Enroll Now. Help Protect Your Loved Ones And Your Income. HOSPICE OF SURRY COUNTY, INC. All Active Full Time Employees

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1 Enroll Now Help Protect Your Loved Ones And Your Income HOSPICE OF SURRY COUNTY, INC. All Active Full Time Employees Employee Optional Term Life with Matching OADD Insurance Optional Dependent Term Life with Matching OADD Insurance The Prudential Insurance Company of America IFS-A Ed ECEd Exp

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3 Welcome Letter Dear Valued Employee: After careful review, we ve selected a group plan issued by The Prudential Insurance Company of America (Prudential)--a name you know and trust. An insurance leader for over 130 years, they have financial strength. With your family s future at stake, you owe it to them to consider the opportunity described in this kit. HOSPICE OF SURRY COUNTY, INC. is very pleased to provide you with Basic Term Life and Basic Accidental Death & Dismemberment (AD&D) Insurance as employee benefits. Because you may need additional coverage, we offer you an opportunity to purchase-- at competitive group rates--extra financial security, including: Employee Optional Term Life with Matching OADD --For you. Optional Dependent Term Life with Matching OADD --For your eligible spouse and children. How can I enroll? Complete the attached Enrollment Form and return it. Don t miss out on this valuable employee benefit! 3

4 How much insurance can I buy How much insurance can I buy? You can customize coverage to fit your family's needs. Your salary determines the maximum coverage amount available to you. See the chart below for details. Coverage Options EMPLOYEE n Purchase coverage in increments of $10,000 up to a maximum of $500,000, not to exceed 7.0 times your covered annual earnings of your Employee Optional Term Life with Matching OADD coverage amount. n New Hires: Get up to $150,000 - no medical questions asked - when enrolling when first eligible in Optional Group Term Life. n n Current Participants: Your current coverage amount will be continued. Evidence of insurability satisfactory to The Prudential Insurance Company of America is required for all increases in coverage amounts. Current Employees who were denied coverage in the past, Current Employees who waived coverage in the past or Late Entrants (did not enroll when first eligible): Evidence of insurability satisfactory to The Prudential Insurance Company of America is required for all coverage amounts. n During future annual enrollment periods, if you enrolled when first eligible, you have not waived coverage in the past or you have not been previously denied coverage, you may select to increase your current coverage amount by $40,000, up to a total coverage amount of the plan maximum, without providing evidence of insurability to Prudential. Outside of annual enrollment periods, evidence of insurability satisfactory to the Prudential Insurance Company of America is required for all increases in coverage amounts. n Coverage will be reduced as you age - by 35% at age 65 and 50% at age 70. SPOUSE n Purchase coverage for your spouse in increments of $5,000 up to a maximum of $250,000, not to exceed 50% of your Employee Optional Term Life with Matching OADD coverage amount. n New Hires: Get up to $25,000 for your spouse- no medical questions asked - when enrolling when first eligible in Optional Dependent Group Term Life. n Current Spouse Participants: Your spouse's current coverage amount will be continued. Evidence of insurability satisfactory to the Prudential Insurance Company of America is required for all increases in coverage amounts. n Current Employees whose spouse has been denied coverage in the past, Current Employees who waived spouse coverage in the past or Late Entrants (did not enroll when first eligible): Evidence of insurability satisfactory to The Prudential Insurance Company of America is required for all coverage amounts. n Coverage will be reduced as you age - by 35% at age 65 and 50% at age 70. CHILDREN n Purchase coverage for your children in increments of $2,000 up to a maximum of $10,000, not to exceed 50% of your Employee Optional Term Life with Matching OADD coverage amount. There are no health requirements for this coverage. n Coverage begins from 14 days, and continues to age 26, if unmarried. If unmarried, dependent on you and a full-time student, coverage continues to age 26. xxxxxx 4

5 How much it will cost How much does life insurance cost? Use the grids below to find the cost of insurance for yourself, your spouse, and each of your children. Employee Optional Term Life with Matching OADD - Employee Bi-Weekly Cost per Coverage Amount Age $10,000 $20,000 $30,000 $40,000 $50,000 $60,000 $70,000 $80,000 $90,000 $100,000 $110,000 $120,000 $130,000 < 30 $0.37 $0.75 $1.12 $1.50 $1.87 $2.24 $2.62 $2.99 $3.36 $3.74 $4.11 $4.49 $ $0.56 $1.12 $1.68 $2.23 $2.79 $3.35 $3.91 $4.47 $5.03 $5.58 $6.14 $6.70 $ $0.65 $1.30 $1.95 $2.60 $3.25 $3.90 $4.56 $5.21 $5.86 $6.51 $7.16 $7.81 $ $0.74 $1.49 $2.23 $2.97 $3.72 $4.46 $5.20 $5.94 $6.69 $7.43 $8.17 $8.92 $ $0.97 $1.95 $2.92 $3.90 $4.87 $5.84 $6.82 $7.79 $8.76 $9.74 $10.71 $11.69 $ $1.48 $2.96 $4.44 $5.93 $7.41 $8.89 $10.37 $11.85 $13.33 $14.82 $16.30 $17.78 $ $2.59 $5.18 $7.77 $10.36 $12.95 $15.54 $18.12 $20.71 $23.30 $25.89 $28.48 $31.07 $ $3.84 $7.67 $11.51 $15.34 $19.18 $23.01 $26.85 $30.68 $34.52 $38.35 $42.19 $46.02 $ $7.34 $14.69 $22.03 $29.37 $36.72 $44.06 $51.40 $58.74 $66.09 $73.43 $80.77 $88.12 $ $11.13 $22.26 $33.38 $44.51 $55.64 $66.77 $77.89 $89.02 $ $ $ $ $ Age $140,000 $150,000 $160,000 $170,000 $180,000 $190,000 $200,000 $210,000 $220,000 $230,000 $240,000 $250,000 $260,000 < 30 $5.23 $5.61 $5.98 $6.36 $6.73 $7.10 $7.48 $7.85 $8.22 $8.60 $8.97 $9.35 $ $7.82 $8.38 $8.94 $9.49 $10.05 $10.61 $11.17 $11.73 $12.29 $12.84 $13.40 $13.96 $ $9.11 $9.76 $10.41 $11.06 $11.71 $12.36 $13.02 $13.67 $14.32 $14.97 $15.62 $16.27 $ $10.40 $11.15 $11.89 $12.63 $13.38 $14.12 $14.86 $15.60 $16.35 $17.09 $17.83 $18.58 $ $13.63 $14.61 $15.58 $16.56 $17.53 $18.50 $19.48 $20.45 $21.42 $22.40 $23.37 $24.35 $ $20.74 $22.22 $23.70 $25.19 $26.67 $28.15 $29.63 $31.11 $32.59 $34.08 $35.56 $37.04 $ $36.25 $38.84 $41.43 $44.02 $46.61 $49.20 $51.78 $54.37 $56.96 $59.55 $62.14 $64.73 $ $53.70 $57.53 $61.37 $65.20 $69.04 $72.87 $76.71 $80.54 $84.38 $88.21 $92.05 $95.88 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ Age $270,000 $280,000 $290,000 $300,000 $310,000 $320,000 $330,000 $340,000 $350,000 $360,000 $370,000 $380,000 < 30 $10.09 $10.47 $10.84 $11.22 $11.59 $11.96 $12.34 $12.71 $13.08 $13.46 $13.83 $ $15.08 $15.64 $16.20 $16.75 $17.31 $17.87 $18.43 $18.99 $19.55 $20.10 $20.66 $ $17.57 $18.22 $18.87 $19.52 $20.17 $20.82 $21.48 $22.13 $22.78 $23.43 $24.08 $ $20.06 $20.81 $21.55 $22.29 $23.04 $23.78 $24.52 $25.26 $26.01 $26.75 $27.49 $ $26.29 $27.27 $28.24 $29.22 $30.19 $31.16 $32.14 $33.11 $34.08 $35.06 $36.03 $ $40.00 $41.48 $42.96 $44.45 $45.93 $47.41 $48.89 $50.37 $51.85 $53.34 $54.82 $ $69.91 $72.50 $75.09 $77.68 $80.27 $82.86 $85.44 $88.03 $90.62 $93.21 $95.80 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ Age $390,000 $400,000 $410,000 $420,000 $430,000 $440,000 $450,000 $460,000 $470,000 $480,000 $490,000 $500,000 < 30 $14.58 $14.95 $15.33 $15.70 $16.08 $16.45 $16.82 $17.20 $17.57 $17.94 $18.32 $ $21.78 $22.34 $22.90 $23.46 $24.01 $24.57 $25.13 $25.69 $26.25 $26.81 $27.36 $ $25.38 $26.03 $26.68 $27.33 $27.98 $28.63 $29.28 $29.94 $30.59 $31.24 $31.89 $ $28.98 $29.72 $30.47 $31.21 $31.95 $32.70 $33.44 $34.18 $34.92 $35.67 $36.41 $ $37.98 $38.95 $39.93 $40.90 $41.88 $42.85 $43.82 $44.80 $45.77 $46.74 $47.72 $ $57.78 $59.26 $60.74 $62.22 $63.71 $65.19 $66.67 $68.15 $69.63 $71.11 $72.60 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ Rates may change as the insured enters a higher age category. Also, rates may change if plan experience requires a change for all insureds. Optional Dependent Term Life with Matching OADD - Spouse Bi-Weekly Cost per Coverage Amount Spouse rate is based on employee's age Age $5,000 $10,000 $15,000 $20,000 $25,000 $30,000 $35,000 $40,000 $45,000 $50,000 $55,000 $60,000 $65,000 < 30 $0.21 $0.42 $0.62 $0.83 $1.04 $1.25 $1.45 $1.66 $1.87 $2.08 $2.28 $2.49 $2.70 5

6 "How much it will cost?" (continued from previous page) $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 $ $0.39 $0.78 $1.18 $1.57 $1.96 $2.35 $2.75 $3.14 $3.53 $3.92 $4.32 $4.71 $ $0.51 $1.02 $1.52 $2.03 $2.54 $3.05 $3.55 $4.06 $4.57 $5.08 $5.58 $6.09 $ $0.76 $1.52 $2.28 $3.05 $3.81 $4.57 $5.33 $6.09 $6.85 $7.62 $8.38 $9.14 $ $1.32 $2.63 $3.95 $5.26 $6.58 $7.89 $9.21 $10.52 $11.84 $13.15 $14.47 $15.78 $ $1.94 $3.88 $5.82 $7.75 $9.69 $11.63 $13.57 $15.51 $17.45 $19.38 $21.32 $23.26 $ $3.69 $7.38 $11.08 $14.77 $18.46 $22.15 $25.85 $29.54 $33.23 $36.92 $40.62 $44.31 $ $5.58 $11.17 $16.75 $22.34 $27.92 $33.51 $39.09 $44.68 $50.26 $55.85 $61.43 $67.02 $72.60 Optional Dependent Term Life with Matching OADD - Spouse Bi-Weekly Cost per Coverage Amount Spouse rate is based on employee's age Age $70,000 $75,000 $80,000 $85,000 $90,000 $95,000 $100,000 $105,000 $110,000 $115,000 $120,000 $125,000 $130,000 < 30 $2.91 $3.12 $3.32 $3.53 $3.74 $3.95 $4.15 $4.36 $4.57 $4.78 $4.98 $5.19 $ $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 $ $5.49 $5.88 $6.28 $6.67 $7.06 $7.45 $7.85 $8.24 $8.63 $9.02 $9.42 $9.81 $ $7.11 $7.62 $8.12 $8.63 $9.14 $9.65 $10.15 $10.66 $11.17 $11.68 $12.18 $12.69 $ $10.66 $11.42 $12.18 $12.95 $13.71 $14.47 $15.23 $15.99 $16.75 $17.52 $18.28 $19.04 $ $18.42 $19.73 $21.05 $22.36 $23.68 $24.99 $26.31 $27.62 $28.94 $30.25 $31.57 $32.88 $ $27.14 $29.08 $31.02 $32.95 $34.89 $36.83 $38.77 $40.71 $42.65 $44.58 $46.52 $48.46 $ $51.69 $55.38 $59.08 $62.77 $66.46 $70.15 $73.85 $77.54 $81.23 $84.92 $88.62 $92.31 $ $78.18 $83.77 $89.35 $94.94 $ $ $ $ $ $ $ $ $ Age $135,000 $140,000 $145,000 $150,000 $155,000 $160,000 $165,000 $170,000 $175,000 $180,000 $185,000 $190,000 < 30 $5.61 $5.82 $6.02 $6.23 $6.44 $6.65 $6.85 $7.06 $7.27 $7.48 $7.68 $ $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 $ $10.59 $10.98 $11.38 $11.77 $12.16 $12.55 $12.95 $13.34 $13.73 $14.12 $14.52 $ $13.71 $14.22 $14.72 $15.23 $15.74 $16.25 $16.75 $17.26 $17.77 $18.28 $18.78 $ $20.56 $21.32 $22.08 $22.85 $23.61 $24.37 $25.13 $25.89 $26.65 $27.42 $28.18 $ $35.52 $36.83 $38.15 $39.46 $40.78 $42.09 $43.41 $44.72 $46.04 $47.35 $48.67 $ $52.34 $54.28 $56.22 $58.15 $60.09 $62.03 $63.97 $65.91 $67.85 $69.78 $71.72 $ $99.69 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ Age $195,000 $200,000 $205,000 $210,000 $215,000 $220,000 $225,000 $230,000 $235,000 $240,000 $245,000 $250,000 < 30 $8.10 $8.31 $8.52 $8.72 $8.93 $9.14 $9.35 $9.55 $9.76 $9.97 $10.18 $ $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 $ $15.30 $15.69 $16.08 $16.48 $16.87 $17.26 $17.65 $18.05 $18.44 $18.83 $19.22 $ $19.80 $20.31 $20.82 $21.32 $21.83 $22.34 $22.85 $23.35 $23.86 $24.37 $24.88 $ $29.70 $30.46 $31.22 $31.98 $32.75 $33.51 $34.27 $35.03 $35.79 $36.55 $37.32 $ $51.30 $52.62 $53.93 $55.25 $56.56 $57.88 $59.19 $60.51 $61.82 $63.14 $64.45 $ $75.60 $77.54 $79.48 $81.42 $83.35 $85.29 $87.23 $89.17 $91.11 $93.05 $94.98 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ Rates may change as the insured enters a higher age category. Also, rates may change if plan experience requires a change for all insureds. 6

7 "How much it will cost?" (continued from previous page) Child Optional Dependent Term Life with Matching OADD - Children Bi-Weekly Cost per Coverage Amount One premium rate covers all eligible children $2,000 $4,000 $6,000 $8,000 $10,000 $0.11 $0.22 $0.34 $0.45 $0.56 Rates may change if plan experience requires a change for all insureds. 7

8 IMPORTANT NOTICE A record of your beneficiary is required for Basic Term Life Insurance, Basic AD&D Insurance, and Optional Term Life Insurance 8

9 Who can answer my questions? Here are the answers to some common questions regarding these insurance coverages. For additional information, contact your Human Resources Department or Benefits Administrator. How to enroll How can I enroll?" To enroll, simply complete the Enrollment Form with Beneficiary Designations. Then, return it as instructed. After the date your group insurance becomes effective, you will receive a Booklet-Certificate that details your plan provisions. Implementation of the insurance plan(s) will depend upon having a specific percentage of all eligible employees enrolling in the plan(s). In the event the minimum participation level is not met, Prudential retains the right to re-evaluate the rates, require a re-enrollment, reduce the rate guarantee period, or terminate coverage. All benefit features may not be available in all states. Group Term Life, Accidental Death and Dismemberment and Disability coverages are issued by The Prudential Insurance Company of America, a Prudential Financial Company, 751 Broad Street, Newark, NJ Life Claims: and Disability Support: This brochure is intended to be a summary of your benefits and does not include all plan provisions, exclusions and limitations. Please refer to the Booklet-Certificate, which is made a part of the Group Contract, for all plan details, including any exclusions, limitations and restrictions which may apply. If there is a discrepancy between this document and the Booklet-Certificate/Group Contract issued by The Prudential Insurance Company of America, the terms of the Group Contract will govern. Contract provisions may vary by state. Contract Series: California COA #1179 NAIC # Prudential Financial, Inc., and its related entities. Prudential, the Prudential logo, and the Rock symbol are service marks of Prudential Financial, Inc. and its related entities, registered in many jurisdictions worldwide. 9

10 IMPORTANT NOTICE A record of your beneficiary is required for Basic Term Life Insurance, Basic AD&D Insurance, and Optional Term Life Insurance 10

11 Enrollment Form HOSPICE OF SURRY COUNTY, INC. Page 1 of 4 The Prudential Insurance Company of America 751 Broad Street, Newark, New Jersey General Information (Employee) Effective Date of Coverage (for office use only) / / Last Name First Name Middle Initial Phone Address City State Zip Code Social Security No. Marital Status Date of Birth - - Date Employed Month Day Year / / q Single q Divorced q Married q Widowed Your Annual Earnings $ Employee Optional Term Life with Matching OADD q Coverage amount chosen: $ Payroll deduction: $ Month Day Year / / (For Prudential Use Only) Control # q No coverage chosen. Optional Dependent Term Life with Matching OADD You must be enrolled for Optional Term Life to elect coverage for your dependents.spouse coverage cannot exceed 50% of your Optional Term Life coverage amount. Child(ren) coverage cannot exceed 50% of your Optional Term Life coverage amount. Spouse Children q Coverage amount chosen: $ Payroll deduction: $ q No coverage chosen. q Coverage amount chosen: $ Payroll deduction: $ NOTICE TO CONSUMER: THIS IS A SUPPLEMENT TO HEALTH INSURANCE AND IS NOT A SUBSTITUTE FOR MAJOR MEDICAL COVERAGE. LACK OF MAJOR MEDICAL COVERAGE (OR OTHER MINIMAL ESSENTIAL COVERAGE) MAY RESULT IN AN ADDITIONAL PAYMENT WITH YOUR TAXES. ALSO, THE BENEFITS PROVIDED BY THIS POLICY CANNOT BE COORDINATED WITH THE BENEFITS PROVIDED BY OTHER COVERAGE. PLEASE REVIEW THE BENEFITS PROVIDED BY THIS POLICY CAREFULLY TO AVOID A DUPLICATION OF COVERAGE. Group Term Life and Disability coverages are issued by The Prudential Insurance Company of America, a Prudential Financial company, 751 Broad Street, Newark, NJ Life Claims: , Disability Support: This brochure is intended to be a summary of your benefits and does not include all plan provisions, exclusions and limitations. Please refer to the Booklet-Certificate, which is made a part of the Group Contract, for all plan details, including any exclusions, limitations and restrictions which may apply. If there is a discrepancy between this document and the Booklet-Certificate/Group Contract issued by The Prudential Insurance Company of America, the Group Contract will govern. Contract provisions may vary by state. Contract Series: California COA # 1179 NAIC # Prudential Financial, Inc., and its related entities. Prudential, the Prudential logo, and the Rock symbol are service marks of Prudential Financial, Inc. and its related entities, registered in many jurisdictions worldwide. GL

12 Enrollment Form HOSPICE OF SURRY COUNTY, INC. Page 2 of 4 Employee General Information Last Name First Name Middle Initial Social Security No. - - Acceptance or Waiver of Coverage q I am enrolling for coverage and I authorize HOSPICE OF SURRY COUNTY, INC. to deduct from my earnings until further notice my contributions for insurance under a contract issued by The Prudential Insurance Company of America. I understand that if I desire to increase the amount of my insurance or add dependent coverage hereafter, I may be required to furnish evidence of insurability for myself and/or my dependents. To the best of my knowledge and belief, I declare the statement above is true and understand it is the basis for determining the monthly contribution for coverage. I also understand that for coverage to become effective, I must be actively at work during the enrollment period and on the effective date of the plan. If I apply for an amount that requires evidence of insurability satisfactory to The Prudential Insurance Company of America, I must be actively at work on the date of approval for the amount requiring satisfactory evidence of insurability. q I do not wish to enroll for any of the above optional coverages. I certify that I have been given the opportunity by my above named employer to enroll for coverage. I understand that if I desire to enroll hereafter, I may be required to furnish satisfactory evidence of insurability to The Prudential Insurance Company of America for myself and/or my dependents. FOR RESIDENTS OF ALL STATES EXCEPT ALABAMA, DISTRICT OF COLUMBIA, FLORIDA, KENTUCKY, MARYLAND, NEW JERSEY, NEW YORK, PENNSYLVANIA, PUERTO RICO, RHODE ISLAND, UTAH, VERMONT, VIRGINIA AND WASHINGTON; WARNING: Any person who knowingly and with intent to injure, defraud, or deceive any insurance company or other person, or knowing that he is facilitating commission of a fraud, submits incomplete, false, fraudulent, deceptive or misleading facts or information when filing an insurance application or a statement of claim for payment of a loss or benefit commits a fraudulent insurance act, is/may be guilty of a crime and may be prosecuted and punished under state law. Penalties may include fines, civil damages and criminal penalties, including confinement in prison. In addition, an insurer may deny insurance benefits if false information materially related to a claim was provided by the applicant or if the applicant conceals, for the purpose of misleading, information concerning any fact material thereto. ALABAMA RESIDENTS - Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or who knowingly presents false information in an application for insurance is guilty of a crime and may be subject to restitution fines or confinement in prison, or any combination thereof. DISTRICT OF COLUMBIA and RHODE ISLAND RESIDENTS --Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. KENTUCKY RESIDENTS--Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance 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. MARYLAND RESIDENTS - Any person who knowingly or willfully presents a false or fraudulent claim for payment of a loss or benefit or who knowingly or willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. NEW JERSEY RESIDENTS--Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and civil penalties. PENNSYLVANIA AND UTAH RESIDENTS--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 material fact thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties. PUERTO RICO RESIDENTS: Any person who knowingly and with the intention of defrauding presents false information in an insurance application, or presents, helps, or causes the presentation of a fraudulent claim for the payment of a loss or any other benefit, or presents more than one claim for the same damage or loss, shall incur a felony and, upon conviction, shall be sanctioned for each violation by a fine of not less than five thousand dollars ($5,000) and not more than ten thousand dollars ($10,000), or a fixed term of imprisonment for three (3) years, or both penalties. Should aggravating circumstances [be] present, the penalty thus established may be increased to a maximum of five (5) years, if extenuating circumstances are present, it may be reduced to a minimum of two (2) years. VERMONT RESIDENTS--Any person who knowingly presents a false or fraudulent claim for payment of a loss or knowingly makes a false statement in an application for insurance may be guilty of a criminal offense under state law. VIRGINIA RESIDENTS--Any person who knowingly and with intent to injure, defraud, or deceive any insurance company or other person, or knowing that he is facilitating commission of a fraud, submits incomplete, false, fraudulent, deceptive or misleading facts or information when filing a statement of claim for payment of a loss or benefit may have violated state law, is guilty of a crime and may be prosecuted and punished under state law. Penalties may include fines, civil damages and criminal penalties, including confinement in prison. In addition, an insurer may deny insurance GL

13 Enrollment Form HOSPICE OF SURRY COUNTY, INC. Page 3 of 4 Employee General Information Last Name First Name Middle Initial Social Security No. - - benefits if false information materially related to a claim was provided by the applicant or if the applicant conceals, for the purpose of misleading, information concerning any fact material thereto. WASHINGTON RESIDENTS--Any person who knowingly provides false, incomplete, or misleading information to an insurance company for the purpose of defrauding the company commits a crime. Penalties include imprisonment, fines, and denial of insurance benefits. ACCELERATED BENEFIT OPTION - A Receipt of accelerated death benefits may affect eligibility for public assistance programs and may be taxable. Please contact your personal tax advisor for further information. There is no administrative fee to accelerate death benefits. The accelerated amount is not discounted. FLORIDA RESIDENTS--Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing false, incomplete, or misleading information is guilty of a felony of the third degree. NEW YORK RESIDENTS--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. This warning ONLY applies to accident and disability coverage. Employee Signature Date (Month/Day/Year) / / Spouse Signature Date (Month/Day/Year) / / Michigan and Minnesota Residents only Dependent Consent for Coverage: If you wish to enroll your spouse and/or dependent child(ren) 18 years of age or older for dependent life or accidental death and dismemberment insurance coverage, your spouse and each child must acknowledge consent for coverage. Child Signature Date (Month/Day/Year) / / Child Signature Date (Month/Day/Year) / / You must also complete a separate beneficiary designation form. GL

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15 1 Page 1 of 2 Beneficiary Designation - HOSPICE OF SURRY COUNTY, INC.Control # Last Name First Name Middle Initial Social Security No. Employee Optional Term Life with Matching OADD- Primary Beneficiary Designation 2 Employee Optional Term Life with Matching OADD- Contingent Beneficiary Designation 1 2

16 Page 2 of 2 The above beneficiary designation only applies to: Employee Optional Term Life with Matching OADD Employee Signature Date (mm/dd/yyyy) If you have any questions, please see Human Resources for details. Group Term Life and Disability coverages are issued by The Prudential Insurance Company of America, a Prudential Financial company, 751 Broad Street, Newark, NJ Life Claims: , Disability Support: This brochure is intended to be a summary of your benefits and does not include all plan provisions, exclusions and limitations. Please refer to the Booklet-Certificate, which is made a part of the Group Contract, for all plan details, including any exclusions, limitations and restrictions which may apply. If there is a discrepancy between this document and the Booklet-Certificate/Group Contract issued by The Prudential Insurance Company of America, the Group Contract will govern. Contract provisions may vary by state. Contract Series: California COA # 1179 NAIC # Prudential Financial, Inc., and its related entities. Prudential, the Prudential logo, and the Rock symbol are service marks of Prudential Financial, Inc. and its related entities, registered in many jurisdictions worldwide. GL Ed ECEd Exp

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