What if you needed dental work performed... Would you have to pay for it out-of-pocket? Benefit coverage for Fox & Hound Restaurant Group

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1 What if you needed dental work performed... EXAM CLEANING X-RAY FILLING Would you have to pay for it out-of-pocket? Benefit coverage for Fox & Hound Restaurant Group Heritage Choice Dental Plan Looking for a flexible dental plan that offers provider choice, comprehensive coverage and orthodontic services? Get ready to smile. A Great Smile Begins With Planning and Prevention - When it comes to achieving a winning smile, there are two things that come to mind...dental Care and Allstate Benefits. ABJ25971X Page 1 of 4

2 heritage choice dental plan We pay benefits for covered dental procedures you receive while you are insured under the Group Policy. Some categories of services require that you be continuously insured during the Elimination Period before a benefit is payable. Some services are subject to a copayment, or deductible as described. We will not pay more than the Maximum Benefit for all services you receive. Dental insurance coverage helps offer peace of mind when dental needs arise. Below is an example of how benefits are paid. John chooses Plan 1 from the Group Dental coverage offered by his Employer Category 1 Yearly Wellness Exam John visits his dentist for a yearly wellness exam. His dentist performs an oral examination, takes X-rays and preforms a routine cleaning. During the visit, his dentist tells John he needs to have a filling and extraction of one wisdom tooth. Category 2 General Services Two weeks later, John is in for his appointment to have his filling performed on his lower molar and have his wisdom tooth pulled. Our dental insurance policy provided John with the following benefits: Category 1 - Wellness Benefit 0120 Oral Examination 0274 Bite wing X-rays-four films 1110 Routine Cleaning - Adult Category 2 -General Services 2330 Resin based composite - One Surface 7240 Removal of Impacted Tooth - completely bony The example shown may vary from the plan your employer is offering. Your individual experience may also vary. Please see page 2a for plan examples. meeting your needs Our coverage can help provide financial support for yourself, your spouse and your family. The covered percent paid by your plan increases the 2nd and 3rd coverage year Credit is given for previous group coverage, if sponsored by Fox & Hound Restaurant Group Orthodontic Services/Braces available after six months of coverage Choose the Dentist you prefer there is no network of Dentists Guaranteed issue - no health questions Your entire family can be covered Wellness Benefit benefit coverage Wellness Benefit - Pays a benefit amount minus the copayment. This benefit is payable two times during a coverage year, with at least 150 days between the two visits. Each wellness visit by you or your insured dependents is subject to a copayment. Deductible - The deductible amount must be satisfied each year you are covered under the plan. The deductible applies to all services except those covered under Wellness Services. (The copayment may not be used to satisfy either your or your dependents deductible.) Insured Percent - Pays the benefit amount shown in the Schedule of Dental Procedures, times the percent shown for each Category listed on Page 2a. If the charge for the procedure is greater than the benefit amount, you pay the difference. Elimination Period - The period of time you must be insured before we pay benefits. We will not pay for services performed during this period, except for those covered under the Dental Wellness Benefit. Annual Plan Maximum - The maximum amount the plan will pay for dental treatment for each covered person in a coverage year. Page 2 of 4 ABJ25971X

3 You go in for your annual dental wellness visit The dentist says you need a crown, and then you undergo the procedure A percentage of the cost is paid POLICY PROVISIONS Enrollment - You must enroll within 31 days of the date you first become eligible. If you do not, and later decide to enroll, you must wait until the annual enrollment period for your group. If you acquire a dependent after your insurance is effective, you may enroll that dependent within 31 days of the date of marriage, birth, adoption, etc. There is no other provision for enrolling other than during the annual enrollment period. This is a one-month period, usually just before the group policy anniversary date. You will be notified of the eligibility requirements and annual enrollment period that apply to your group. Dependent Eligibility/Termination - (a) Coverage may include you, your spouse and children under age 26. (b) Coverage ends on the date the policy is canceled; the last day premium payments were made; the last day of active employment; the date your class is no longer eligible; or the date the group policy terminates. (c) Coverage for children ends when the child reaches age 26, unless he or she continues to meet the requirements of an eligible dependent. Portability Privilege - Coverage may be continued under the Portability Provision when coverage under the policy ends. Exclusions and Limitations - Allstate Benefits does not pay benefits for: procedures not listed in the Schedule of Dental Procedures; or injury or sickness benefits paid under the Workers Compensation Law or Act; any act of war; participation in a riot or committing an assault or felony. Dental services or supplies: performed by a relative of the insured person; or not prescribed or performed by a dentist or licensed dental hygienist; or oral hygiene, dietary instructions, or plaque control; or implants, full or partial dentures or bridgework made to replace teeth pulled prior to being insured*; or duplicate or replace bridgework, dentures or other dental appliance, due to loss, theft or other**; or straightening the teeth, to correct a malocclusion or for other orthodontic services, unless the insured person is an insured child under the age of 19 years. Insurance for your dependents will terminate on the earliest of: the date your insurance terminates; the last day for which the dependent premium has been paid; the date coverage for dependents is terminated under the group policy; or the date the dependent ceases to be a dependent as defined in the policy. COBRA Continuation - Since this plan is employersponsored, it is subject to the same federal COBRA continuation requirements that apply to medical plans. In general, this allows you to continue your insurance under the group policy for 18 months after your employment terminates. If your dependent would lose coverage due to your death, divorce, or attainment of the limiting age for eligibility of dependents, the coverage may be discontinued for up to 36 months. If the group policy is terminated by the employer before the end of the COBRA continuation period, you are entitled to be covered under a replacement group plan. *This exclusion will cease to apply after a person has been insured for 3 consecutive years. **Does not apply if replacement cannot be restored or be in place for at least 3 years; if damaged due to facial injury; or if a tooth is pulled and an adjustment is required. ABJ25971X Page 3 of 4

4 This material is valid as long as information remains current, but in no event later than November 15, Heritage Choice Dental benefits provided by policy form G-DEN-P, or state variations thereof. This brochure highlights some features of the policy but is not the insurance contract. For complete details, contact your Allstate Benefits Agent. This is a brief overview of the benefits available under the Group Voluntary Policy underwritten by American Heritage Life Insurance Company (Home Office, Jacksonville, FL). Details of the insurance, including exclusions, restrictions and other provisions are included in the certificates issued. This brochure is for use in the Fox & Hound Restaurant Group enrollment which in sitused in TX. Allstate Benefits is the marketing name used by American Heritage Life Insurance Company (Home Office, Jacksonville, FL), a subsidiary of The Allstate Corporation Allstate Insurance Company. or allstatebenefits.com Page 4 of 4 ABJ25971X

5 Benefit coverage for Fox & Hound Restaurant Group heritage choice dental plan (group voluntary) BENEFITS FOR THE HERITAGE CHOICE DENTAL YEAR 1 YEAR 2 YEAR 3+ Wellness Benefit No Deductible No Deductible No Deductible Pays the Pays the Pays the schedule schedule schedule amount minus amount minus amount minus the copayment the copayment the copayment $15/visit $15/visit $15/visit Deductible Employee (Insured Person) $50/year $50/year $50/year Family $100/year $100/year $100/year Insured Percent Category 1 - Wellness Benefit 100% 100% 100% Category 1 - Other Preventive Services 1 100%* 100% 100% Category 2 - General Services 1 50%* 60% 80% Category 3 - Special Services 1 25%* 35% 50% Category 4 - Orthodontic/Braces Services 1,2 25%* 35% 50% Elimination Period Category 1 - Wellness Benefit None None None Category 1 - Other Preventive Services 6 months None None Category 2 - General Services 6 months None None Category 3 - Special Services 6 months None None Category 4 - Orthodontic/Braces Services 6 months None None Annual Plan Maximum Categories 1, 2, and 3 Services $500/year $750/year $1,000/year Category 4 - Orthodontic/Braces Services 3,4 $500/year $500/year $500/year sample schedule of dental procedures *Available to dependent children only, under the age of 19 *No benefit is available for these services during the first 6 months of the first coverage year. Refer to the Elimination Period to the left 1 subject to deductible 2 limited to dependent children under age 19 3 available to dependent children under age 19 4 $1,500 lifetime maximum CATEGORY 1 - Wellness benefit 0120 Oral Examination $ Routine Cleaning - Adult $ Routine Cleaning - Child $ Bitewings X-rays - four films $ Sealant - per tooth $ Panoramic X-ray - film $65.00 CATEGORY 1 - Other preventive services 0220 Intraoral X-ray Periapical - first film $ Intraoral X-ray Periapical - each additional film $12.00 CATEGORY 2 - GENERAL SERVICES 2330 Resin-based composite - one surface $ Removal of impacted tooth - completely bony $ CATEGORY 3 - SPECIAL SERVICES 2740 Crown - porcelain $ Crown - full cast high noble metal $ Complete denture- maxillary $ Fixed partial denture - pontic - cast high noble metal $ Fixed partial denture - pontic - porcelain fused to high $ noble metal CATEGORY 4 - ORTHODONTIC/BRACES services* 8220 Fixed appliance therapy $ Periodic orthodontic treatment visit $22.75 ABJ25971X-Insert-FHRG Page 2a

6 premiums MODE Employee Employee + Spouse Employee + Child(ren) Family Bi-Weekly $7.70 $14.78 $14.78 $25.86 This insert is for use in: TX This insert is part of brochure ABJ25971X and is not to be used on its own. Allstate Benefits is the marketing name used by American Heritage Life Insurance Company (Home Office, Jacksonville, FL), a subsidiary of The Allstate Corporation Allstate Insurance Company. or allstatebenefits.com. ABJ25971X-Insert-FHRG Page 2b