Summary of Benefits WESTERN MISSOURI MEDICAL CENTER

Transcription

1 Summary of Beefits WESTERN MISSOURI MEDICAL CENTER All Full Time Maagemet ad Physicias other tha Executives Basic Term Life, Basic Accidetal Death & Dismembermet, Optioal Term Life, Optioal Depedet Term Life, Optioal Accidetal Death & Dismembermet ad Log Term Disability Issued by The Prudetial Isurace Compay of America Effective: 01/01/2018 Basic Term Life 100% Employer Paid Basic Term Life: You are automatically erolled for 1.0 times your covered aual earigs to $50,000. Please refer to your pla certificate(s) to review the required miimum ad maximum coverage amouts allowed. If you are termially ill, you ca get a partial paymet of your group life isurace beefit. You ca use this paymet as you see fit. The paymet to your beeficiary will be reduced by the amout you receive with the Accelerated Beefit Optio.* Refer to the pla booklet for details. Paymet of premium ca be waived if you are totally disabled for 6 moths, you are less tha 60 years old whe the disability begis, ad you cotiue to be totally disabled. This waiver termiates at age 65. This provisio may vary by state. Coverage will be reduced as you age - by 35% at age 65 ad 50% at age 70. Coverage will ed o your termiatio of employmet or as specified i the pla booklet. You may covert your isurace to a idividual life isurace policy issued by the Prudetial Isurace Compay of America. Basic Accidetal Death & Dismembermet 100% Employer Paid Basic AD&D pays you ad your beeficiary a beefit for the loss of life or other ijuries resultig from a covered accidet % for loss of life ad a lesser percetage for other ijuries. Ijuries covered may iclude loss of sight or speech, paralysis, ad dismembermet of hads or feet. Basic AD&D beefits are paid regardless of other coverages you may have. Basic AD&D: You are automatically erolled for a amout equal to your Basic Term Life coverage amout

2 Optioal Term Life 100% Employee Paid Purchase coverage i icremets of $10,000 up to a maximum of $500,000, ot to exceed 7.0 times your covered aual earigs. Please refer to your pla certificate(s) to review the required miimum ad maximum coverage amouts allowed. If erollig whe first eligible withi the specified period of your date of hire or the occurrece of a life evet, you ca elect up to $200,000, without providig proof of good health to Prudetial. All other electios or erollig after the erollmet period will require proof of good health satisfactory to Prudetial for all coverage amouts. If you have bee previously deied coverage i the past, proof of good health satisfactory to Prudetial is required for all coverage amouts. If termially ill, you ca get a partial paymet of your group term life isurace beefit. You ca use this paymet as you see fit. I the evet of your death, your beeficiary will receive a beefit payout which has bee reduced by the amout you receive. Paymet of premium ca be waived if you are totally disabled for 6 moths, you are less tha 60 years old whe the disability begis, ad you cotiue to be totally disabled. This waiver termiates at age 65. This provisio may vary by state. Refer to the pla booklet for details. Durig future aual erollmet periods, if you erolled whe first eligible, you have ot waived coverage i the past or you have ot bee previously deied coverage, you ca elect a coverage amout up to $40,000, up to a total coverage amout of the pla maximum, without providig proof of good health to Prudetial. All other electios or erollig after the erollmet period will require proof of good health satisfactory to Prudetial for all coverage amouts. Coverage will be reduced as you age - by 35% at age 65 ad 50% at age 70. Upo termiatio of employmet, you (if eligible to port) may choose to cotiue a coverage amout equal to or lower tha your curret beefit amout. Coverage amouts will be subject to maximum of five times your aual earigs or $1 millio, whichever is less. Spouse - Optioal Depedet Term Life 100% Employee Paid Purchase coverage for your spouse i icremets of $5,000 up to a maximum of $250,000. Please ote: The Depedet Term Life Isurace coverage amout o your spouse may ot exceed 50% of your Optioal Term Life coverage amout. If erollig your spouse whe first eligible, you ca elect up to $30,000, o your spouse without providig proof of good health to Prudetial. All other electios, or erollig after the erollmet period will require proof of good health satisfactory to Prudetial for all coverage amouts. If your spouse has bee previously deied coverage i the past, proof of good health satisfactory to Prudetial is required for all coverage amouts. Coverage will be reduced as you age - by 35% at age 65 ad 50% at age 70. Upo termiatio of employmet, your spouse (if eligible to port) may choose to cotiue a coverage amout equal to or lower tha your curret beefit amout. Coverage amouts for you ad your spouse will be subject to a maximum of five times your aual earigs or $1 millio, whichever is less.

3 100% Employee Paid Child - Optioal Depedet Term Life Purchase coverage for $10,000. Please ote: The Optioal Depedet Term Life Isurace coverage amout o your childre may ot exceed 50% of your Optioal Term Life coverage amout. There are o health requiremets for this coverage. Coverage begis from live birth, ad cotiues to age 25, if umarried. If umarried, depedet o you ad a full-time studet, coverage cotiues to age 26. Upo termiatio of employmet, you (if eligible to port) may choose to cotiue a depedet child coverage amout equal to or lower tha your curret beefit amout. Employee - Optioal Accidetal Death & Dismembermet 100% Employee Paid You are automatically erolled for a equal amout of Optioal AD&D Isurace coverage whe you eroll for Optioal Term Life Isurace. Coverage will be reduced as you age - by 35% at age 65 ad 50% at age 70. Spouse - Optioal Accidetal Death & Dismembermet 100% Employee Paid Your spouse is automatically erolled for a equal amout of Optioal AD&D Isurace coverage whe you eroll your spouse for Optioal Depedet Term Life Isurace coverage. Coverage will be reduced as you age - by 35% at age 65 ad 50% at age 70. Child - Optioal Accidetal Death & Dismembermet 100% Employee Paid Your child(re) will be automatically erolled for a equal amout of Optioal AD&D Isurace coverage whe you eroll your child(re) for Optioal Depedet Term Life Isurace coverage. Coverage begis from live birth ad cotiues to age 25, if umarried. If umarried, depedet o you ad a full-time studet, coverage cotiues to age 26. Log Term Disability 100% Employer Paid Your mothly Log Term Disability beefit will be 66 2/3% of your mothly pre-disability earigs, up to the maximum of $10,000, less deductible sources of icome. The miimum mothly beefit is the greater of $100 or 15% of your gross mothly beefit. Deductible sources of icome may iclude beefits from statutory plas, Social Security to you ad your depedets, workers compesatio, uemploymet icome ad other icome. If you meet the defiitio of disability, your beefits will begi 180 days followig a accidetal ijury or sickess. The beefit duratio is up to your ormal retiremet age uder the Social Security Act. However, if you become disabled at or after age 65 beefits are payable accordig to a age-based schedule. Refer to the Booklet-Certificate for details.

4 You are cosidered disabled whe, because of ijury or sickess, you are uder the regular care of a doctor, you are uable to perform the material ad substatial duties of your regular occupatio ad your disability results i a loss of icome of at least 20%. After receivig beefits for 24 moths, you are cosidered disabled whe, due to the same sickess or ijury, you are uable to perform the material ad substatial duties of ay gaiful occupatio for which you are reasoably fitted by educatio, traiig or experiece, ad disability results i a loss of icome of a specified percetage determied by your pla. Disabilities due to metal illess are limited to 24 moths of beefits durig your lifetime. Examples of metal illess iclude schizophreia, depressio, maic depressive or bipolar illess, axiety, somatizatio, substace related disorders (icludig drug ad alcohol abuse), ad/or adjustmet disorders. Disabilities which are primarily based o self-reported symptoms are limited to 24 moths of beefits durig your lifetime. Examples of self-reported symptoms iclude headache, pai, fatigue, stiffess, soreess, rigig i the ears, dizziess, umbess ad loss of eergy. Disabilities due to metal illess ad disabilities which are primarily based o self-reported symptoms have a combied limited pay period durig your lifetime. LTD beefits will ot be paid for a disability that begis durig the first 12 moths of coverage ad due to a pre-existig coditio. A pre-existig coditio is a ijury or sickess for which you received medical treatmet, cosultatio, diagostic measures, prescribed drugs or medicies, or for which you followed treatmet recommedatios durig the 3 moths prior to your effective date of coverage. Durig the first 24 moths of part-time work while disabled, you ca receive full beefits as log as your combied icome ad disability beefits do ot exceed your mothly pre-disability earigs. If you die while collectig disability beefits, a lump sum paymet may be paid to your eligible survivors. You are ot covered for a disability caused by war or ay act of war, declared or udeclared, a itetioally self-iflicted ijury, active participatio i a riot, ad commissio of a crime for which you have bee covicted. Beefits are ot payable for ay period of icarceratio as a result of a covictio. Beefits, exclusios ad provisios may vary by state. Refer to the pla booklet for details. For your coverage to become effective, you must be actively at work o the effective date of the pla. If you apply for a amout that requires satisfactory evidece of isurability to The Prudetial Isurace Compay of America, you must be actively at work o the date of approval for the amout requirig satisfactory evidece of isurability.. *Accelerated Death Beefit optio is a feature that is made available to group life isurace participats. It is ot a health, ursig home, or log-term care isurace beefit ad is ot desiged to elimiate the eed for those types of isurace coverage. The death beefit is reduced by the amout of the accelerated death beefit paid. There is o admiistrative fee to accelerate beefits. Receipt of accelerated death beefits may affect eligibility for public assistace ad may be taxable. The federal icome tax treatmet of paymets made uder this rider depeds upo whether the isured is the recipiet of the beefits ad is cosidered "termially ill" or "chroically ill." You may wish to seek professioal tax advice before exercisig this optio. This coverage is ot health isurace coverage (ofte referred to as Major Medical Coverage ). This type of pla is NOT cosidered miimum essetial coverage uder the Affordable Care Act ad therefore does NOT satisfy the idividual madate that you have health isurace coverage. If you do ot have other health isurace coverage, you may be subject to a federal tax pealty. This policy provides ACCIDENT isurace oly. It does NOT provide basic hospital, basic medical or major medical isurace as defied by the New York Departmet of Fiacial Services. IMPORTANT NOTICE - THIS POLICY DOES NOT PROVIDE COVERAGE FOR SICKNESS. This policy provides disability icome isurace oly. It does NOT provide basic hospital, basic medical or major medical isurace as defied by the New York Departmet of Fiacial Services. North Carolia residets: THIS IS NOT A MEDICARE SUPPLEMENT PLAN. If you are eligible for Medicare, review the Guide to Health Isurace for People with Medicare, which is available from the compay.

5 Group Isurace coverages are issued by The Prudetial Isurace Compay of America, a Prudetial Fiacial compay, Newark, NJ The Booklet-Certificate cotais all details, icludig ay policy exclusios, limitatios, ad restrictios, which may apply. Cotract Series: Prudetial Fiacial, Ic. ad its related etities. Prudetial, the Prudetial logo, the Rock symbol ad Brig Your Challeges are service marks of Prudetial Fiacial, Ic., ad its related etities, registered i may jurisdictios worldwide.

6 How much it will cost Rate Sheet WESTERN MISSOURI MEDICAL CENTER All Full Time Maagemet ad Physicias other tha Executives Issued by The Prudetial Isurace Compay of America Effective: 01/01/2018 Employee - Optioal Term Life Bi-Weekly Cost per Coverage Amout with Matchig OAD&D Coverage is available i icremets of $10,000 to a maximum of $500,000, ot to exceed 7.0 times your covered aual earigs. Refer to the Optioal Term Life sectio for evidece of isurability details. Iitial rates based o age as of effective date of your coverage. Rates will chage based o the followig age schedule. $10,000 $20,000 $30,000 $40,000 $50,000 $60,000 $70,000 $80,000 $90,000 $100,000 $110,000 $120,000 $130, $0.30 $0.60 $0.90 $1.20 $1.50 $1.80 $2.10 $2.40 $2.70 $3.00 $3.30 $3.60 $ $0.35 $0.69 $1.04 $1.38 $1.73 $2.08 $2.42 $2.77 $3.12 $3.46 $3.81 $4.15 $ $0.44 $0.88 $1.32 $1.75 $2.19 $2.63 $3.07 $3.51 $3.95 $4.38 $4.82 $5.26 $ $0.53 $1.06 $1.59 $2.12 $2.65 $3.18 $3.72 $4.25 $4.78 $5.31 $5.84 $6.37 $ $0.76 $1.52 $2.28 $3.05 $3.81 $4.57 $5.33 $6.09 $6.85 $7.62 $8.38 $9.14 $ $1.13 $2.26 $3.39 $4.52 $5.65 $6.78 $7.92 $9.05 $10.18 $11.31 $12.44 $13.57 $ $2.05 $4.11 $6.16 $8.22 $10.27 $12.32 $14.38 $16.43 $18.48 $20.54 $22.59 $24.65 $ $2.65 $5.31 $7.96 $10.62 $13.27 $15.92 $18.58 $21.23 $23.88 $26.54 $29.19 $31.85 $ $3.72 $7.43 $11.15 $14.86 $18.58 $22.29 $26.01 $29.72 $33.44 $37.15 $40.87 $44.58 $ $6.25 $12.51 $18.76 $25.02 $31.27 $37.52 $43.78 $50.03 $56.28 $62.54 $68.79 $75.05 $81.30 $140,000 $150,000 $160,000 $170,000 $180,000 $190,000 $200,000 $210,000 $220,000 $230,000 $240,000 $250,000 $260, $4.20 $4.50 $4.80 $5.10 $5.40 $5.70 $6.00 $6.30 $6.60 $6.90 $7.20 $7.50 $ $4.85 $5.19 $5.54 $5.88 $6.23 $6.58 $6.92 $7.27 $7.62 $7.96 $8.31 $8.65 $ $6.14 $6.58 $7.02 $7.45 $7.89 $8.33 $8.77 $9.21 $9.65 $10.08 $10.52 $10.96 $ $7.43 $7.96 $8.49 $9.02 $9.55 $10.08 $10.62 $11.15 $11.68 $12.21 $12.74 $13.27 $ $10.66 $11.42 $12.18 $12.95 $13.71 $14.47 $15.23 $15.99 $16.75 $17.52 $18.28 $19.04 $ $15.83 $16.96 $18.09 $19.22 $20.35 $21.48 $22.62 $23.75 $24.88 $26.01 $27.14 $28.27 $ $28.75 $30.81 $32.86 $34.92 $36.97 $39.02 $41.08 $43.13 $45.18 $47.24 $49.29 $51.35 $ $37.15 $39.81 $42.46 $45.12 $47.77 $50.42 $53.08 $55.73 $58.38 $61.04 $63.69 $66.35 $ $52.02 $55.73 $59.45 $63.16 $66.88 $70.59 $74.31 $78.02 $81.74 $85.45 $89.17 $92.88 $ $87.55 $93.81 $ $ $ $ $ $ $ $ $ $ $ Implemetatio of the isurace pla(s) will deped o havig a specific percetage of all eligible employees erollig i the pla(s). If this percetage of erollmet level is ot met, these coverage(s) may ot be effective

7 Employee - Optioal Term Life Bi-Weekly Cost per Coverage Amout with Matchig OAD&D Coverage is available i icremets of $10,000 to a maximum of $500,000, ot to exceed 7.0 times your covered aual earigs. Refer to the Optioal Term Life sectio for evidece of isurability details. Iitial rates based o age as of effective date of your coverage. Rates will chage based o the followig age schedule. $270,000 $280,000 $290,000 $300,000 $310,000 $320,000 $330,000 $340,000 $350,000 $360,000 $370,000 $380, $8.10 $8.40 $8.70 $9.00 $9.30 $9.60 $9.90 $10.20 $10.50 $10.80 $11.10 $ $9.35 $9.69 $10.04 $10.38 $10.73 $11.08 $11.42 $11.77 $12.12 $12.46 $12.81 $ $11.84 $12.28 $12.72 $13.15 $13.59 $14.03 $14.47 $14.91 $15.35 $15.78 $16.22 $ $14.33 $14.86 $15.39 $15.92 $16.45 $16.98 $17.52 $18.05 $18.58 $19.11 $19.64 $ $20.56 $21.32 $22.08 $22.85 $23.61 $24.37 $25.13 $25.89 $26.65 $27.42 $28.18 $ $30.53 $31.66 $32.79 $33.92 $35.05 $36.18 $37.32 $38.45 $39.58 $40.71 $41.84 $ $55.45 $57.51 $59.56 $61.62 $63.67 $65.72 $67.78 $69.83 $71.88 $73.94 $75.99 $ $71.65 $74.31 $76.96 $79.62 $82.27 $84.92 $87.58 $90.23 $92.88 $95.54 $98.19 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $390,000 $400,000 $410,000 $420,000 $430,000 $440,000 $450,000 $460,000 $470,000 $480,000 $490,000 $500, $11.70 $12.00 $12.30 $12.60 $12.90 $13.20 $13.50 $13.80 $14.10 $14.40 $14.70 $ $13.50 $13.85 $14.19 $14.54 $14.88 $15.23 $15.58 $15.92 $16.27 $16.62 $16.96 $ $17.10 $17.54 $17.98 $18.42 $18.85 $19.29 $19.73 $20.17 $20.61 $21.05 $21.48 $ $20.70 $21.23 $21.76 $22.29 $22.82 $23.35 $23.88 $24.42 $24.95 $25.48 $26.01 $ $29.70 $30.46 $31.22 $31.98 $32.75 $33.51 $34.27 $35.03 $35.79 $36.55 $37.32 $ $44.10 $45.23 $46.36 $47.49 $48.62 $49.75 $50.88 $52.02 $53.15 $54.28 $55.41 $ $80.10 $82.15 $84.21 $86.26 $88.32 $90.37 $92.42 $94.48 $96.53 $98.58 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ Rates may chage as the isured eters a higher age category. Also, rates may chage if pla experiece requires a chage for all isureds. Spouse - Optioal Depedet Term Life Bi-Weekly Cost per Coverage Amout with Matchig OAD&D Coverage is available i icremets of $5,000 to a maximum of $250,000, ot to exceed 50% of your Optioal Term Life coverage amout. Refer to the Optioal Depedet Term Life sectio for evidece of isurability details. Iitial rates based o age as of effective date of your coverage. Rates will chage based o the followig age schedule. $5,000 $10,000 $15,000 $20,000 $25,000 $30,000 $35,000 $40,000 $45,000 $50,000 $55,000 $60,000 $65, $0.15 $0.30 $0.45 $0.60 $0.75 $0.90 $1.05 $1.20 $1.35 $1.50 $1.65 $1.80 $ $0.17 $0.35 $0.52 $0.69 $0.87 $1.04 $1.21 $1.38 $1.56 $1.73 $1.90 $2.08 $ $0.22 $0.44 $0.66 $0.88 $1.10 $1.32 $1.53 $1.75 $1.97 $2.19 $2.41 $2.63 $ $0.27 $0.53 $0.80 $1.06 $1.33 $1.59 $1.86 $2.12 $2.39 $2.65 $2.92 $3.18 $ $0.38 $0.76 $1.14 $1.52 $1.90 $2.28 $2.67 $3.05 $3.43 $3.81 $4.19 $4.57 $ $0.57 $1.13 $1.70 $2.26 $2.83 $3.39 $3.96 $4.52 $5.09 $5.65 $6.22 $6.78 $ $1.03 $2.05 $3.08 $4.11 $5.13 $6.16 $7.19 $8.22 $9.24 $10.27 $11.30 $12.32 $ $1.33 $2.65 $3.98 $5.31 $6.63 $7.96 $9.29 $10.62 $11.94 $13.27 $14.60 $15.92 $ $1.86 $3.72 $5.57 $7.43 $9.29 $11.15 $13.00 $14.86 $16.72 $18.58 $20.43 $22.29 $ $3.13 $6.25 $9.38 $12.51 $15.63 $18.76 $21.89 $25.02 $28.14 $31.27 $34.40 $37.52 $40.65

8 Spouse - Optioal Depedet Term Life Bi-Weekly Cost per Coverage Amout with Matchig OAD&D Coverage is available i icremets of $5,000 to a maximum of $250,000, ot to exceed 50% of your Optioal Term Life coverage amout. Refer to the Optioal Depedet Term Life sectio for evidece of isurability details. Iitial rates based o age as of effective date of your coverage. Rates will chage based o the followig age schedule. $70,000 $75,000 $80,000 $85,000 $90,000 $95,000 $100,000 $105,000 $110,000 $115,000 $120,000 $125,000 $130, $2.10 $2.25 $2.40 $2.55 $2.70 $2.85 $3.00 $3.15 $3.30 $3.45 $3.60 $3.75 $ $2.42 $2.60 $2.77 $2.94 $3.12 $3.29 $3.46 $3.63 $3.81 $3.98 $4.15 $4.33 $ $3.07 $3.29 $3.51 $3.73 $3.95 $4.17 $4.38 $4.60 $4.82 $5.04 $5.26 $5.48 $ $3.72 $3.98 $4.25 $4.51 $4.78 $5.04 $5.31 $5.57 $5.84 $6.10 $6.37 $6.63 $ $5.33 $5.71 $6.09 $6.47 $6.85 $7.23 $7.62 $8.00 $8.38 $8.76 $9.14 $9.52 $ $7.92 $8.48 $9.05 $9.61 $10.18 $10.74 $11.31 $11.87 $12.44 $13.00 $13.57 $14.13 $ $14.38 $15.40 $16.43 $17.46 $18.48 $19.51 $20.54 $21.57 $22.59 $23.62 $24.65 $25.67 $ $18.58 $19.90 $21.23 $22.56 $23.88 $25.21 $26.54 $27.87 $29.19 $30.52 $31.85 $33.17 $ $26.01 $27.87 $29.72 $31.58 $33.44 $35.30 $37.15 $39.01 $40.87 $42.73 $44.58 $46.44 $ $43.78 $46.90 $50.03 $53.16 $56.28 $59.41 $62.54 $65.67 $68.79 $71.92 $75.05 $78.17 $81.30 $135,000 $140,000 $145,000 $150,000 $155,000 $160,000 $165,000 $170,000 $175,000 $180,000 $185,000 $190, $4.05 $4.20 $4.35 $4.50 $4.65 $4.80 $4.95 $5.10 $5.25 $5.40 $5.55 $ $4.67 $4.85 $5.02 $5.19 $5.37 $5.54 $5.71 $5.88 $6.06 $6.23 $6.40 $ $5.92 $6.14 $6.36 $6.58 $6.80 $7.02 $7.23 $7.45 $7.67 $7.89 $8.11 $ $7.17 $7.43 $7.70 $7.96 $8.23 $8.49 $8.76 $9.02 $9.29 $9.55 $9.82 $ $10.28 $10.66 $11.04 $11.42 $11.80 $12.18 $12.57 $12.95 $13.33 $13.71 $14.09 $ $15.27 $15.83 $16.40 $16.96 $17.53 $18.09 $18.66 $19.22 $19.79 $20.35 $20.92 $ $27.73 $28.75 $29.78 $30.81 $31.83 $32.86 $33.89 $34.92 $35.94 $36.97 $38.00 $ $35.83 $37.15 $38.48 $39.81 $41.13 $42.46 $43.79 $45.12 $46.44 $47.77 $49.10 $ $50.16 $52.02 $53.87 $55.73 $57.59 $59.45 $61.30 $63.16 $65.02 $66.88 $68.73 $ $84.43 $87.55 $90.68 $93.81 $96.93 $ $ $ $ $ $ $ $195,000 $200,000 $205,000 $210,000 $215,000 $220,000 $225,000 $230,000 $235,000 $240,000 $245,000 $250, $5.85 $6.00 $6.15 $6.30 $6.45 $6.60 $6.75 $6.90 $7.05 $7.20 $7.35 $ $6.75 $6.92 $7.10 $7.27 $7.44 $7.62 $7.79 $7.96 $8.13 $8.31 $8.48 $ $8.55 $8.77 $8.99 $9.21 $9.43 $9.65 $9.87 $10.08 $10.30 $10.52 $10.74 $ $10.35 $10.62 $10.88 $11.15 $11.41 $11.68 $11.94 $12.21 $12.47 $12.74 $13.00 $ $14.85 $15.23 $15.61 $15.99 $16.37 $16.75 $17.13 $17.52 $17.90 $18.28 $18.66 $ $22.05 $22.62 $23.18 $23.75 $24.31 $24.88 $25.44 $26.01 $26.57 $27.14 $27.70 $ $40.05 $41.08 $42.10 $43.13 $44.16 $45.18 $46.21 $47.24 $48.27 $49.29 $50.32 $ $51.75 $53.08 $54.40 $55.73 $57.06 $58.38 $59.71 $61.04 $62.37 $63.69 $65.02 $ $72.45 $74.31 $76.17 $78.02 $79.88 $81.74 $83.60 $85.45 $87.31 $89.17 $91.03 $ $ $ $ $ $ $ $ $ $ $ $ $ Rates may chage as the isured eters a higher age category. Also, rates may chage if pla experiece requires a chage for all isureds. Spouse rate is based o Spouse's age. Childre - Optioal Depedet Term Life Bi-Weekly Cost per Coverage Amout with Matchig OAD&D Oe premium rate covers all eligible childre Coverage is available for $10,000, ot to exceed 50% of your Optioal Term Life coverage amout. $10,000 $0.49

9 Rates may chage if pla experiece requires a chage for all isureds. Beefits, exclusios ad provisios may vary by state. Refer to the pla booklet for details. For your coverage to become effective, you must be actively at work o the effective date of the pla. If you apply for a amout that requires satisfactory evidece of isurability to The Prudetial Isurace Compay of America, you must be actively at work o the date of approval for the amout requirig satisfactory evidece of isurability.. *Accelerated Death Beefit optio is a feature that is made available to group life isurace participats. It is ot a health, ursig home, or log-term care isurace beefit ad is ot desiged to elimiate the eed for those types of isurace coverage. The death beefit is reduced by the amout of the accelerated death beefit paid. There is o admiistrative fee to accelerate beefits. Receipt of accelerated death beefits may affect eligibility for public assistace ad may be taxable. The federal icome tax treatmet of paymets made uder this rider depeds upo whether the isured is the recipiet of the beefits ad is cosidered "termially ill" or "chroically ill." You may wish to seek professioal tax advice before exercisig this optio. This coverage is ot health isurace coverage (ofte referred to as Major Medical Coverage ). This type of pla is NOT cosidered miimum essetial coverage uder the Affordable Care Act ad therefore does NOT satisfy the idividual madate that you have health isurace coverage. If you do ot have other health isurace coverage, you may be subject to a federal tax pealty. This policy provides ACCIDENT isurace oly. It does NOT provide basic hospital, basic medical or major medical isurace as defied by the New York Departmet of Fiacial Services. IMPORTANT NOTICE - THIS POLICY DOES NOT PROVIDE COVERAGE FOR SICKNESS. Group Isurace coverages are issued by The Prudetial Isurace Compay of America, a Prudetial Fiacial compay, Newark, NJ The Booklet-Certificate cotais all details, icludig ay policy exclusios, limitatios, ad restrictios, which may apply. Cotract Series: Prudetial Fiacial, Ic. ad its related etities. Prudetial, the Prudetial logo, the Rock symbol ad Brig Your Challeges are service marks of Prudetial Fiacial, Ic., ad its related etities, registered i may jurisdictios worldwide

10 1 Page 1 of 2 Beeficiary Desigatio - WESTERN MISSOURI MEDICAL CENTER Cotrol # Last Name First Name Middle Iitial Social Security No. Basic Term Life, Basic AD&D, Optioal Term Life, Optioal AD&D- Primary Beeficiary Desigatio 2 Basic Term Life, Basic AD&D, Optioal Term Life, Optioal AD&D- Cotiget Beeficiary Desigatio 1 2

11 Page 2 of 2 The above beeficiary desigatio oly applies to: Basic Term Life, Basic AD&D, Optioal Term Life, Optioal AD&D Employee Sigature Date (mm/dd/yyyy) If you have ay questios, please see Huma Resources for details. Group Isurace coverages are issued by The Prudetial Isurace Compay of America, a Prudetial Fiacial compay, Newark, NJ Life Claims: , Disability Support: This brochure is iteded to be a summary of your beefits ad does ot iclude all pla provisios, exclusios ad limitatios. Please refer to the Booklet-Certificate, which is made a part of the Group Cotract, for all pla details, icludig ay exclusios, limitatios ad restrictios which may apply. If there is a discrepacy betwee this documet ad the Booklet-Certificate/Group Cotract issued by The Prudetial Isurace Compay of America, the Group Cotract will gover. Cotract provisios may vary by state. Cotract Series: Califoria COA # 1179 NAIC # Prudetial Fiacial, Ic., ad its related etities. Prudetial, the Prudetial logo, the Rock symbol ad Brig Your Challeges are service marks of Prudetial Fiacial, Ic., ad its related etities, registered i may jurisdictios worldwide. GL Ed ECEd Exp