Capitol Association Plans PO Box , Sacramento, CA Phone: (916) Fax: (866)

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1 Capitl Assciatin Plans PO Bx , Sacrament, CA Phne: (916) Fax: (866) CVMA Emplyer Dental & Visin Enrllment Frm Thank yu fr yur interest in the Califrnia Veterinary Medical Assciatin (CVMA) dental and visin prgrams. Attached please find the necessary enrllment dcuments t get yu started. Shuld yu have any questins, please cntact ur ffice by phne at (916) r at caps@capsplans.cm. DENTAL PLANS: A. CVMA MEMBER EMPLOYERS: Delta Dental Nn-Vluntary Prgram Under this grup plan, full-time emplyees (32+hrs) f CVMA members will have access t any DeltaPremier dentist, which encmpasses the entire Delta Dental netwrk f dentists, apprximately 22,000. If they chse t see a DeltaPreferred Dentist (DPO Dentist), they will have access t apprximately 11,000 dentists, the annual deductible is waived and the maximum annual benefit is increased. Unlike many ther plans, there are n waiting perids t utilize benefits and the percentage paid by Delta Dental increases each year ver a perid f fur years t reach 100%. All emplyees wh wrk ver 32 hurs are required t be cvered unless they sign a waiver declining cverage. Emplyees declining cverage will nt be eligible t enrll at a later date unless they can shw prf f lss f prir cverage. *Emplyees are eligible n the first day f the mnth fllwing six full mnths f emplyment. Emplyers must cntribute a minimum f 50% t the emplyee s premium, but are nt required t cntribute fr dependent cverage. B. CVMA MEMBER EMPLOYERS & INDIVIDUALS: Delta Dental Vluntary Prgram Vluntary prgrams allw individual members and their emplyees (part-time and full-time) a chice t participate in dental benefits n a vluntary basis. These prgrams prvide n waiting perids t receive benefits. There are tw cverage ptins in the vluntary prgram, DeltaPremier and DeltaCare. Prvider Netwrk Deductible Cmplete series x-ray including bitewings Cleaning adult r child Silver Filling One Surface Single Tth Extractin Rt Canal Therapy, Frnt Tth Crwn prcelain (with nn-precius metal) Cmplete denture, upper Orthdntic Nn-Vluntary Plan A DeltaPremier DeltaCare In Netwrk/DPO: 11,000 Out f Netwrk: 22,000+ In Netwrk: $0 Out f Netwrk: $25 Individual/ $75 Family Plan Pays 70% 1 st year, 80% 2 nd year, 90% 3 rd year and 100% thereafter (Based n calendar year) 22, Offices $50 Individual $150 Family Nne Plan Pays $45 Plan Pays %100 Plan Pays $36 Plan Pays %100 Plan Pays $35 Plan Pays %100 Plan Pays $39 Member Pays $3 Plan Pays $193 Member Pays $55 Plan Pays 50% Plan Pays $163 Member Pays $ Plan Pays 50%* Plan Pays $240 Member Pays $110 Plan Pays 50% ($1,000 Max Per Child) Maximum Annual In Netwrk: $1,500 Benefit Out f Netwrk: $1,000 *12 mnth waiting perid n prsthdntics applies. Nt Cvered $1,000 Requires C-Payment $1,600 fr Child $1,800 fr Adult N Maximum, Except fr Accidental Injury

2 DELTA DENTAL MONTHLY RATE COMPARISON *Nn- Vluntary Plan A *DeltaPremier *DeltaCare Rates are based n netwrk service area. See chart belw fr lcatins. Level 1 & 2 Level 3 Level 4 Level 5 Emplyee Only $ $ $ $ $ $ Emplyee + One $ $ $ $ $ $ Emplyee + Family $ $ $ $ $ $ Level 1 & 2 Ls Angeles and Orange Cunties Level 3 Alameda, Cntra Csta, Fresn, Kern, Maripsa, Riverside, San Bernardin, San Dieg, San Francisc, San Mate, Santa Clara and Ventura Cunties Level 4 Alpine, Amadr, Calaveras, Clusa, El Drad, Imperial, Iny, Kings, Madera, Marin, Merced, Mnterey, Napa, Nevada, Placer, Plumas, Sacrament, San Jaquin, San Luis Obisp, Santa Barbara, Sierra, Slan, Snma, Stanislaus, Tulumne, Tulare, and Yl Cunties Level 5 Butte, Del Nrte, Glenn, Humbldt, Lake, Lassen, Mendcin, Mdc, Mn, San Benit, Santa Cruz, Shasta, Siskiyu, Sutter, Tehama, Trinity, and Yuba Cunties *Rates are effective thrugh 10/01/2019. VISION PLANS: As with the Dental plans, we have nn-vluntary and vluntary prgrams fr yu and yur emplyees t chse frm. The vluntary prgram is available t all individual CVMA members and individual emplyees (including part-time emplyees), where the nn-vluntary prgram is a grup plan that is nly t available emplyers and their full-time emplyees. Cverage Plan A (Nn-Vluntary) Plan B (Vluntary) Exam Every 12 Mnths Every 12 Mnths Prescriptin Glasses Lenses (Single visin, lined bifcal, and lined trifcal lenses) Frames (Frame f yur chice cvered up t $130. Plus, %20 ff any ut-f pcket csts) Every 24 Mnths Every 24 Mnths Every 12 Mnths Every 24 Mnths -- OR -- Cntacts Every 24 Mnths Every 12 Mnths VISION SERVICE PLAN MONTHLY RATE COMPARISON Plan A (Nn-Vluntary) Plan B (Vluntary) Emplyee Only $ 8.23 $ Emplyee + One Dependent $ $ Emplyee + Family $ $ *Rates are effective thrugh 6/01/2019.

3 ENROLLMENT INSTRUCTIONS T apply fr dental and/r visin benefits, cmplete the applicatin by fllwing these six simple steps: Step 1 Cmplete cntact infrmatin. Step 2 Select yu preferred methd f billing and payments. Please als make sure t calculate yur ttal premium at the bttm f the page, as this will be yur dwn payment and mnthly premium amunt (see Step 3 fr plan selectins and rates). Step 3 Select the plan(s) yu wuld like t sign up fr and hw many emplyees will be enrlled in each plan. Step 4 - Cmplete Emplyee / Individual Enrllment Frm fr each individual applying fr cverage. Make sure t include any dependent infrmatin. It is imprtant t nte that fr Nn-Vluntary Plans dependents cannt be added t the plan after initial enrllment unless there they suffer a lss f cverage. Step 5 - Each emplyee wh chses t waive cverage must cmplete the attached Waiver f Cverage Frm. Please submit the riginals with yur applicatin and keep a cpy fr yur recrds. Step 6 - Return the applicatin, enrllment frms and waivers, alng with yur first payment t us t begin cverage. Yu will receive a cnfirmatin letter nce yu have been enrlled. Please nte that we must receive yur applicatin fr enrllment, alng with payment n later than the 10 th f the current mnth in which yu want yur benefits t begin. We lk frward t wrking with yu. Please feel free t cntact us by phne at (916) r by at caps@capsplans.cm if yu have any questins r wuld like additinal infrmatin. CVMA DENTAL & VISION ENROLLMENT STEP 1 CONTACT INFORMATION (please print) CVMA Member: Cmpany (If applicable): Billing Cntact: Address: City, State, Zip: Phne/ Fax: *Ttal # f Full Time Emplyees: *Ttal # f Enrllees: *Please nte that all full time emplyees are required t participate in plans unless they prvide a waiver f cverage. All waivers must accmpany applicatins fr cverage. Emplyees waiving cverage will nt be eligible fr benefits at a later date unless they can prvide prf f a lss f prir cverage (see Waiver f Cverage).

4 STEP 2 PAYMENT AND BILLING INFORMATION Please select preferred methd f billing (hw yu wuld like t receive yur statements): Regular Mail Please select preferred methd f payment: Check/ Mney Order Make Checks Payable t Capitl Assciatin Plans Mail Payments t P.O , Sacrament, CA Autmatic Bank Debit (ACH) Please cmplete ACH authrizatin frm BILLING FREQUENCY Mnthly Quarterly Bi-Annually Annually PREMIUM CALCULATION Cverage Delta Dental Plan A $ DeltaPremier(PPO) $ DeltaCare Vluntary $ VSP Plan A $ VSP Plan B $ **Setup Fee $10 (New Accunts Only) $ Admin ($1 per Emplyee, $5 Min.) $ Ttal Ttal Amunt Due $. This sectin must be cmpleted and returned.

5 STEP 3 SELECT PLAN(S) DENTAL COVERAGE NON-VOLUNTARY PROGRAM PLAN A Delta Dental Cverage Type # f Emplyees Mnthly Rate Emplyee Only $ One Dependent $ Family $ VOLUNTARY PROGRAM PLAN B DeltaPremier DeltaCare see chart Cverage Type # f Emplyees Mnthly Rate Cverage Type # f Emplyees Mnthly Rate Emplyee Only $ Emplyee Only + One Dependent $ One Dependent Family $ Family VISION PLAN Visin Service Plan A Nn-Vluntary Visin Service Plan B - Vluntary Cverage Type # f Emplyees Mnthly Rate Cverage Type # f Emplyees Mnthly Rate Emplyee Only $ One Dependent $ Family $ Emplyee Only + One Dependent Family $ $ $ 25.55

6 STEP 4 EMPLOYEE/ INDVIDUAL ENROLLMENT Please cmplete ne frm fr each emplyee. Emplyee Name: Scial Security #: Hme Address: Date f City, State, Zip: Dependent: Scial Security #: Dependent: Scial Security #: Dependent: Scial Security #: Dependent: Scial Security #: Relatinship: Date f Relatinship: Date f Relatinship: Date f Relatinship: Date f Emplyee Signature: Date: Plan Chice(s): Delta Dental Plan A DeltaPremier(PPO) DeltaCare* VSP Plan A VSP Plan B Emplyee/Dependent Cverage: Emplyee Only Emplyee + One Emplyee + Family *DeltaCare Enrllees Please Nte: If yu d nt specify a dentist f yur chice, a dentist will be autmatically selected fr yu. Yur dentist chice must be submitted n later than 7 days befre the end f the mnth. Fr a list f DeltaCare Dentists, please visit Dentist Name Dentist #:

7 WAIVER OF COVERAGE I d hereby attest that I have been ffered the pprtunity t participate in s Dental and/r Visin Insurance Plans (if eligible). (Name f Cmpany) I d nt wish t participate in the plan(s) I have checked belw. I understand that I will nt be eligible t jin the belw checked plans (if eligible) at a later date, unless I can prvide prf f a lss f prir cverage. Cverage(s) waived: Delta Dental Visin Service Plan Reasn fr waiving cverage: I (and my dependents) are cvered by my spuse s plan Other Print Name: Signature: Date:

8 CAPITOL ASSOCIATION PLANS PO Bx , Sacrament, CA Phne: (916) Fax: (866) Website: AUTOMATIC BANK DEBIT (ACH) AUTHORIZATION FORM FAX TO: I authrize Capitl Assciatin Plans t debit my bank accunt as fllws: Autmatically debit my bank accunt fr my insurance premiums One time nly bank accunt debit in the amunt f $ BILLING FREQUENCY (fr future autmatic payments) Mnthly Quarterly Bi-Annually Annually BANK ACCOUNT INFORMATION Bank: Name n Accunt: Bank Ruting N.: Checking Acct. N.: Custmer Address: Daytime Phne: Address: Signature: Date: POLICIES & FEES: If yu select autmatic billing, yur accunt will be debited autmatically by the 10 th f the mnth which crrespnds with yur frequency f payment. Yu will nt be mailed an invice; hwever ne can be mailed upn request. NOTE: A $2.00 transactin fee fr each ACH (autmatic debit) will apply. If yu wish t cancel this authrizatin, yu must ntify Capitl Assciatin Plans in writing at least 10 days in advance f the scheduled transactin.