection Caifornia aw requires the foowing to appear on this form: The fasity of any statement in the appication sha not bar the right to recovery under the poicy uness such fase statement was made with actua intent to deceive or uness it materiay affected either the acceptance of the risk or the hazard assumed by the insurer. Coorado: It is unawfu to knowingy provide fase, incompete, or miseading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penaties may incude imprisonment, fines, denia of insurance, and civi damages. Any insurance company or agent of an insurance company who knowingy provides fase, incompete, or miseading facts or information to a poicy hoder or caimant for the purpose of defrauding or attempting to defraud the poicy hoder or caimant with regard to a settement or award payabe from insurance proceeds sha be reported to the Coorado Division of Insurance within the Department of Reguatory Agencies. Connecticut, Iowa, Kansas, Nebraska, Oregon, and Vermont: Any person who knowingy, and with intent to defraud any insurance company or other person, fies an appication of insurance or statement of caim containing any materiay fase information or conceas, for the purpose of miseading, information concerning any fact materia thereto, may be guity of a frauduent insurance act, which may be a crime, and may aso be subject to civi penaties. Deaware, Indiana and Okahoma: WARNING: Any person who knowingy, and with intent to injure, defraud or deceive any insurer, makes any caim for the proceeds of an insurance poicy containing any fase, incompete or miseading information is guity of a feony. District of Coumbia: WARNING: It is a crime to provide fase or miseading information to an insurer for the purpose of defrauding the insurer or any other person. Penaties incude imprisonment and/or fines. In addition, an insurer may deny insurance benefits, if fase information materiay reated to a caim was provided by the appicant. Forida: Any person who knowingy and with intent to injure, defraud, or deceive any insurer fies a statement of caim or an appication containing any fase, incompete, or miseading information is guity of a feony of the third degree. Kentucky: Any person who knowingy and with intent to defraud any insurance company or other person fies a statement of caim containing any materiay fase information or conceas, for the purpose of miseading, information concerning any fact materia thereto commits a frauduent insurance act, which is a crime. Louisiana and Texas: Any person who knowingy presents a fase or frauduent caim for payment of a oss or benefit is guity of a crime and may be subject to fines and confinements in state prison. Maine, Tennessee, Virginia and Washington: It is a crime to knowingy provide fase, incompete or miseading information to an insurance company for the purpose of defrauding the company. Penaties may incude imprisonment, fines or a denia of insurance benefits. Maryand : Any person who knowingy or wifuy presents a fase or frauduent caim for payment of a oss or benefit or knowingy or wifuy presents fase information in an appication for insurance is guity of a crime and may be subject to fines and confinement in prison. Rhode Isand: Any person who knowingy and wifuy presents a fase or frauduent caim for payment of a oss or benefit or knowingy and wifuy presents fase information in an appication for insurance is guity of a crime and may be subject to fines and confinement in prison. Minnesota: A person who fies a caim with intent to defraud or heps commit a fraud against an insurer is guity of a crime. New Hampshire: Any person who, with a purpose to injure, defraud or deceive any insurance company, fies a statement of caim containing any fase, incompete or miseading information is subject to prosecution and punishment for insurance fraud, as provided in N.H. Rev. Stat. Ann. 638:20 New Jersey: Any person who knowingy fies a statement of caim containing any fase or miseading information is subject to crimina and civi penaties. New York: Any person who knowingy and with intent to defraud any insurance company or other person fies an appication for insurance or statement of caim containing any materiay fase information, or conceas for the purpose of miseading, information concerning any fact materia thereto, commits a frauduent insurance act, which is a crime, and sha aso be subject to a civi penaty not to exceed five thousand doars and the stated vaue of the caim for each such vioation. (Does not appy to Life Insurance.) New Mexico: Any person who knowingy presents a fase or frauduent caim for payment or a oss or benefit or knowingy presents fase information in an appication for insurance is guity of a crime and may be subject to civi fines and crimina penaties or denia of insurance benefits. Ohio: Any person who with intent to defraud or knowing that he/she is faciitating a fraud against an insurer, submits an appication or fies a caim containing a fase or deceptive statement is guity of insurance fraud. Pennsyvania: Any person who knowingy and with intent to defraud any insurance company or other person fies an appication for insurance or statement of caim containing any materiay fase information or conceas for the purpose of miseading, information concerning any fact materia thereto commits a frauduent insurance act, which is a crime and subjects such person to crimina and civi penaties. DETACH ENTIRE FORM AND RETURN TO YOUR EMPLOYER 5

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7 P.O. Box Lexington, KY Suppementa Data - Life Coverage PLEASE TYPE or PRINT CLEARLY. The entire form, propery competed, signed and dated by the Insured. EMPLOYER/PLANHOLDER NAME: GROUP NUMBER EMPLOYEE NAME (LAST, FIRST, M.) SOCIAL SECURITY # Pease provide information beow for empoyee and dependents if not aready provided. Empoyee: Date of Birth Name Address Phone# Emai Spouse: (First, MI, Last Name) Socia Security Number Chid/Dependent 1: (First, MI, Last Name) Emai: Socia Security Number Chid/Dependent 2: (First, MI, Last Name) Emai: Socia Security Number Chid/Dependent 3: (First, MI, Last Name) Emai: Socia Security Number Chid/Dependent 4: (First, MI, Last Name) Emai: Socia Security Number Emai: Primary Beneficiaries: (Primary beneficiary percentages must tota 100%) Name: Socia Security Number: - - % Date of Birth: Date of Birth (mm-dd-yy): - - Reationship to empoyee: Name: Socia Security Number: - - % Date of Birth: Date of Birth (mm-dd-yy): - - Reationship to empoyee: Contingent Beneficiary Name: Socia Security Number: - - % Date of Birth: Date of Birth (mm-dd-yy): - - Reationship to empoyee: (In the event the designated beneficiaries are deceased, the contingent beneficiary wi receive the benefit.)

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