PORTSMOUTH PUBLIC SCHOOLS BENEFIT GUIDE

Transcription

1 PORTSMOUTH PUBLIC SCHOOLS BENEFIT GUIDE Plan Year: January 1, 2017 December 31, 2017 Information Provided By: First Financial Group of America 3904 Oleander Drive, Suite 200 Wilmington NC

2 TABLE OF CONTENTS PAGE BENEFIT OVERVIEW 1 SECTION 125 INFORMATION FLEXIBLE SPENDING ACCOUNT DETAILS 2 3 DISABILITY INSURANCE LIFE INSURANCE 5 8 CANCER INSURANCE 35 HEART / STROKE INSURANCE 43 CRITICAL ILLNESS INSURANCE 50 ACCIDENT INSURANCE 55 VISION INSURANCE RETIREMENT PLANNING RATES 68

3 Overview Portsmouth Public Schools and First Financial Group of America would like to take this opportunity to present to you the information for the upcoming plan year. This information has been created to bring forth a brief overview of your choices as well as offer you a reference guide when questions may arise regarding your insurance plans. Please take the time to look over the information contained in this booklet to familiarize yourself with the benefits that are provided to you as an employee. Benefits Enrollment will be October 31 November 18. All employees must review plan options and make any necessary changes to your supplementary elections under the Cafeteria Plan. This is the only time you can make changes to your supplemental insurance, unless there is a qualified family status change during the year. Your plan year is January 1 through December 31. Payroll deductions for your benefits will begin in January. This guide contains a summary of the benefits offered by your employer. If there is a conflict between the terms of this outline of benefits and the actual contracts, the terms of the contracts will prevail. For a more detailed explanation of benefits you may contact First Financial Administrators at or visit the website listed below. For detailed information your benefits website is: 1

4 Section 125 Cafeteria Plan First Financial Administrators, Inc. As a district employee, you are eligible to participate in a Section 125 Flexible Plan. Enrollment opportunities are limited to the plan year dates for your district. A Section 125 Flexible Plan allows you, the employee, to select from a list of available benefits that will meet your family s healthcare needs. Certain premiums are deducted from your gross earnings before federal withholding taxes are figured. The amount you elect to have deducted pre-tax actually lowers your taxable income. By implementing this plan, your employer is helping you reduce your taxes and increase your take home pay. You cannot change your elections during the plan year except for certain specified changes in family status. Those changes include: Marriage Divorce Death of a spouse/child Birth or adoption of a child Termination of spouse s employment You must notify your employer within 31 days of the qualifying event to make changes. Section 125 Plan Sample Paycheck The example below shows how a married employee claiming 1 exemption can reduce their taxable income Retirement Retirement 2

5 Flexible Spending Accounts (FSAs) Flexible Spending Accounts (FSAs) are tax-favored accounts that allow participants to set aside money pretax for eligible Medical and Dependent Care costs. FSAs allow an employee the opportunity to put some of his/her salary aside before taxes to pay for many common out-of-pocket expenses. Use-it-or-lose-it-Rule: Money remaining in your FSA account(s) will not be returned to you at the end of the plan year. Any amount remaining after the end of 2.5 month grace period will be forfeited. Because of the use-it-or-lose-it rule, it is important for you to carefully estimate your out-of-pocket health and dependent care expenses for the upcoming plan year. Your employer has chosen the 2.5 month grace period for your plan. This option gives you the opportunity to continue to incur eligible expenses if you have unused funds in your account on the plan year end date for an additional 2.5 months. If the money is not used during the 2.5 months it will be forfeited. Medical FSA Your Medical FSA may be used to reimburse you for expenses that you incur for treatment of yourself, spouse and dependent children during your plan year. Eligible medical expenses include deductibles and coinsurance amounts under a group health plan, charges that are in excess of the amount reimbursed under a group health plan, and charges that are not covered under a group health plan such as certain corrective surgeries, vision care, dental care and hearing aids. Effective January 1, 2011, all over -the counter medications eligible for reimbursement must be accompanied by a doctor s prescription. Maximum contribution amount for 2017/2018 plan year is $2,550 ($ per month). Reminder If you or your spouse participate in a Qualified High Deductible Health Plan and contribute to a Health Savings Account, you are not eligible to enroll in Medical Reimbursement. Dependent Care Reimbursement A Dependent Care FSA allows you to pay for daycare expenses for your qualified dependent/child with pretax dollars while you (and your spouse) are working, seeking employment, or attending school as a full- time student for at least 4 months during the year. Eligible dependents must be claimed as an exemption on your tax return. These dependents can include step-children, grandchildren, adopted children or foster children. Under IRS regulations, eligible dependents are further defined as: under age 13 and/or physically or mentally unable to care for themselves, such as a disabled spouse, disabled child, or elderly parents that live with you. The IRS allows employees to contribute up to $5,000 annually to a Dependent Care FSA. 3

6 Flex Benefits Card The Flex Benefits Card is available to all employees that participate in Medical Reimbursement FSA. The Benefits Flex Card gives you immediate access to your money at the point of purchase. Cards are available for participating employees, their spouse and eligible dependents that are at least 18 years old. The IRS requires validation of most transactions. You must submit receipts for validation of expenses when requested. If you fail to substantiate by providing a receipt to First Financial within 60 days of the purchase or date of service your card will be suspended until the necessary receipt or explanation of benefits from your insurance provider is received. FF Flex Mobile App The FF Flex Mobile App is available for Apple or AndroidTM devices on the App StoreSM or the Google Play StoreTM. With the FF Flex Mobile App you can: Submit Claims View Account Balance & History See Claim Status View Alerts Upload Receipts and Documentation Download & register your app today! FSA Store First Financial has partnered with the FSA Store to bring you an easy to use online store to better understand and manage your Flexible Spending Account (FSA). Shop at FSA Store for eligible items from bandages to vitamins and thousands of products in between, browse or search for eligible products and services using the FSA Eligibility List, and visit the FSA Learning Center to help find answers to questions you may have about your FSA. 4

7 Disability Income Plus Virginia Disability Income Plus provides a monthly disability income benefit as a result of a non-occupational off-the-job accident or sickness. If you re totally disabled by an accident or illness, Disability Income Plus can be there to help, helping pay the bills that won t go away just because you can t work: housing costs, food, car payments, and additional medical costs. You can focus on a full recovery and successful return to the workplace. Coverage type Disability Income Plus is a group disability income insurance policy that provides a monthly disability income benefit due to a non-occupational off-the-job accident or injury. Benefit amount Minimum benefit of $200 and maximum benefit of $3,000 per month ($5,000 for Superintendents and County Administrators), not to exceed 65% of base monthly income. Plan design Accident & Sickness: Provides coverage for disabilities caused by either an accidental injury or sickness. Pregnancy is covered the same as any other illness. Twelve months Benefit period Elimination period Definition of disability Provides non-occupational coverage for injuries after 0, 7, 14 or 30 days and off-the job sicknesses after 7, 14 or 30 days of total disability (depending on your selection). Total disability: the complete inability to perform the material and substantial duties of the employee s regular occupation as certified by the employee s attending physician. Regular occupation is that which the employee was performing immediately before total disability began. The total disability must be the result of and accident, if accident only coverage is show in the policy specification, or accident or sickness, if accident and sickness coverage is shown in the policy specifications. The employee must be under the regular care of a physician and not, in fact, engaged in any employment or occupation for wages or profit. Recurrent disability: total disability that is due to the same or related causes as a prior period of disability, follows a prior period for which a monthly benefit was paid, and occurs within 180 days after the end of a prior period for which a monthly benefit was paid. Presented by Bill Mode Frequency Action Monthly Semi-Monthly Divide modal premium by 2 Monthly Bi-Weekly Multiply modal premium by 12, then divide by 26 Monthly Weekly Multiply modal premium by 12, then divide by 52 Thirteenthly (Billed every 28 days) Bi-Weekly Divide modal premium by 2 Thirteenthly (Billed every 28 days) Weekly Divide modal premium by 4 Tenthly Monthly for 10 Months Multiply modal premium by 12, then divide by Pay Semi-monthly for 10 Months Multiply modal premium by 12, then divide by 20 Ninthly Monthly for 9 Months Multiply modal premium by 12, then divide by 9 This is not a complete disclosure of plan qualifications and limitations. Please access our website to obtain a completed list for the Workplace Voluntary Benefit products at Disclosure.Humana.com. Please review this information before applying for coverage. The amount of benefits provided depends on the plan selected. Premiums will vary according to the selection made. THIS POLICY PROVIDES LIMITED BENEFITS. Policy: 8000 Insured by Kanawha Insurance Company, a Humana company HumanaVoluntaryBenefits.com VAHJEK8EN 5

8 Disability Income Plus rates Disability Income plus rates Monthly deductions for a 12 month benefit period with 0/7 accident/sickness elimination period. Age Benefit Amount BENEFIT: $200 $300 $400 $500 $600 $700 $800 $900 $1,000 $1, $7.72 $11.58 $15.44 $19.31 $23.17 $27.03 $30.89 $34.75 $38.61 $ $11.24 $16.86 $22.48 $28.10 $33.73 $39.35 $44.97 $50.59 $56.21 $ $17.40 $26.10 $34.80 $43.51 $52.21 $60.91 $69.61 $78.31 $87.01 $95.71 BENEFIT: $1,200 $1,300 $1,400 $1,500 $1,600 $1,700 $1,800 $1,900 $2,000 $2, $46.33 $50.19 $54.05 $57.92 $61.78 $65.64 $69.50 $73.36 $77.22 $ $67.45 $73.07 $78.69 $84.31 $89.94 $95.56 $ $ $ $ $ $ $ $ $ $ $ $ $ $ BENEFIT: $2,200 $2,300 $2,400 $2,500 $2,600 $2,700 $2,800 $2,900 $3, $84.94 $88.80 $92.66 $96.53 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ Monthly deductions for a 12 month benefit period with 7/7 accident/sickness elimination period. Age Benefit Amount BENEFIT: $200 $300 $400 $500 $600 $700 $800 $900 $1,000 $1, $7.61 $11.42 $15.22 $19.03 $22.84 $26.64 $30.45 $34.25 $38.06 $ $11.07 $16.60 $22.13 $27.67 $33.20 $38.73 $44.26 $49.80 $55.33 $ $17.09 $25.64 $34.19 $42.74 $51.28 $59.83 $68.38 $76.92 $85.47 $94.02 BENEFIT: $1,200 $1,300 $1,400 $1,500 $1,600 $1,700 $1,800 $1,900 $2,000 $2, $45.67 $49.48 $53.28 $57.09 $60.90 $45.67 $49.48 $53.28 $57.09 $ $66.40 $71.93 $77.46 $83.00 $88.53 $66.40 $71.93 $77.46 $83.00 $ $ $ $ $ $ $ $ $ $ $ BENEFIT: $2,200 $2,300 $2,400 $2,500 $2,600 $2,700 $2,800 $2,900 $3, $83.73 $87.54 $91.34 $95.15 $98.96 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ Monthly deductions for a 12 month benefit period with 14/14 accident/sickness elimination period. Age Benefit Amount BENEFIT: $200 $300 $400 $500 $600 $700 $800 $900 $1,000 $1, $6.05 $9.07 $12.10 $15.12 $18.15 $21.17 $24.20 $27.22 $30.25 $ $9.46 $14.19 $18.92 $23.65 $28.38 $33.11 $37.84 $42.57 $47.30 $ $15.71 $23.56 $31.42 $39.27 $47.12 $54.98 $62.83 $70.69 $78.54 $86.39 BENEFIT: $1,200 $1,300 $1,400 $1,500 $1,600 $1,700 $1,800 $1,900 $2,000 $2, $36.30 $39.32 $42.35 $45.37 $48.40 $51.42 $54.45 $57.47 $60.50 $ $56.76 $61.49 $66.22 $70.95 $75.68 $80.41 $85.14 $89.87 $94.60 $ $94.25 $ $ $ $ $ $ $ $ $ BENEFIT: $2,200 $2,300 $2,400 $2,500 $2,600 $2,700 $2,800 $2,900 $3, $66.55 $69.57 $72.60 $75.62 $78.65 $81.67 $84.70 $87.72 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ HumanaVoluntaryBenefits.com VAHJEK8EN 6

9 Disability Income Plus rates Disability Income plus rates Monthly deductions for a 12 month benefit period with 30/30 accident/sickness elimination period. Age Benefit Amount BENEFIT: $200 $300 $400 $500 $600 $700 $800 $900 $1,000 $1, $3.81 $5.71 $7.61 $9.51 $11.42 $13.32 $15.22 $17.13 $19.03 $ $6.47 $9.70 $12.94 $16.17 $19.40 $22.64 $25.87 $29.11 $32.34 $ $11.62 $17.42 $23.23 $29.04 $34.85 $40.66 $46.46 $52.27 $58.08 $63.89 BENEFIT: $1,200 $1,300 $1,400 $1,500 $1,600 $1,700 $1,800 $1,900 $2,000 $2, $22.84 $24.74 $26.64 $28.54 $30.45 $32.35 $34.25 $36.16 $38.06 $ $38.81 $42.04 $45.28 $48.51 $51.74 $54.98 $58.21 $61.45 $64.68 $ $69.70 $75.50 $81.31 $87.12 $92.93 $98.74 $ $ $ $ BENEFIT: $2,200 $2,300 $2,400 $2,500 $2,600 $2,700 $2,800 $2,900 $3, $41.87 $43.77 $45.67 $47.57 $49.48 $51.38 $53.28 $55.19 $ $71.15 $74.38 $77.62 $80.85 $84.08 $87.32 $90.55 $93.79 $ $ $ $ $ $ $ $ $ $ HumanaVoluntaryBenefits.com VAHJEK8EN 7

10 Life Insurance Highlights For the employee purelife-plus Flexible Premium Life Insurance to Age 121 Policy Form PRFNG-NI-10 Voluntary permanent life insurance can be an ideal complement to the group term and optional term your employer might provide. Designed to be in force when you die, this voluntary universal life product is yours to keep, even when you change jobs or retire, as long as you pay the necessary premium. Group and voluntary term, on the other hand, typically are not portable if you change jobs and, even if you can keep them after you retire, usually costs more and declines in death benefit. The policy, purelife-plus, is underwritten by Texas Life Insurance Company, and it has these outstanding features: High Death Benefit. With one of the highest death benefits available at the worksite, 1 purelife-plus gives your loved ones peace of mind, knowing there will be significant life insurance in force should you die prematurely. Minimal Cash Value. Designed to provide high death benefit, purelife-plus does not compete with the cash accumulation in your employer-sponsored retirement plans. Long Guarantees. Enjoy the assurance of a policy that has a guaranteed death benefit to age 121 and level premium that guarantees coverage for a significant period of time (after the guaranteed period, premiums may go down, stay the same, or go up). Refund of Premium. Unique in the marketplace, purelife-plus offers you a refund of 10 years premium, should you surrender the policy if the premium you pay when you buy the policy ever increases. (Conditions apply.) Accelerated Death Benefit Rider. Should you be diagnosed as terminally ill with the expectation of death within 12 months (24 months in Illinois), you will have the option to receive 92% (84% in Illinois) of the death benefit, minus a $150 ($100 in Florida) administrative fee. This valuable living benefit gives you peace of mind knowing that, should you need it, you can take the large majority of your death benefit while still alive. (Conditions apply.) You may apply for this permanent, portable coverage, not only for yourself, but also for your spouse, minor children and grandchildren by answering just 3 questions: During the last six months, has the proposed insured: a. Been actively at work on a full time basis, performing usual duties? b. Been absent from work due to illness or medical treatment for a period of more than five consecutive working days? c. Been disabled or received tests, treatment or care of any kind in a hospital or nursing home or received chemotherapy, hormonal therapy for cancer, radiation therapy, dialysis treatment, or treatment for alcohol or drug abuse? Like most life insurance policies, Texas Life policies contain certain exclusions, limitations, exceptions, reductions of benefits, waiting periods and terms for keeping them in force. Please contact a Texas Life representative for costs and complete details. 1 Voluntary and Universal Whole Life Products, Eastbridge Consulting Group, October 2008 See the purelife-plus brochure for details. 10M055-C 1040 (exp0612) 8 Not for use in WA.

11 20peryear premiums PureLife Standard Risk Table Premiums Express & Simplified Issue GUARANTEED 20 per year Premiums for Life Insurance Face Amounts Shown PERIOD Includes Added Cost for Age to Which Issue Accidental Death Benefit (Ages 17-59) Coverage is Age Employee Group Size Guaranteed at (ALB) $10,000 $15,000 $20,000 $25,000 $50,000 $100,000 $150,000 $200,000 $250,000 Table Premium 15D PureLife is permanent life insurance to Attained Age 121 that can never be cancelled as long as you pay the necessary premiums. After the Guaranteed Period, the premiums can be lower, the same, or higher than the Table Premium. See the brochure under Permanent Coverage. PL-B4AHB5ABD9CH 9

12 20peryear premiums PureLife Standard Risk Table Premiums Express & Simplified Issue Life Insurance Face Amounts for 20 per year Premiums Shown GUARANTEED PERIOD Prem Includes Added Cost for Age to Which Issue For Accidental Death Benefit (Ages 17-59) Coverage is Age $10,000 Employee Group Size Guaranteed at (ALB) Face $7.00 $8.00 $10.00 $12.00 $14.00 $16.00 $18.00 $20.00 Table Premium ,470 35,470 45,470 55,470 65,470 75,470 85,470 95, ,745 33,462 42,896 52,330 61,764 71,198 80,632 90, ,745 33,462 42,896 52,330 61,764 71,198 80,632 90, ,954 32,541 41,716 50,890 60,064 69,239 78,413 87, ,205 31,670 40,598 49,527 58,455 67,384 76,312 85, ,496 30,843 39,539 48,235 56,930 65,626 74,322 83, ,822 30,059 38,534 47,008 55,483 63,958 72,432 80, ,182 29,314 37,579 45,843 54,107 62,372 70,636 78, ,929 35,803 43,677 51,551 59,425 67,299 75, ,669 34,188 41,707 49,226 56,744 64,263 71, ,518 32,712 39,906 47,101 54,295 61,489 68, ,723 37,480 44,236 50,993 57,750 64, ,526 36,019 42,513 49,006 55,500 61, ,419 34,669 40,919 47,169 53,419 59, ,905 32,822 38,740 44,657 50,574 56, ,122 30,646 36,171 41,696 47,221 52, ,741 33,922 39,104 44,285 49, ,668 31,476 36,284 41,091 45, ,590 32,956 37,323 41, ,188 30,188 34,188 38, ,849 31,539 35, ,583 28,973 32, ,793 29, ,138 28, , ,724 13,083 15,441 17,800 20,158 22, ,981 14,140 16,300 18,460 20, ,855 12,812 14,769 16,726 18, ,712 13,501 15,290 17, ,786 12,433 14,081 15, ,088 11,629 13,169 14, ,115 12,588 14, ,781 12,210 13, ,424 11,805 13, ,009 11,336 12, ,043 12, ,139 11, , PureLife is permanent life insurance to Attained Age 121 that can never be cancelled as long as you pay the necessary premiums. After the Guaranteed Period, the premiums can be lower, the same, or higher than the Table Premium. See the brochure under Permanent Coverage. PL-B4AHB5ABD9CH 10

13 Humana Whole Life 65 Virginia Child(ren) Summary - Portsmouth Public Schools If people depend financially on you, you need life insurance, no matter what your age or marital status. With life insurance, you can help spare your grieving loved ones the additional stress of economic difficulties and preserve their quality of life. Premiums for this whole life product are payable to age 65. The policy providers guaranteed coverage and cash values stay with the policy for its lifetime you can take funds as loans or use to buy paid-up coverage. Coverage type Benefit type Humana Whole Life 65 is an individual whole life insurance product with premiums payable to age 65. Defined benefit Policyholder Child Benefit amount Benefit amounts are available at various levels. You can choose: Child(ren): $2,500 to $25,000 for each eligible child Stand-alone Child(ren) Coverage Simplified Issue - Up to $25,000 For child stand-alone coverage Humana Whole Life to age 65 is only plan available. Issue ages Child(ren) stand-alone coverage: 14 days - 24 years Additional included benefits Terminal illness acceleration benefit: For the primary insured provides an acceleration of up to 50 percent of the original death benefit, base and term rider, amount including any ABI amounts, upon diagnosis of a terminal illness. 12-month waiting period. This is not a complete disclosure of plan qualifications and limitations. Please access our website to obtain a completed list for the Workplace Voluntary Benefit products at Disclosure.Humana.com. Please review this information before applying for coverage. The amount of benefits provided depends on the plan selected. Premiums will vary according to the selection made. Policy: Underwritten by Kanawha Insurance Company, a Humana company HumanaVoluntaryBenefits.com VOL

14 Humana Whole Life 65 Child(ren) Summary - Portsmouth Public Schools Virginia Additional included benefits Facility Care Acceleration Benefit: provides an acceleration of one percent of the face amount, up to $2,000/month up to a maximum of 36 months for Licensed Adult Day Care and/or up to two percent of the face amount, up to $4,000/month up to a maximum of 18 months for inpatient resident care. Benefits cannot exceed the lesser of 36 percent of the face amount, $72,000, or the face amount of the policy less the cash value. Product restrictions Total amount of permanent life insurance coverage and term life insurance coverage with Kanawha Insurance Company not to exceed $300,000. If both parents are eligible employees, their eligible children may be insured by either spouse but not both. Purchasing option, whether money purchase or flat face amount, will be determined by the employer. When optional riders are selected, the weekly money purchase premium will be calculated to include the base benefit and any rider(s) (per applicant). If an employee's base policy, rider(s), and any additional Kanawha Insurance Company life insurance products exceed our company maximum of $300,000, we will first reduce the applicant's rider(s) on this coverage. If additional reductions are necessary, we will reduce the face amount of the base policy. Age calculation Age at effective date of policy Portability Yes Guarantee renewable Yes Cash value Whole Life 65 is a whole life policy with guaranteed values, not an interest sensitive policy. As such, there is not an interest rate associated with the cash value of the policy; the cash values are all guaranteed in the table of cash values inside each and every Whole Life policy. This is not a complete disclosure of plan qualifications and limitations. Please access our website to obtain a completed list for the Workplace Voluntary Benefit products at Disclosure.Humana.com. Please review this information before applying for coverage. The amount of benefits provided depends on the plan selected. Premiums will vary according to the selection made. Policy: Underwritten by Kanawha Insurance Company, a Humana company HumanaVoluntaryBenefits.com VOL

15 Humana Whole Life 65 rates Virginia Child(ren) Summary - Portsmouth Public Schools Humana Whole Life 65 rates Child, Non-tobacco coverage, Defined Benefit amounts displaying monthly payroll deductions based on monthly premium calculation. Age Benefit Amount BENEFIT: $5,000 CASH VALUE* $10,000 CASH VALUE* $15,000 CASH VALUE* 0 $3.42 $2,405 $4.76 $4,811 $6.11 $7,216 1 $3.42 $2,405 $4.76 $4,811 $6.11 $7,216 2 $3.42 $2,405 $4.76 $4,811 $6.11 $7,216 3 $3.42 $2,405 $4.76 $4,811 $6.11 $7,216 4 $3.42 $2,405 $4.76 $4,811 $6.11 $7,216 5 $3.42 $2,405 $4.76 $4,811 $6.11 $7,216 6 $3.50 $2,405 $4.91 $4,811 $6.33 $7,216 7 $3.57 $2,405 $5.06 $4,811 $6.55 $7,216 8 $3.65 $2,405 $5.21 $4,811 $6.78 $7,216 9 $3.72 $2,405 $5.35 $4,811 $6.99 $7, $3.79 $2,405 $5.51 $4,811 $7.22 $7, $3.88 $2,405 $5.69 $4,811 $7.49 $7, $3.97 $2,405 $5.86 $4,811 $7.75 $7, $4.06 $2,405 $6.05 $4,811 $8.03 $7, $4.15 $2,405 $6.23 $4,811 $8.30 $7, $4.24 $2,405 $6.41 $4,811 $8.57 $7, $4.40 $2,405 $6.73 $4,811 $9.05 $7, $4.57 $2,405 $7.05 $4,811 $9.54 $7, $4.73 $2,405 $7.38 $4,811 $10.03 $7, $4.89 $2,405 $7.70 $4,811 $10.50 $7, $5.05 $2,405 $8.02 $4,811 $10.99 $7, $5.21 $2,405 $8.35 $4,811 $11.48 $7, $5.37 $2,405 $8.66 $4,811 $11.95 $7, $5.53 $2,405 $8.99 $4,811 $12.44 $7, $5.70 $2,405 $9.31 $4,811 $12.93 $7, $5.85 $2,405 $9.63 $4,811 $13.40 $7, $6.08 $2,405 $10.09 $4,811 $14.09 $7,216 *Cash values are calculated as of age 65. The proposed rates are for an effective date no later than January 1, HumanaVoluntaryBenefits.com Policy: Underwritten by Kanawha Insurance Company, a Humana company. 13

16 Humana Whole Life 65 rates Virginia Child(ren) Summary - Portsmouth Public Schools Humana Whole Life 65 rates Child, Non-tobacco coverage, Defined Benefit amounts displaying monthly payroll deductions based on monthly premium calculation. Age Benefit Amount BENEFIT: $20,000 CASH VALUE* $25,000 CASH VALUE* 0 $7.45 $9,622 $8.79 $12,027 1 $7.45 $9,622 $8.79 $12,027 2 $7.45 $9,622 $8.79 $12,027 3 $7.45 $9,622 $8.79 $12,027 4 $7.45 $9,622 $8.79 $12,027 5 $7.45 $9,622 $8.79 $12,027 6 $7.75 $9,622 $9.16 $12,027 7 $8.05 $9,622 $9.54 $12,027 8 $8.35 $9,622 $9.91 $12,027 9 $8.63 $9,622 $10.27 $12, $8.93 $9,622 $10.64 $12, $9.30 $9,622 $11.10 $12, $9.65 $9,622 $11.54 $12, $10.01 $9,622 $12.00 $12, $10.38 $9,622 $12.45 $12, $10.74 $9,622 $12.90 $12, $11.38 $9,622 $13.70 $12, $12.03 $9,622 $14.52 $12, $12.68 $9,622 $15.33 $12, $13.31 $9,622 $16.12 $12, $13.96 $9,622 $16.93 $12, $14.61 $9,622 $17.75 $12, $15.25 $9,622 $18.54 $12, $15.90 $9,622 $19.35 $12, $16.55 $9,622 $20.16 $12, $17.18 $9,622 $20.95 $12, $18.10 $9,622 $22.10 $12,027 *Cash values are calculated as of age 65. The proposed rates are for an effective date no later than January 1, HumanaVoluntaryBenefits.com Policy: Underwritten by Kanawha Insurance Company, a Humana company. 14

17 Humana Whole Life 99 Virginia Employee Summary - Portsmouth Public Schools Here's a simple, voluntary whole life policy you can get at a reasonable cost during your working years, when you and your families need coverage the most. It's also a benefit that'll stay in place when retirement rolls around, too. You buy a policy with guaranteed coverage and actual cash value. Coverage stays level and cash values stay with the policy for as long as you have it, enabling you to take out funds as loans or buy paid-up coverage. Coverage type Benefit type Humana Whole Life 99 is an individual whole life insurance product with premiums payable to age 99. Defined benefit Policyholder Employee Benefit amount Benefit amounts are available at various levels. You can choose: $2,500 to $300,000 for employees Employee Simplified Issue Amount up to $300,000 all ages Issue ages Employee base coverage: Additional included benefits Terminal illness acceleration benefit: For the primary insured provides an acceleration of up to 50 percent of the original death benefit, base and term rider, amount including any ABI amounts, upon diagnosis of a terminal illness. 12-month waiting period. Facility Care Acceleration Benefit: provides an acceleration of one percent of the face amount, up to $2,000/month up to a maximum of 36 months for Licensed Adult Day Care and/or up to two percent of the face amount, up to $4,000/month up to a maximum of 18 months for inpatient resident care. Benefits cannot exceed the lesser of 36 percent of the face amount, $72,000, or the face amount of the policy less the cash value. This is not a complete disclosure of plan qualifications and limitations. Please access our website to obtain a completed list for the Workplace Voluntary Benefit products at Disclosure.Humana.com. Please review this information before applying for coverage. The amount of benefits provided depends on the plan selected. Premiums will vary according to the selection made. Policy: Underwritten by Kanawha Insurance Company, a Humana company HumanaVoluntaryBenefits.com VOL

18 Humana Whole Life 99 Employee Summary - Portsmouth Public Schools Virginia Product restrictions Total amount of permanent life insurance coverage and term life insurance coverage with Kanawha Insurance Company not to exceed $300,000. If both parents are eligible employees, their eligible children may be insured by either spouse but not both. Purchasing option, whether money purchase or flat face amount, will be determined by the employer. When optional riders are selected, the weekly money purchase premium will be calculated to include the base benefit and any rider(s) (per applicant). If an employee's base policy, rider(s), and any additional Kanawha Insurance Company life insurance products exceed our company maximum of $300,000, we will first reduce the applicant's rider(s) on this coverage. If additional reductions are necessary, we will reduce the face amount of the base policy. Age calculation Age at effective date of policy Portability Yes Guarantee renewable Yes Cash value Whole Life 99 is a whole life policy with guaranteed values, not an interest sensitive policy. As such, there is not an interest rate associated with the cash value of the policy; the cash values are all guaranteed in the table of cash values inside each and every Whole Life policy. This is not a complete disclosure of plan qualifications and limitations. Please access our website to obtain a completed list for the Workplace Voluntary Benefit products at Disclosure.Humana.com. Please review this information before applying for coverage. The amount of benefits provided depends on the plan selected. Premiums will vary according to the selection made. Policy: Underwritten by Kanawha Insurance Company, a Humana company HumanaVoluntaryBenefits.com VOL

19 Humana Whole Life 99 rates Virginia Employee Summary - Portsmouth Public Schools Humana Whole Life 99 rates Employee, Non-tobacco coverage, Defined Benefit amounts displaying monthly payroll deductions based on monthly premium calculation. Age Benefit Amount BENEFIT: $10,000 CASH VALUE* $20,000 CASH VALUE* $30,000 CASH VALUE* 18 $6.72 $4,628 $11.36 $9,256 $16.00 $13, $6.96 $4,628 $11.85 $9,256 $16.73 $13, $7.08 $4,628 $12.08 $9,256 $17.08 $13, $7.28 $4,628 $12.48 $9,256 $17.68 $13, $7.49 $4,628 $12.90 $9,256 $18.30 $13, $7.69 $4,628 $13.30 $9,256 $18.90 $13, $7.90 $4,628 $13.71 $9,256 $19.53 $13, $8.10 $4,628 $14.11 $9,256 $20.13 $13, $8.35 $4,628 $14.61 $9,256 $20.88 $13, $8.59 $4,628 $15.10 $9,256 $21.60 $13, $8.84 $4,620 $15.60 $9,239 $22.35 $13, $9.08 $4,572 $16.08 $9,144 $23.08 $13, $9.33 $4,527 $16.58 $9,054 $23.83 $13, $9.71 $4,475 $17.35 $8,950 $24.98 $13, $10.10 $4,422 $18.11 $8,845 $26.13 $13, $10.48 $4,367 $18.88 $8,733 $27.28 $13, $10.86 $4,308 $19.65 $8,616 $28.43 $12, $11.25 $4,246 $20.41 $8,493 $29.58 $12, $11.73 $4,181 $21.38 $8,363 $31.03 $12, $12.21 $4,113 $22.35 $8,225 $32.48 $12, $12.70 $4,041 $23.31 $8,081 $33.93 $12, $13.18 $3,964 $24.28 $7,929 $35.38 $11, $13.66 $3,884 $25.25 $7,768 $36.83 $11, $14.35 $3,799 $26.61 $7,598 $38.88 $11, $15.04 $3,709 $28.00 $7,418 $40.95 $11, $15.72 $3,614 $29.36 $7,229 $43.00 $10, $16.41 $3,515 $30.75 $7,029 $45.08 $10, $17.10 $3,409 $32.11 $6,818 $47.13 $10, $18.11 $3,471 $34.15 $6,942 $50.18 $10, $19.12 $3,535 $36.16 $7,069 $53.20 $10, $20.14 $3,601 $38.20 $7,202 $56.25 $10, $21.15 $3,670 $40.23 $7,340 $59.30 $11,010 *Cash values are for age 65 through age 45 and for 20 years for ages over 45. The proposed rates are for an effective date no later than January 1, HumanaVoluntaryBenefits.com Policy: Underwritten by Kanawha Insurance Company, a Humana company. 17

20 Humana Whole Life 99 rates Virginia Employee Summary - Portsmouth Public Schools Humana Whole Life 99 rates Employee, Non-tobacco coverage, Defined Benefit amounts displaying monthly payroll deductions based on monthly premium calculation. Age Benefit Amount BENEFIT: $10,000 CASH VALUE* $20,000 CASH VALUE* $30,000 CASH VALUE* 50 $22.16 $3,742 $42.25 $7,483 $62.33 $11, $23.50 $3,816 $44.93 $7,631 $66.35 $11, $24.85 $3,892 $47.61 $7,783 $70.38 $11, $26.19 $3,970 $50.29 $7,939 $74.40 $11, $27.53 $4,050 $52.98 $8,099 $78.43 $12, $28.86 $4,132 $55.64 $8,265 $82.43 $12, $31.14 $4,218 $60.19 $8,436 $89.25 $12, $33.40 $4,306 $64.73 $8,613 $96.05 $12, $35.67 $4,397 $69.26 $8,794 $ $13, $37.94 $4,488 $73.79 $8,977 $ $13, $40.20 $4,496 $78.33 $8,993 $ $13, $43.27 $4,618 $84.46 $9,237 $ $13, $46.34 $4,737 $90.60 $9,474 $ $14, $49.41 $4,854 $96.73 $9,707 $ $14, $52.48 $4,968 $ $9,936 $ $14, $55.55 $5,080 $ $10,159 $ $15, $58.57 $5,190 $ $10,380 $ $15, $61.81 $5,306 $ $10,612 $ $15, $65.26 $5,419 $ $10,838 $ $16, $69.05 $5,525 $ $11,051 $ $16, $73.15 $5,630 $ $11,260 $ $16,889 *Cash values are for age 65 through age 45 and for 20 years for ages over 45. The proposed rates are for an effective date no later than January 1, Humana Whole Life 99 rates Employee, Tobacco coverage, Defined Benefit amounts displaying monthly payroll deductions based on monthly premium calculation. Age Benefit Amount BENEFIT: $10,000 CASH VALUE* $20,000 CASH VALUE* $30,000 CASH VALUE* 18 $8.74 $5,293 $15.40 $10,587 $22.05 $15, $9.07 $5,293 $16.06 $10,587 $23.05 $15, $9.29 $5,293 $16.50 $10,587 $23.70 $15, $9.62 $5,293 $17.16 $10,587 $24.70 $15,880 *Cash values are for age 65 through age 45 and for 20 years for ages over 45. The proposed rates are for an effective date no later than January 1, HumanaVoluntaryBenefits.com Policy: Underwritten by Kanawha Insurance Company, a Humana company. 18

21 Humana Whole Life 99 rates Virginia Employee Summary - Portsmouth Public Schools Humana Whole Life 99 rates Employee, Tobacco coverage, Defined Benefit amounts displaying monthly payroll deductions based on monthly premium calculation. Age Benefit Amount BENEFIT: $10,000 CASH VALUE* $20,000 CASH VALUE* $30,000 CASH VALUE* 22 $9.95 $5,293 $17.81 $10,587 $25.68 $15, $10.28 $5,293 $18.48 $10,587 $26.68 $15, $10.61 $5,293 $19.15 $10,587 $27.68 $15, $10.94 $5,293 $19.80 $10,587 $28.65 $15, $11.38 $5,293 $20.68 $10,587 $29.98 $15, $11.82 $5,293 $21.56 $10,587 $31.30 $15, $12.26 $5,259 $22.45 $10,517 $32.63 $15, $12.70 $5,206 $23.33 $10,412 $33.95 $15, $13.14 $5,151 $24.20 $10,302 $35.25 $15, $13.70 $5,092 $25.31 $10,184 $36.93 $15, $14.25 $5,030 $26.41 $10,060 $38.58 $15, $14.80 $4,965 $27.53 $9,929 $40.25 $14, $15.35 $4,896 $28.63 $9,791 $41.90 $14, $15.90 $4,823 $29.73 $9,646 $43.55 $14, $16.65 $4,746 $31.23 $9,492 $45.80 $14, $17.40 $4,665 $32.73 $9,330 $48.05 $13, $18.15 $4,580 $34.23 $9,159 $50.30 $13, $18.90 $4,489 $35.73 $8,978 $52.55 $13, $19.65 $4,394 $37.23 $8,788 $54.80 $13, $20.60 $4,293 $39.13 $8,586 $57.65 $12, $21.55 $4,186 $41.01 $8,372 $60.48 $12, $22.50 $4,074 $42.91 $8,147 $63.33 $12, $23.44 $3,955 $44.79 $7,910 $66.15 $11, $24.39 $3,830 $46.69 $7,660 $69.00 $11, $25.86 $3,872 $49.64 $7,744 $73.43 $11, $27.35 $3,916 $52.61 $7,832 $77.88 $11, $28.82 $3,962 $55.56 $7,923 $82.30 $11, $30.30 $4,009 $58.53 $8,018 $86.75 $12, $31.78 $4,059 $61.48 $8,118 $91.18 $12, $33.72 $4,110 $65.36 $8,221 $97.00 $12, $35.66 $4,163 $69.24 $8,327 $ $12, $37.60 $4,217 $73.13 $8,434 $ $12, $39.54 $4,272 $76.99 $8,545 $ $12,817 *Cash values are for age 65 through age 45 and for 20 years for ages over 45. The proposed rates are for an effective date no later than January 1, HumanaVoluntaryBenefits.com Policy: Underwritten by Kanawha Insurance Company, a Humana company. 19

22 Humana Whole Life 99 rates Virginia Employee Summary - Portsmouth Public Schools Humana Whole Life 99 rates Employee, Tobacco coverage, Defined Benefit amounts displaying monthly payroll deductions based on monthly premium calculation. Age Benefit Amount BENEFIT: $10,000 CASH VALUE* $20,000 CASH VALUE* $30,000 CASH VALUE* 55 $41.48 $4,330 $80.88 $8,661 $ $12, $44.28 $4,391 $86.48 $8,782 $ $13, $47.08 $4,454 $92.08 $8,909 $ $13, $49.88 $4,519 $97.68 $9,037 $ $13, $52.68 $4,584 $ $9,167 $ $13, $55.48 $4,565 $ $9,130 $ $13, $59.16 $4,661 $ $9,322 $ $13, $62.85 $4,759 $ $9,519 $ $14, $66.53 $4,857 $ $9,714 $ $14, $70.21 $4,951 $ $9,902 $ $14, $73.90 $5,040 $ $10,079 $ $15, $77.76 $5,126 $ $10,251 $ $15, $81.84 $5,207 $ $10,413 $ $15, $86.25 $5,276 $ $10,553 $ $15, $90.89 $5,336 $ $10,673 $ $16, $95.96 $5,392 $ $10,784 $ $16,177 *Cash values are for age 65 through age 45 and for 20 years for ages over 45. The proposed rates are for an effective date no later than January 1, HumanaVoluntaryBenefits.com Policy: Underwritten by Kanawha Insurance Company, a Humana company. 20

23 Humana Whole Life 99 rates Virginia Employee Summary - Portsmouth Public Schools Humana Whole Life 99 rates Employee, Non-tobacco coverage, Defined Benefit amounts displaying monthly payroll deductions based on monthly premium calculation. Age Benefit Amount BENEFIT: $40,000 CASH VALUE* $50,000 CASH VALUE* $75,000 CASH VALUE* 18 $20.65 $18,512 $25.29 $23,140 $36.89 $34, $21.61 $18,512 $26.50 $23,140 $38.70 $34, $22.08 $18,512 $27.08 $23,140 $39.58 $34, $22.88 $18,512 $28.08 $23,140 $41.08 $34, $23.71 $18,512 $29.12 $23,140 $42.64 $34, $24.51 $18,512 $30.12 $23,140 $44.14 $34, $25.35 $18,512 $31.16 $23,140 $45.70 $34, $26.15 $18,512 $32.16 $23,140 $47.20 $34, $27.15 $18,512 $33.41 $23,140 $49.08 $34, $28.11 $18,512 $34.62 $23,140 $50.89 $34, $29.11 $18,478 $35.87 $23,098 $52.77 $34, $30.08 $18,288 $37.08 $22,860 $54.58 $34, $31.08 $18,109 $38.33 $22,636 $56.45 $33, $32.61 $17,900 $40.25 $22,374 $59.33 $33, $34.15 $17,689 $42.16 $22,111 $62.20 $33, $35.68 $17,467 $44.08 $21,833 $65.08 $32, $37.21 $17,232 $45.99 $21,540 $67.95 $32, $38.75 $16,985 $47.91 $21,231 $70.83 $31, $40.68 $16,725 $50.33 $20,907 $74.45 $31, $42.61 $16,451 $52.74 $20,564 $78.08 $30, $44.54 $16,163 $55.16 $20,203 $81.70 $30, $46.48 $15,857 $57.58 $19,822 $85.33 $29, $48.41 $15,536 $59.99 $19,419 $88.95 $29, $51.14 $15,195 $63.41 $18,994 $94.08 $28, $53.91 $14,837 $66.87 $18,546 $99.26 $27, $56.64 $14,458 $70.29 $18,072 $ $27, $59.41 $14,058 $73.74 $17,573 $ $26, $62.14 $13,637 $77.16 $17,046 $ $25, $66.21 $13,883 $82.24 $17,354 $ $26, $70.24 $14,139 $87.28 $17,673 $ $26, $74.31 $14,404 $92.37 $18,005 $ $27, $78.38 $14,680 $97.45 $18,350 $ $27,525 *Cash values are for age 65 through age 45 and for 20 years for ages over 45. The proposed rates are for an effective date no later than January 1, HumanaVoluntaryBenefits.com Policy: Underwritten by Kanawha Insurance Company, a Humana company. 21

24 Humana Whole Life 99 rates Virginia Employee Summary - Portsmouth Public Schools Humana Whole Life 99 rates Employee, Non-tobacco coverage, Defined Benefit amounts displaying monthly payroll deductions based on monthly premium calculation. Age Benefit Amount BENEFIT: $40,000 CASH VALUE* $50,000 CASH VALUE* $75,000 CASH VALUE* 50 $82.41 $14,966 $ $18,708 $ $28, $87.78 $15,263 $ $19,078 $ $28, $93.14 $15,567 $ $19,458 $ $29, $98.51 $15,878 $ $19,848 $ $29, $ $16,198 $ $20,248 $ $30, $ $16,530 $ $20,662 $ $30, $ $16,872 $ $21,090 $ $31, $ $17,225 $ $21,532 $ $32, $ $17,587 $ $21,984 $ $32, $ $17,954 $ $22,442 $ $33, $ $17,986 $ $22,482 $ $33, $ $18,474 $ $23,092 $ $34, $ $18,949 $ $23,686 $ $35, $ $19,414 $ $24,268 $ $36, $ $19,872 $ $24,840 $ $37, $ $20,319 $ $25,399 $ $38, $ $20,761 $ $25,951 $ $38, $ $21,224 $ $26,530 $ $39, $ $21,675 $ $27,094 $ $40, $ $22,102 $ $27,627 $ $41, $ $22,519 $ $28,149 $ $42,224 *Cash values are for age 65 through age 45 and for 20 years for ages over 45. The proposed rates are for an effective date no later than January 1, Humana Whole Life 99 rates Employee, Tobacco coverage, Defined Benefit amounts displaying monthly payroll deductions based on monthly premium calculation. Age Benefit Amount BENEFIT: $40,000 CASH VALUE* $50,000 CASH VALUE* $75,000 CASH VALUE* 18 $28.71 $21,174 $35.37 $26,467 $52.02 $39, $30.05 $21,174 $37.04 $26,467 $54.52 $39, $30.91 $21,174 $38.12 $26,467 $56.14 $39, $32.25 $21,174 $39.79 $26,467 $58.64 $39,701 *Cash values are for age 65 through age 45 and for 20 years for ages over 45. The proposed rates are for an effective date no later than January 1, HumanaVoluntaryBenefits.com Policy: Underwritten by Kanawha Insurance Company, a Humana company. 22

25 Humana Whole Life 99 rates Virginia Employee Summary - Portsmouth Public Schools Humana Whole Life 99 rates Employee, Tobacco coverage, Defined Benefit amounts displaying monthly payroll deductions based on monthly premium calculation. Age Benefit Amount BENEFIT: $40,000 CASH VALUE* $50,000 CASH VALUE* $75,000 CASH VALUE* 22 $33.55 $21,174 $41.41 $26,467 $61.08 $39, $34.88 $21,174 $43.08 $26,467 $63.58 $39, $36.21 $21,174 $44.74 $26,467 $66.08 $39, $37.51 $21,174 $46.37 $26,467 $68.51 $39, $39.28 $21,174 $48.58 $26,467 $71.83 $39, $41.05 $21,174 $50.79 $26,467 $75.14 $39, $42.81 $21,035 $52.99 $26,293 $78.45 $39, $44.58 $20,825 $55.20 $26,031 $81.76 $39, $46.31 $20,603 $57.37 $25,754 $85.01 $38, $48.54 $20,369 $60.16 $25,461 $89.20 $38, $50.74 $20,121 $62.91 $25,151 $93.33 $37, $52.98 $19,859 $65.70 $24,824 $97.51 $37, $55.18 $19,583 $68.45 $24,478 $ $36, $57.38 $19,291 $71.20 $24,114 $ $36, $60.38 $18,984 $74.95 $23,730 $ $35, $63.38 $18,660 $78.70 $23,325 $ $34, $66.38 $18,318 $82.45 $22,898 $ $34, $69.38 $17,957 $86.20 $22,446 $ $33, $72.38 $17,575 $89.95 $21,969 $ $32, $76.18 $17,171 $94.70 $21,464 $ $32, $79.94 $16,744 $99.41 $20,931 $ $31, $83.74 $16,295 $ $20,368 $ $30, $87.51 $15,820 $ $19,774 $ $29, $91.31 $15,320 $ $19,150 $ $28, $97.21 $15,489 $ $19,361 $ $29, $ $15,663 $ $19,579 $ $29, $ $15,846 $ $19,808 $ $29, $ $16,036 $ $20,045 $ $30, $ $16,235 $ $20,294 $ $30, $ $16,442 $ $20,552 $ $30, $ $16,653 $ $20,816 $ $31, $ $16,868 $ $21,085 $ $31, $ $17,090 $ $21,362 $ $32,044 *Cash values are for age 65 through age 45 and for 20 years for ages over 45. The proposed rates are for an effective date no later than January 1, HumanaVoluntaryBenefits.com Policy: Underwritten by Kanawha Insurance Company, a Humana company. 23

26 Humana Whole Life 99 rates Virginia Employee Summary - Portsmouth Public Schools Humana Whole Life 99 rates Employee, Tobacco coverage, Defined Benefit amounts displaying monthly payroll deductions based on monthly premium calculation. Age Benefit Amount BENEFIT: $40,000 CASH VALUE* $50,000 CASH VALUE* $75,000 CASH VALUE* 55 $ $17,321 $ $21,652 $ $32, $ $17,564 $ $21,955 $ $32, $ $17,817 $ $22,271 $ $33, $ $18,075 $ $22,594 $ $33, $ $18,334 $ $22,918 $ $34, $ $18,261 $ $22,826 $ $34, $ $18,643 $ $23,304 $ $34, $ $19,038 $ $23,797 $ $35, $ $19,429 $ $24,286 $ $36, $ $19,803 $ $24,754 $ $37, $ $20,158 $ $25,198 $ $37, $ $20,503 $ $25,628 $ $38, $ $20,826 $ $26,033 $ $39, $ $21,106 $ $26,382 $ $39, $ $21,345 $ $26,682 $ $40, $ $21,569 $ $26,961 $ $40,442 *Cash values are for age 65 through age 45 and for 20 years for ages over 45. The proposed rates are for an effective date no later than January 1, HumanaVoluntaryBenefits.com Policy: Underwritten by Kanawha Insurance Company, a Humana company. 24

27 Humana Whole Life 99 rates Virginia Employee Summary - Portsmouth Public Schools Humana Whole Life 99 rates Employee, Non-tobacco coverage, Defined Benefit amounts displaying monthly payroll deductions based on monthly premium calculation. Age Benefit Amount BENEFIT: $80,000 CASH VALUE* $90,000 CASH VALUE* $100,000 CASH VALUE* 18 $39.21 $37,024 $43.85 $41,652 $48.49 $46, $41.15 $37,024 $46.03 $41,652 $50.91 $46, $42.08 $37,024 $47.08 $41,652 $52.08 $46, $43.68 $37,024 $48.88 $41,652 $54.08 $46, $45.34 $37,024 $50.75 $41,652 $56.16 $46, $46.94 $37,024 $52.55 $41,652 $58.16 $46, $48.61 $37,024 $54.43 $41,652 $60.24 $46, $50.21 $37,024 $56.23 $41,652 $62.24 $46, $52.21 $37,024 $58.48 $41,652 $64.74 $46, $54.14 $37,024 $60.65 $41,652 $67.16 $46, $56.14 $36,956 $62.90 $41,576 $69.66 $46, $58.08 $36,577 $65.08 $41,149 $72.08 $45, $60.08 $36,217 $67.33 $40,744 $74.58 $45, $63.14 $35,799 $70.78 $40,274 $78.41 $44, $66.21 $35,378 $74.23 $39,801 $82.24 $44, $69.28 $34,933 $77.68 $39,300 $86.08 $43, $72.34 $34,464 $81.13 $38,772 $89.91 $43, $75.41 $33,970 $84.58 $38,216 $93.74 $42, $79.28 $33,450 $88.93 $37,632 $98.58 $41, $83.14 $32,902 $93.28 $37,015 $ $41, $87.01 $32,325 $97.63 $36,366 $ $40, $90.88 $31,715 $ $35,679 $ $39, $94.74 $31,071 $ $34,955 $ $38, $ $30,391 $ $34,190 $ $37, $ $29,674 $ $33,383 $ $37, $ $28,915 $ $32,530 $ $36, $ $28,116 $ $31,631 $ $35, $ $27,273 $ $30,682 $ $34, $ $27,766 $ $31,237 $ $34, $ $28,277 $ $31,812 $ $35, $ $28,807 $ $32,408 $ $36, $ $29,360 $ $33,030 $ $36,700 *Cash values are for age 65 through age 45 and for 20 years for ages over 45. The proposed rates are for an effective date no later than January 1, HumanaVoluntaryBenefits.com Policy: Underwritten by Kanawha Insurance Company, a Humana company. 25

28 Humana Whole Life 99 rates Virginia Employee Summary - Portsmouth Public Schools Humana Whole Life 99 rates Employee, Non-tobacco coverage, Defined Benefit amounts displaying monthly payroll deductions based on monthly premium calculation. Age Benefit Amount BENEFIT: $80,000 CASH VALUE* $90,000 CASH VALUE* $100,000 CASH VALUE* 50 $ $29,932 $ $33,674 $ $37, $ $30,525 $ $34,341 $ $38, $ $31,133 $ $35,025 $ $38, $ $31,756 $ $35,726 $ $39, $ $32,396 $ $36,446 $ $40, $ $33,059 $ $37,192 $ $41, $ $33,744 $ $37,962 $ $42, $ $34,451 $ $38,757 $ $43, $ $35,175 $ $39,571 $ $43, $ $35,907 $ $40,395 $ $44, $ $35,971 $ $40,468 $ $44, $ $36,948 $ $41,566 $ $46, $ $37,898 $ $42,635 $ $47, $ $38,828 $ $43,682 $ $48, $ $39,744 $ $44,712 $ $49, $ $40,638 $ $45,717 $ $50, $ $41,522 $ $46,712 $ $51, $ $42,449 $ $47,755 $ $53, $ $43,351 $ $48,769 $ $54, $ $44,203 $ $49,728 $ $55, $ $45,038 $ $50,668 $ $56,298 *Cash values are for age 65 through age 45 and for 20 years for ages over 45. The proposed rates are for an effective date no later than January 1, Humana Whole Life 99 rates Employee, Tobacco coverage, Defined Benefit amounts displaying monthly payroll deductions based on monthly premium calculation. Age Benefit Amount BENEFIT: $80,000 CASH VALUE* $90,000 CASH VALUE* $100,000 CASH VALUE* 18 $55.34 $42,348 $62.00 $47,641 $68.66 $52, $58.01 $42,348 $65.00 $47,641 $71.99 $52, $59.74 $42,348 $66.95 $47,641 $74.16 $52, $62.41 $42,348 $69.95 $47,641 $77.49 $52,934 *Cash values are for age 65 through age 45 and for 20 years for ages over 45. The proposed rates are for an effective date no later than January 1, HumanaVoluntaryBenefits.com Policy: Underwritten by Kanawha Insurance Company, a Humana company. 26

29 Humana Whole Life 99 rates Virginia Employee Summary - Portsmouth Public Schools Humana Whole Life 99 rates Employee, Tobacco coverage, Defined Benefit amounts displaying monthly payroll deductions based on monthly premium calculation. Age Benefit Amount BENEFIT: $80,000 CASH VALUE* $90,000 CASH VALUE* $100,000 CASH VALUE* 22 $65.01 $42,348 $72.88 $47,641 $80.74 $52, $67.68 $42,348 $75.88 $47,641 $84.08 $52, $70.34 $42,348 $78.88 $47,641 $87.41 $52, $72.94 $42,348 $81.80 $47,641 $90.66 $52, $76.48 $42,348 $85.78 $47,641 $95.08 $52, $80.01 $42,348 $89.75 $47,641 $99.49 $52, $83.54 $42,069 $93.73 $47,328 $ $52, $87.08 $41,650 $97.70 $46,856 $ $52, $90.54 $41,206 $ $46,357 $ $51, $95.01 $40,738 $ $45,830 $ $50, $99.41 $40,241 $ $45,272 $ $50, $ $39,718 $ $44,682 $ $49, $ $39,165 $ $44,061 $ $48, $ $38,583 $ $43,406 $ $48, $ $37,968 $ $42,714 $ $47, $ $37,321 $ $41,986 $ $46, $ $36,636 $ $41,216 $ $45, $ $35,914 $ $40,403 $ $44, $ $35,150 $ $39,544 $ $43, $ $34,342 $ $38,635 $ $42, $ $33,489 $ $37,675 $ $41, $ $32,589 $ $36,663 $ $40, $ $31,639 $ $35,594 $ $39, $ $30,640 $ $34,470 $ $38, $ $30,978 $ $34,850 $ $38, $ $31,327 $ $35,243 $ $39, $ $31,693 $ $35,654 $ $39, $ $32,072 $ $36,081 $ $40, $ $32,471 $ $36,530 $ $40, $ $32,884 $ $36,994 $ $41, $ $33,306 $ $37,470 $ $41, $ $33,736 $ $37,953 $ $42, $ $34,180 $ $38,452 $ $42,725 *Cash values are for age 65 through age 45 and for 20 years for ages over 45. The proposed rates are for an effective date no later than January 1, HumanaVoluntaryBenefits.com Policy: Underwritten by Kanawha Insurance Company, a Humana company. 27

30 Humana Whole Life 99 rates Virginia Employee Summary - Portsmouth Public Schools Humana Whole Life 99 rates Employee, Tobacco coverage, Defined Benefit amounts displaying monthly payroll deductions based on monthly premium calculation. Age Benefit Amount BENEFIT: $80,000 CASH VALUE* $90,000 CASH VALUE* $100,000 CASH VALUE* 55 $ $34,643 $ $38,973 $ $43, $ $35,127 $ $39,518 $ $43, $ $35,634 $ $40,089 $ $44, $ $36,150 $ $40,669 $ $45, $ $36,668 $ $41,252 $ $45, $ $36,522 $ $41,087 $ $45, $ $37,286 $ $41,947 $ $46, $ $38,076 $ $42,835 $ $47, $ $38,857 $ $43,714 $ $48, $ $39,606 $ $44,557 $ $49, $ $40,317 $ $45,356 $ $50, $ $41,005 $ $46,131 $ $51, $ $41,652 $ $46,859 $ $52, $ $42,211 $ $47,488 $ $52, $ $42,690 $ $48,027 $ $53, $ $43,138 $ $48,530 $ $53,922 *Cash values are for age 65 through age 45 and for 20 years for ages over 45. The proposed rates are for an effective date no later than January 1, HumanaVoluntaryBenefits.com Policy: Underwritten by Kanawha Insurance Company, a Humana company. 28

31 Humana Whole Life 99 Spouse Summary - Portsmouth Public Schools Virginia Here's a simple, voluntary whole life policy you can get at a reasonable cost during your working years, when you and your families need coverage the most. It's also a benefit that'll stay in place when retirement rolls around, too. You buy a policy with guaranteed coverage and actual cash value. Coverage stays level and cash values stay with the policy for as long as you have it, enabling you to take out funds as loans or buy paid-up coverage. Coverage type Benefit type Humana Whole Life 99 is an individual whole life insurance product with premiums payable to age 99. Defined benefit Policyholder Spouse Benefit amount Benefit amounts are available at various levels. You can choose: Spouse: $2,500 to $50,000 Stand-alone Spouse Coverage Simplified Issue - Up to $50,000 Issue ages Spouse stand-alone coverage: Additional included benefits Terminal illness acceleration benefit: For the primary insured provides an acceleration of up to 50 percent of the original death benefit, base and term rider, amount including any ABI amounts, upon diagnosis of a terminal illness. 12-month waiting period. Facility Care Acceleration Benefit: provides an acceleration of one percent of the face amount, up to $2,000/month up to a maximum of 36 months for Licensed Adult Day Care and/or up to two percent of the face amount, up to $4,000/month up to a maximum of 18 months for inpatient resident care. Benefits cannot exceed the lesser of 36 percent of the face amount, $72,000, or the face amount of the policy less the cash value. This is not a complete disclosure of plan qualifications and limitations. Please access our website to obtain a completed list for the Workplace Voluntary Benefit products at Disclosure.Humana.com. Please review this information before applying for coverage. The amount of benefits provided depends on the plan selected. Premiums will vary according to the selection made. Policy: Underwritten by Kanawha Insurance Company, a Humana company HumanaVoluntaryBenefits.com VOL

32 Humana Whole Life 99 Spouse Summary - Portsmouth Public Schools Virginia Product restrictions Total amount of permanent life insurance coverage and term life insurance coverage with Kanawha Insurance Company not to exceed $300,000. If both parents are eligible employees, their eligible children may be insured by either spouse but not both. Purchasing option, whether money purchase or flat face amount, will be determined by the employer. When optional riders are selected, the weekly money purchase premium will be calculated to include the base benefit and any rider(s) (per applicant). If an employee's base policy, rider(s), and any additional Kanawha Insurance Company life insurance products exceed our company maximum of $300,000, we will first reduce the applicant's rider(s) on this coverage. If additional reductions are necessary, we will reduce the face amount of the base policy. Age calculation Age at effective date of policy Portability Yes Guarantee renewable Yes Cash value Whole Life 99 is a whole life policy with guaranteed values, not an interest sensitive policy. As such, there is not an interest rate associated with the cash value of the policy; the cash values are all guaranteed in the table of cash values inside each and every Whole Life policy. This is not a complete disclosure of plan qualifications and limitations. Please access our website to obtain a completed list for the Workplace Voluntary Benefit products at Disclosure.Humana.com. Please review this information before applying for coverage. The amount of benefits provided depends on the plan selected. Premiums will vary according to the selection made. Policy: Underwritten by Kanawha Insurance Company, a Humana company HumanaVoluntaryBenefits.com VOL

33 Humana Whole Life 99 rates Virginia Spouse Summary - Portsmouth Public Schools Humana Whole Life 99 rates Spouse, Non-tobacco coverage, Defined Benefit amounts displaying monthly payroll deductions based on monthly premium calculation. Age Benefit Amount BENEFIT: $5,000 CASH VALUE* $10,000 CASH VALUE* $15,000 CASH VALUE* 18 $4.53 $2,405 $6.98 $4,811 $9.43 $7, $4.66 $2,405 $7.25 $4,811 $9.83 $7, $4.80 $2,405 $7.51 $4,811 $10.23 $7, $4.93 $2,405 $7.78 $4,811 $10.63 $7, $5.06 $2,405 $8.05 $4,811 $11.03 $7, $5.20 $2,405 $8.31 $4,811 $11.43 $7, $5.33 $2,405 $8.58 $4,811 $11.83 $7, $5.46 $2,405 $8.85 $4,811 $12.23 $7, $5.64 $2,405 $9.20 $4,811 $12.77 $7, $5.82 $2,405 $9.55 $4,811 $13.29 $7, $6.00 $2,394 $9.91 $4,787 $13.83 $7, $6.18 $2,371 $10.27 $4,741 $14.37 $7, $6.35 $2,346 $10.63 $4,692 $14.90 $7, $6.59 $2,320 $11.10 $4,641 $15.60 $6, $6.82 $2,293 $11.56 $4,586 $16.30 $6, $7.05 $2,265 $12.02 $4,529 $16.99 $6, $7.28 $2,234 $12.49 $4,469 $17.69 $6, $7.52 $2,202 $12.95 $4,405 $18.39 $6, $7.84 $2,169 $13.60 $4,338 $19.37 $6, $8.16 $2,133 $14.25 $4,267 $20.33 $6, $8.48 $2,096 $14.89 $4,192 $21.29 $6, $8.80 $2,057 $15.53 $4,113 $22.25 $6, $9.13 $2,015 $16.17 $4,030 $23.22 $6, $9.56 $1,971 $17.04 $3,942 $24.52 $5, $9.99 $1,924 $17.90 $3,849 $25.82 $5, $10.43 $1,875 $18.77 $3,751 $27.12 $5, $10.86 $1,824 $19.64 $3,647 $28.42 $5, $11.29 $1,769 $20.50 $3,539 $29.72 $5, $11.91 $1,800 $21.75 $3,599 $31.58 $5, $12.53 $1,831 $22.99 $3,662 $33.44 $5, $13.16 $1,864 $24.24 $3,727 $35.32 $5, $13.78 $1,897 $25.48 $3,795 $37.18 $5, $14.40 $1,932 $26.72 $3,865 $39.04 $5,797 *Cash values are for age 65 through age 45 and for 20 years for ages over 45. The proposed rates are for an effective date no later than January 1, HumanaVoluntaryBenefits.com Policy: Underwritten by Kanawha Insurance Company, a Humana company. 31

34 Humana Whole Life 99 rates Virginia Spouse Summary - Portsmouth Public Schools Humana Whole Life 99 rates Spouse, Non-tobacco coverage, Defined Benefit amounts displaying monthly payroll deductions based on monthly premium calculation. Age Benefit Amount BENEFIT: $5,000 CASH VALUE* $10,000 CASH VALUE* $15,000 CASH VALUE* 51 $15.20 $1,969 $28.33 $3,938 $41.45 $5, $16.01 $2,006 $29.94 $4,012 $43.87 $6, $16.82 $2,044 $31.55 $4,088 $46.29 $6, $17.62 $2,083 $33.16 $4,166 $48.70 $6, $18.43 $2,123 $34.77 $4,247 $51.12 $6, $19.78 $2,165 $37.48 $4,330 $55.18 $6, $21.13 $2,208 $40.19 $4,416 $59.24 $6, $22.49 $2,252 $42.90 $4,503 $63.30 $6, $23.84 $2,295 $45.60 $4,591 $67.36 $6, $25.20 $2,297 $48.31 $4,594 $71.43 $6, $27.83 $2,355 $53.58 $4,709 $79.33 $7, $30.47 $2,411 $58.85 $4,821 $87.23 $7, $33.10 $2,465 $64.12 $4,931 $95.14 $7, $35.74 $2,519 $69.39 $5,038 $ $7, $38.37 $2,571 $74.66 $5,142 $ $7, $40.37 $2,628 $78.66 $5,256 $ $7, $42.56 $2,682 $83.04 $5,365 $ $8, $44.88 $2,733 $87.67 $5,466 $ $8, $47.44 $2,780 $92.80 $5,560 $ $8, $50.13 $2,825 $98.18 $5,650 $ $8,476 *Cash values are for age 65 through age 45 and for 20 years for ages over 45. The proposed rates are for an effective date no later than January 1, HumanaVoluntaryBenefits.com Policy: Underwritten by Kanawha Insurance Company, a Humana company. 32

35 Humana Whole Life 99 rates Virginia Spouse Summary - Portsmouth Public Schools Humana Whole Life 99 rates Spouse, Non-tobacco coverage, Defined Benefit amounts displaying monthly payroll deductions based on monthly premium calculation. Age Benefit Amount BENEFIT: $20,000 CASH VALUE* $25,000 CASH VALUE* 18 $11.88 $9,622 $14.33 $12, $12.41 $9,622 $15.00 $12, $12.95 $9,622 $15.66 $12, $13.48 $9,622 $16.33 $12, $14.01 $9,622 $17.00 $12, $14.55 $9,622 $17.66 $12, $15.08 $9,622 $18.33 $12, $15.61 $9,622 $19.00 $12, $16.33 $9,622 $19.89 $12, $17.03 $9,622 $20.77 $12, $17.75 $9,574 $21.66 $11, $18.46 $9,482 $22.56 $11, $19.18 $9,385 $23.45 $11, $20.11 $9,282 $24.62 $11, $21.05 $9,173 $25.79 $11, $21.96 $9,058 $26.93 $11, $22.90 $8,937 $28.10 $11, $23.83 $8,810 $29.27 $11, $25.13 $8,675 $30.89 $10, $26.41 $8,533 $32.50 $10, $27.70 $8,384 $34.10 $10, $28.98 $8,226 $35.70 $10, $30.26 $8,060 $37.31 $10, $32.00 $7,883 $39.47 $9, $33.73 $7,698 $41.64 $9, $35.46 $7,502 $43.81 $9, $37.20 $7,295 $45.97 $9, $38.93 $7,077 $48.14 $8, $41.41 $7,198 $51.24 $8, $43.89 $7,324 $54.35 $9, $46.39 $7,454 $57.47 $9, $48.88 $7,590 $60.58 $9, $51.36 $7,730 $63.68 $9,662 *Cash values are for age 65 through age 45 and for 20 years for ages over 45. The proposed rates are for an effective date no later than January 1, HumanaVoluntaryBenefits.com Policy: Underwritten by Kanawha Insurance Company, a Humana company. 33

36 Humana Whole Life 99 rates Virginia Spouse Summary - Portsmouth Public Schools Humana Whole Life 99 rates Spouse, Non-tobacco coverage, Defined Benefit amounts displaying monthly payroll deductions based on monthly premium calculation. Age Benefit Amount BENEFIT: $20,000 CASH VALUE* $25,000 CASH VALUE* 51 $54.58 $7,876 $67.70 $9, $57.79 $8,025 $71.72 $10, $61.03 $8,176 $75.76 $10, $64.24 $8,333 $79.79 $10, $67.46 $8,494 $83.81 $10, $72.88 $8,660 $90.58 $10, $78.29 $8,832 $97.35 $11, $83.71 $9,007 $ $11, $89.13 $9,182 $ $11, $94.54 $9,187 $ $11, $ $9,419 $ $11, $ $9,643 $ $12, $ $9,862 $ $12, $ $10,076 $ $12, $ $10,284 $ $12, $ $10,511 $ $13, $ $10,730 $ $13, $ $10,933 $ $13, $ $11,120 $ $13, $ $11,301 $ $14,126 *Cash values are for age 65 through age 45 and for 20 years for ages over 45. The proposed rates are for an effective date no later than January 1, HumanaVoluntaryBenefits.com Policy: Underwritten by Kanawha Insurance Company, a Humana company. 34

37 If you were told you had cancer, what might you or your family have to do without? CAR SAVINGS HOME Cancer Insurance Supplements existing coverage and can provide cash to help with medical and living expenses Cancer Insurance from Allstate Benefits pays cash benefits for cancer and 20 specified diseases to help with the costs associated with treatments and expenses as they happen. ABJ Page 1 of 6

38 cancer Receiving a diagnosis of cancer or a specified disease can be difficult on anyone, both emotionally and financially. Having the right coverage to help when undergoing treatments is important. Our cancer coverage can help provide added financial support when it is needed most. Cancer coverage can help offer peace of mind when a diagnosis of cancer or a specified disease occurs. Below is an example of how benefits might be paid.* Jane Chooses Cancer Coverage from the plan benefits her employer is offering Jane s annual wellness exam results in her first diagnosis of cancer and she is told she needs surgery. She gets a second surgical opinion and undergoes pre-op testing. She is admitted to the hospital, undergoes inpatient surgery, anesthesia, private nursing, and is visited by a doctor during a 3-day hospital stay. Every 2 weeks she has radiation/ chemo 120 miles from her home and a family member drives her to her appointments. Our cancer insurance policy paid Jane the following: Wellness $ 50 Second Opinion $ 200 Hospital Confinement $ 600 Surgery $ 3,000 Anesthesia $ 750 Radiation/Chemo $10,000 Inpatient Medicine $ 30 Private Nursing $ 300 Cancer Initial Diagnosis $ 2,000 Non-Local Transportation $ 280 Physician Attendance $ 90 Total Benefits: $17,300 *The example shown may vary from the plan your employer is offering. Your individual experience may also vary. Please see pages 2a and/or 2b for your plan details. meeting your needs Our cancer and specified disease coverage can help offer you and your family financial support. Here s what you get: Coverage for cancer and 20 other specified diseases Benefits that are paid in addition to any other insurance you may have Can be used for non-medical expenses health insurance might not cover Guaranteed renewable for life, subject to change in premiums by class Premiums do not increase due to age Waiver of premium after 90 days of disability due to cancer for as long as your disability lasts** ** primary insured only benefit coverage highlights Cancer and specified disease benefits can help cover the costs of specific treatments and expenses as they happen. Terms and conditions for each benefit will vary. Benefit amounts are shown on pages 2a and/or 2b. See pages 4 and 5 for limits and conditions, and page 5 for state variations. 20 Specified Diseases Covered - Muscular Dystrophy, Poliomyelitis, Multiple Sclerosis, Encephalitis, Rabies, Tetanus, Typhoid Fever, Bubonic Plague, Tuberculosis, Osteomyelitis, Diphtheria, Scarlet Fever, Epidemic Cerebrospinal Meningitis, Undulant Fever, Sickle Cell Anemia, Rocky Mountain Spotted Fever, Smallpox, Addison s Disease, Hansen s Disease, Tularemia. RIDER BENEFIT Cancer Initial Diagnosis Level Benefit - Pays a one-time benefit if diagnosed for the first time with cancer (except skin cancer). RADIATION/CHEMOTHERAPY BENEFITS Radiation Therapy, Radioactive Isotopes Therapy, Chemotherapy or Immunotherapy - Pays a benefit for covered treatment to destroy or modify cancerous tissue. Blood, Plasma and Platelets - Pays a benefit for blood, plasma and platelets. Includes charges for transfusions, administration, processing, procurement and cross-matching. Page 2 of 6 ABJ

39 October 18 A doctor visit is scheduled Tests are run and results received You get cash benefits SURGERY AND RELATED BENEFITS Inpatient Surgery* - Pays a benefit for an inpatient operation. Outpatient Surgery*- Pays a benefit for an outpatient operation. Second Surgical Opinion - Pays a benefit when you get a second surgical opinion. Anesthesia - Pays a benefit for anesthesia received during a covered surgery. Ambulatory Surgical Center - Pays a daily benefit for surgery at an ambulatory surgical center. HOSPITAL CONFINEMENT BENEFITS Hospital Confinement - Pays a daily benefit for inpatient confinement. Extended Hospital Confinement - Pays a daily benefit when continuously confined in a hospital for more than 70 days. In lieu of all other benefits. Government or Charity Hospital - Pays a daily benefit for inpatient confinement to a U.S. government hospital or a hospital that does not charge for its services. In lieu of all other benefits. Private Duty Nursing Services - Pays a daily benefit when receiving physician-authorized inpatient private nursing services. Extended Care Facility - Pays a daily benefit for physicianauthorized inpatient confinement (within 14 days of a hospital stay). At Home Nursing - Pays a daily benefit for physicianauthorized private nursing care (within 14 days of a hospital stay). LODGING AND TRANSPORTATION BENEFITS Ambulance - Pays a benefit for transfer by ambulance service to or from a hospital. Non-Local Transportation - Pays a benefit for transportation for treatment not available locally (up to 700 miles). Family Member Lodging and Transportation - Pays a benefit for one adult family member when confined at a non-local hospital for specialized treatment (more than 100 miles from family member s home). Outpatient Lodging - Pays a daily benefit for lodging when receiving radiation or chemotherapy on an outpatient basis non-locally (more than 100 miles from home). MISCELLANEOUS BENEFITS Hospice Care (Freestanding Hospice Care Center or Hospice Care Team) - Pays a daily benefit when physician approves and determines terminal illness requires hospice care at home or in a freestanding hospice care center (within 14 days of hospital stay). Inpatient Drugs and Medicine - Pays a daily benefit for inpatient drugs and medicine. Physician s Attendance - Pays a daily benefit for one inpatient visit. New or Experimental Treatment - Pays a benefit for physician-approved new or experimental treatments not covered under other benefits. Physical or Speech Therapy - Pays a daily benefit for therapy to restore normal body function. Prosthesis - Pays a benefit for a surgically implanted prosthetic device. Skin Cancer - Pays a benefit for removal of skin cancer diagnosed by a doctor who is not a pathologist. Waiver of Premium (primary insured only) - Pays premiums after being disabled 90 days in a row due to cancer, for as long as disability lasts. *Assistant and cosurgeons are not covered. Two or more surgical procedures done at the same time, through one incision, are considered one operation. The operation with the largest benefit will be paid. 37 ABJ Page 3 of 6

40 RIDER BENEFITS Wellness Benefit - Pays a benefit when you receive one of the following: Biopsy for skin cancer Blood test for triglycerides Bone Marrow Testing CA15-3 (cancer antigen blood test for breast cancer) CA125 (cancer antigen 125 blood test for ovarian cancer) CEA (carcinoembryonic antigen blood test for colon cancer) Chest X-ray Colonoscopy Doppler screening for carotids Doppler screening for peripheral vascular disease Echocardiogram EKG (Electrocardiogram) Flexible sigmoidoscopy Hemoccult stool analysis HPV (Human Papillomavirus) Vaccination Lipid panel (total cholesterol count) Mammography, including Breast Ultrasound Pap Smear, including ThinPrep Pap Test PSA (prostate specific antigen blood test for prostate cancer) Serum Protein Electrophoresis (test for myeloma) Stress test on bike or treadmill Thermography Ultrasound screening of the abdominal aorta for abdominal aortic aneurysms Hospital Intensive Care - Pays a daily benefit for intensive care and ambulance transportation. Cancer and Specified Disease Additional Benefit (CAB) - Enhances some benefits of the base policy and adds new ones not in the base policy. The rider benefit amount is included with each of these base policy benefits. Benefits enhanced by the CAB rider are: Hospital Confinement; Extended Hospital Confinement; Inpatient Drugs and Medicine; Second Surgical Opinion; Physician s Attendance; Private Duty Nursing Services; Radiation Therapy, Radioactive Isotopes Therapy, Chemotherapy, or Immunotherapy; Blood, Plasma and Platelets; Non-Local Transportation; Family Member Transportation; Ambulatory Surgical Center; Hospice Care; and Physical or Speech Therapy. The rider benefit amount is included with each of these base policy benefits. The following benefits are paid in addition to the base policy. Medical Imaging - Pays a benefit when a covered imaging exam leads to an initial diagnosis or follow-up evaluation. Comfort/Anti-Nausea - Pays a benefit for prescribed anti-nausea medication taken on an outpatient basis. Hematological Drugs - Pays a benefit for drugs to boost cell lines when Radiation Therapy, Radioactive Isotopes Therapy, Chemotherapy or Immunotherapy benefit is paid. Hair Prosthesis - Pays a benefit for a wig or hairpiece when hair loss is experienced. Nonsurgical External Breast Prosthesis - Pays a benefit for the initial nonsurgical breast prosthesis after a covered mastectomy. CERTIFICATE SPECIFICATIONS Renewability - The policy is guaranteed renewable for life, subject to change in premiums by class. All premiums may change on a class basis. A notice is mailed in advance of any change. Eligibility/Termination - (a) Coverage may include you, your spouse and children. (b) Coverage for children ends when the child reaches age 26, unless he or she continues to meet the requirements of an eligible dependent. (c) Spouse coverage ends upon valid decree of divorce. Rider Termination - The riders terminate at the end of the grace period, if the policy terminates, or on the next renewal date after you request termination. Policy and Rider(s) Waiting Period - (a) The policy and rider(s) have a 30-day waiting period that starts on the effective date. Benefits are not paid for any person diagnosed with cancer or a specified disease before coverage is in force 30 days from the effective date. (b) If diagnosis is after signing the application, but before the end of the waiting period, benefits for treatment of that cancer or specified disease will apply to losses beginning after 2 years from the effective date; or, you may void the policy and receive a full refund of premium. Exceptions and Limitations - (a) Benefits are not paid for any loss except for losses due to cancer or specified disease. (b) Benefits are not paid for losses caused or aggravated by cancer or a specified disease or as a result of treatment. (c) Treatment must be received in the U.S. or its territories. Cancer and Specified Disease Additional Benefit (CAB) Rider must be purchased to receive the additional benefits described. 38 ABJ Page 4 of 6

41 Hospice Care Team Benefit Limitation - Services are not covered for food or meals, well-baby care, volunteers or support for the family after the covered person s death. Radiation Therapy, Radioactive Isotopes Therapy, Chemotherapy or Immunotherapy Benefit Limitations - Does not pay for: treatment or emergency room charges; treatment planning, management, devices, or supplies; medications other than chemotherapeutic drugs; X-rays, scans, and their interpretations; or any other drug, charge or expense that does not directly modify or destroy cancerous tissues. Hospital Intensive Care Rider Exceptions and Limitations - (a) Benefits are not paid due to: (1) attempted suicide or self-inflicted injury; (2) intoxication or being under the influence of drugs not prescribed by a physician; (3) alcoholism or drug addiction. (b) Benefits are not paid for continuous intensive-care confinements occurring during hospitalization that begins before the effective date. (c) Children born within 10 months of the effective date are not covered for confinement occurring or beginning during the first 30 days of the child s life. STATE VARIATIONS North Carolina (changes affect pages 3, 4, and 5) - The following is added as a policy benefit: Wellness Benefit - Pays a benefit when you receive one of the following: Mammography - low-dose mammography is covered at the following intervals: (a) one or more per year, as recommended by a physician, for women at risk for breast cancer; (b) every other year for women 35 to 39 years of age, inclusive; (c) every other year for any woman 40 to 49 years of age, inclusive, or more frequently upon recommendation of a physician; and (d) every year for women 50 years of age or older; Pap Smears - every year, or more frequently if recommended by a physician; Biopsy for skin cancer; Blood tests for triglycerides, CA15-3 (breast cancer), CA125 (ovarian cancer), CEA (colon cancer), and PSA (prostate cancer); Bone Marrow Testing, Chest X-ray; Colonoscopy; Doppler screening for carotids or peripheral vascular disease; Echocardiogram; EKG; Flexible sigmoidoscopy; Hemoccult stool analysis; HPV Vaccination; Lipid panel (total cholesterol count); Serum Protein Electrophoresis (test for myeloma); Stress test on bike or treadmill; Thermography; and Ultrasound screening for abdominal aortic aneurysms. In the Policy and Rider(s) Waiting Period paragraph, item (b) is replaced with: If diagnosis is after signing the application, but before the end of the waiting period, benefits for that cancer or specified disease will apply to losses beginning after 12 months from the effective date; or you may void the policy and receive a full refund of premium. In the Hospital Intensive Care Rider Exceptions and Limitations paragraph, item (a)(2) is replaced with: from being intoxicated or under the influence of any narcotic not prescribed by a physician; item (c) is deleted. South Carolina (changes affect pages 3 and 4) The Government or Charity Hospital benefit is replaced with: Charity Hospital - Pays a daily benefit for inpatient confinement to a hospital that does not charge for its services. In lieu of all other benefits. In the Exceptions and Limitations paragraph, item (a) is replaced with: Benefits are not paid for any loss except for losses due to cancer or specified disease or other conditions or diseases caused or aggravated by cancer or a specified disease. Item (b) is deleted. Tennessee (changes affect pages 4 and 5) - The Hospital Intensive Care Rider is renamed Hospital Intensive Care Policy. In the Hospital Intensive Care Policy Exceptions and Limitations paragraph, item (a)(2) is replaced with: from being intoxicated or under the influence of any narcotic unless taken on the advice of a physician. Virginia (change affects page 4) - In the Exceptions and Limitations paragraph, item (b) is deleted. West Virginia (changes affect pages 3 and 5) The following is added to the Inpatient Drugs and Medicine benefit: Pays a benefit for rental of equipment necessary for the treatment of the disease. The Radiation Therapy, Radioactive Isotopes Therapy, Chemotherapy, or Immunotherapy Benefit Limitations paragraph is replaced with: Does not pay for: treatment or emergency room charges; treatment planning, management, devices, or supplies; medications other than chemotherapeutic drugs; or any other drug, charge or expense that does not directly modify or destroy cancerous tissues. Page 5 of 6 ABJ

42 Rev. 5/14. This material is valid as long as information remains current, but in no event later than July 1, Policy benefits provided by policy CP10B, or state variations thereof. Riders provided by riders CLR1, WBR5, CABR1, and ICR2, or state variations thereof. The policy and riders provide Limited Benefit Supplemental Cancer and Specified Disease Insurance. The policy is not a Medicare Supplement Policy. If eligible for Medicare, review Medicare Supplement Buyer s Guide available from Allstate Benefits. This brochure highlights some features of the policy but is not the insurance contract. Only the actual policy provisions control. For complete details, contact your Allstate Benefits Agent. Underwritten by American Heritage Life Insurance Company (Home Office, Jacksonville, FL). This coverage does not constitute comprehensive health insurance coverage (often referred to as major medical coverage ) and does not satisfy the requirement of minimum essential coverage under the Affordable Care Act. This brochure is for use in: KY, NC, OH, SC, TN, VA, WV Allstate Benefits is the marketing name used by American Heritage Life Insurance Company, a subsidiary of The Allstate Corporation Allstate Insurance Company. or allstatebenefits.com. Page 6 of 6 ABJ

43 cancer RIDER BENEFIT Basic Enhanced Premier Cancer Initial Diagnosis Level Benefit $2,000 1 $4,000 1 $5,000 1 RADIATION/CHEMOTHERAPY BENEFITS Radiation Therapy, Radioactive Isotopes $10,000 2 $15,000 2, 3 $20,000 2, 3 Therapy, Chemotherapy, and Immunotherapy* Blood, Plasma, and Platelets* $10,000 2 $15,000 2, 3 $20,000 2, 3 SURGERY AND RELATED BENEFITS Inpatient Surgery* $3,000 $3,000 $3,000 Outpatient Surgery* $4,500 $4,500 $4,500 Second Surgical Opinion* $200 $250 3 $300 3 Anesthesia* (% of surgery) 25% 4 25% 4 25% 4 Ambulatory Surgical Center* (daily) $250 $375 3 $500 3 HOSPITAL CONFINEMENT BENEFITS Hospital Confinement (daily, up to 70 days) $200 $250 3 $300 3 Extended Hospital Confinement* (daily) $200 $300 3 $400 3 Government or Charity Hospital (daily) $100 $100 $100 Private Duty Nursing Services* (daily) $100 $150 3 $200 3 Extended Care Facility* (daily) $100 $100 $100 At Home Nursing* (daily) $100 $100 $100 LODGING AND TRANSPORTATION BENEFITS Ambulance* $200 $200 $200 Non-Local Transportation (per trip or mile) Coach Fare Coach Fare Coach Fare or $0.40 or $ or $ Family Member Lodging* (daily) $100 $100 $100 and Transportation (per trip or mile) Coach Fare Coach Fare Coach Fare or $0.40 or $ or $ Outpatient Lodging* (daily) $100 5 $100 5 $100 5 MISCELLANEOUS BENEFITS Hospice Care* (per day) $100 $150 3 $200 3 Inpatient Drugs and Medicine* (daily) $10 $20 3 $30 3 Physician s Attendance* (daily) $30 $40 3 $50 3 New or Experimental Treatment* $10,000 2 $10,000 2 $10,000 2 Physical or Speech Therapy* (daily) $25 $50 3 $75 3 Prosthesis* $2,000 6 $2,000 6 $2,000 6 Skin Cancer* $120 7 $120 7 $120 7 Waiver of Premium Yes Yes Yes RIDER BENEFITS Wellness (per year) $50 $100 $100 Hospital Intensive Care (+Ambulance) (per day) $600 8 $600 8 $600 8 Cancer and Specified Disease Additional Benefits Medical Imaging* (yearly) No $250 $500 Comfort/Anti-Nausea* (yearly) No $100 $200 Hematological Drugs* (yearly) No $100 $200 Hair Prosthesis (every 2 years) No $25 $50 Nonsurgical External Breast Prosthesis* No $50 $100 Listed to the left are benefit amounts associated with the benefits described in the brochure. * Benefit pays for charges/ costs up to amount listed 1 One-time benefit 2 Per 12 mo. 3 Includes the CAB Rider which increases the base policy benefit 4 $100 for Skin Cancer 5 Limit $4,000 per 12 mo. period 6 Per amputation 7 For first removal. $60 each additional removal 8 Reduces to $300 at age 70. Also pays charges for transportation to ICU. Ambulance ICR Benefit not paid if the base policy ambulance benefit is paid. ABJ Insert-GLT-BEP 41 Page 2a (BEP)

44 premiums MODE PLAN EMPLOYEE FAMILY Weekly Monthly Weekly Monthly Weekly Monthly Basic 200 $4.21 $7.25 Basic 200+ICU $5.59 $10.02 Basic 200 $18.22 $31.42 Basic 200+ICU $24.21 $43.41 Enhanced 300 $6.11 $10.86 Enhanced 300+ICU $7.49 $13.62 Enhanced 300 $26.47 $47.03 Enhanced 300+ICU $32.46 $59.02 Premier 400 $7.47 $13.53 Premier 400+ICU $8.85 $16.30 Premier 400 $32.35 $58.63 Premier 400+ICU $38.34 $70.62 Issue Ages: This insert is for use in: KY, OH, TN, VA This insert is part of brochure ABJ and is not to be used on its own. This material is valid as long as information remains current, but in no event later than July 1, Allstate Benefits is the marketing name used by American Heritage Life Insurance Company, a subsidiary of The Allstate Corporation Allstate Insurance Company. or allstatebenefits.com. ABJ Insert-GLT-BEP 42 Page 2b (BEP)

45 What if you suffered from a heart attack or a stroke... could you pay for your out-of-pocket treatmen t expenses, plus cover da ily living expenses? GROCERIES CAR HOME PRESCRIPTIONS Heart/Stroke Insurance Helps cover costs associated with heart attack, stroke, or heart disease No one likes to think about getting heart disease. While you may not be able to prevent the disease, HeartCare Plus and HeartCare Direct (HSP2) from Allstate Benefits can help protect you and your family from its costs. ABJ Page 1 of 6 (B)

46 heart/stroke It s probably crossed your mind that you or your family may need treatment some day for heart disease or stroke. And you may have thought about the ways it would affect your life and your loved ones. But have you considered how cardiovascular diseases could impact your financial security? Heart/Stroke coverage can help offer peace of mind if you have a heart attack, stroke, or are diagnosed with heart disease. Below is an example of how benefits might be paid. Jane chooses benefit coverage from the Plan Benefits Offered Jane suffers a mild heart attack and is taken to the hospital by ambulance. A physician in the emergency room runs several heart-related tests, and the results show she needs an angioplasty and pacemaker surgery. Jane is admitted for a 3-day hospital stay, she is seen by her physician and receives private nursing services. Jane s prognosis is good and she is expected to make a full recovery. Our insurance policy paid Jane the following: Ambulance $ Hospital Confinement $ Physician's Attendance $ Coronary Angioplasty $ Pacemaker Insertion $ Private Duty Nursing $ Total Benefits: $1, The example shown may vary from the plan your employer is offering. Your individual experience may also vary. Please see pages 2a and/or 2b for your plan details. meeting your needs Our coverage can help provide financial support when a heart attack, heart disease or stroke occurs. Here s what you get: Pays you benefits that can be used for non-medical expenses that health insurance might not cover Benefits are paid as you go to help cover the costs of specific treatments and expenses as they happen Supplemental coverage; it pays in addition to other insurance you may have, such as medical and disability Guaranteed renewable for life, subject to change in premiums by class Coverage for yourself or your entire family your benefit coverage HOSPITALIZATION AND RELATED BENEFITS Hospital Confinement Pays a daily benefit for inpatient confinement due to heart attack, heart disease or stroke. Physician s Attendance Pays a daily benefit for one inpatient visit. Inpatient Drugs and Medicine Pays a daily benefit for inpatient drugs and medicine. Private Duty Nursing Services* Pays a daily benefit when receiving physician-authorized inpatient private nursing services Physiotherapy* Pays a benefit for physiotherapy by a licensed physical therapist during a covered hospital stay. Oxygen** Pays a benefit for oxygen equipment during a covered hospital stay. Cardiograms** Pays a benefit for an electro, echo, phono, or vectorcardiogram required during a covered hospital stay. Cerebral or Carotid Angiogram** Pays a benefit for a cerebral or carotid angiogram required during a covered hospital stay. Page 2 of 6 ABJ23234 *Maximum of 60 days per confinement. **Maximum of 1 payment per confinement. Benefit amounts are shown on pages 2a and/or 2b. See pages 3 and 4 for conditions and limits and also see page 4 for state variations. 44

47 Heart Disease tests covered October 18 You're admitted to the hospital Cardiogram tests received You get paid a cash benefit SURGERY AND RELATED BENEFITS Blood, Plasma and Platelets** Pays a benefit for blood, plasma, or platelets during a covered hospital stay. Cardiac Catheterization Pays a benefit for a cardiac catheterization. Pacemaker Insertion Pays a benefit for the initial insertion of a permanent pacemaker. Thromboendarterectomy Pays a benefit for a thromboendarterectomy. Heart Transplant Pays a benefit for the implantation of a natural human heart. Payable once per covered person. Coronary Angioplasty Pays a benefit for a coronary angioplasty, regardless of the number of blood vessels repaired during the procedure. Coronary Artery Bypass Graft Operation Pays a benefit for a coronary artery bypass graft, regardless of the number of grafts performed during the operation. Second Surgical Opinion Pays a benefit for a second opinion. Surgery and Anesthesia 1. Surgery - Pays a benefit for an inpatient or outpatient operation listed in the Policy Surgical Schedule. 2. Anesthesia - Pays 25% of surgery benefit. 3. Ambulatory Surgical Center - Pays when surgery benefit is paid for surgery at an ambulatory surgical center. These benefits do not pay for surgeries covered by other benefits. TRANSPORTATION AND LODGING BENEFITS Ambulance Pays a benefit for transfer to or from a hospital. Non-Local Transportation** Pays a benefit for transportation for physician-prescribed treatment not available locally (more than 100 miles from home). Family Member Lodging* and Transportation** Pays a benefit for lodging and transportation for one adult family member to accompany you when you have physician-prescribed treatment at a hospital or treatment center more than 100 miles from the family member's home. OPTIONAL RIDER BENEFIT Cancer Initial Diagnosis Pays a one-time benefit if diagnosed for the first time with cancer (except skin cancer). POLICY AND RIDER SPECIFICATIONS Please read your policy carefully. This section details some specifics of the policy and rider. Renewability The policy and rider are guaranteed renewable for life, subject to change in premiums by class. Eligibility/Termination (a) Family coverage may include you, your spouse and children under age 26. Spouse coverage ends upon divorce or your death. (b) Coverage for children ends when the child reaches age 26, unless he or she continues to meet the requirements of an eligible dependent. Policy Exclusions and Limitations (a) The policy pays benefits only for heart attack, heart disease or stroke. (b) The policy does not cover any other disease or sickness or incapacity even though caused, complicated or otherwise affected by heart attack, heart disease or stroke. (c) If a covered confinement is due to more than one covered condition, benefits are paid as though the confinement was due to one condition. Pre-Existing Condition Limitation for Policy and Rider (a) We do not pay benefits for pre-existing conditions during the 12-month period beginning on each covered person's effective date. (b) A pre-existing condition is a condition not revealed in the application for which symptoms existed within a 1-year period before the effective date; or medical advice or treatment was recommended by or received from a doctor within the 1-year period before the effective date. Cancer Initial Diagnosis Rider Exclusions and Limitations Benefits are not paid for any disease other than cancer as defined in the rider. Pre-cancerous and skin cancer are not included. *Maximum of 60 days per confinement. **Maximum of 1 payment per confinement. 45 ABJ23234 Page 3 of 6

48 STATE VARIATIONS Delaware (change affects page 3) In the Policy Exclusions and Limitations, item (b) is deleted. In the Pre-Existing Condition Limitation, item (b) is replaced with: A pre-existing condition is the existence of symptoms which would cause an ordinarily prudent person to seek diagnosis, care or treatment within the 1-year period before the effective date, or medical advice or treatment was recommended by or received from a physician within the 1-year period before the effective date. Virginia (changes affect page 3) - In the Exclusions and Limitations, item (b) is deleted. In the Pre-Existing Condition Limitation, item (b) is replaced with: A pre-existing condition is a condition not revealed in the application for which symptoms existed which would cause an ordinarily prudent person to seek diagnosis, care or treatment within one year before the effective date. District of Colombia (change affects page 3) In Eligibility/ Termination paragraph, item (a) is replaced with: Family coverage may include you; your spouse, domestic partner, or civil union partner; and children under 26. Spouse coverage ends upon divorce or your death. If your civil union partner is a covered person, your civil union partner's coverage ends upon termination of the civil union partnership or your death. If your domestic partner is a covered person, your domestic partner's coverage ends upon termination of the domestic partnership or your death. Maryland (change affects page 3) In the Exclusions and Limitations, item (b) is deleted. North Carolina (change affects page 3) In the Pre-Existing Condition Limitation, item (b) is replaced with: A preexisting condition is a condition not revealed in the application for which symptoms existed within a 1-year period before the effective date; and medical advice or treatment was recommended by or received from a doctor within the 1-year period before the effective date. South Carolina (changes affect pages 3) In the Policy Exclusions and Limitations, item (b) is deleted. In the Pre-Existing Condition Limitation, item (b) is replaced with: A pre-existing condition is a condition which is misrepresented or not revealed in the application and for which symptoms existed before the effective date that would cause an ordinarily prudent person to seek diagnosis, care or treatment or medical advice or treatment was recommended by or received from a physician. Tennessee (changes affect page 3) - In the Exclusions and Limitations, item (a) is replaced with: The policy provides benefits only for Heart Attack, Coronary Artery Disease or Stroke; item (b) is replaced with: This policy does not cover any other disease or sickness or incapacity other than Heart Attack, Coronary Artery Disease or Stroke even though such disease, sickness or incapacity may be caused, complicated or otherwise affected by Heart Attack, Coronary Artery Disease or Stroke. 46 ABJ23234 Page 4 of 6

49 Don t wait for a sign... A heart attack or stroke can happen unexpectedly and can be costly, especially if you are financially unprepared. Your current medical coverage will help pay for expenses associated with a heart attack or stroke, but won t cover all of the out-of-pocket expenses you may face. Don t wait until you are rushed to the emergency room to realize you need more protection. Start thinking about the future or your finances today and plan for emergencies that might come your way. You can rely on our insurance to help provide the financial assistance you need, when you need it most, so you can focus on the challenges of recovery. If you suffer a heart attack or stroke, would you be able to handle the extra expenses associated with your recovery? It s never too early to prepare for the future. Page 5 of 6 ABJ

50 This material is valid as long as information remains current, but in no event later than February 15, Policy benefits provided by policy form HSP2, or state variations thereof. Cancer Initial Diagnosis Rider benefit provided by CIDR1, or state variations thereof. The policy and rider provides supplemental, limited benefit insurance. The policy and rider are not Medicare Supplement Policies. If eligible for Medicare, review Medicare Supplement Buyer's Guide available from Allstate Benefits. The policy and rider set forth, in detail, the rights and obligations of both the insured and the insurance company. This brochure highlights some features of the policy but is not the insurance contract. Only the actual policy provisions control. For complete details, contact your Insurance Agent, or call Underwritten by American Heritage Life Insurance Company (Home Office, Jacksonville, FL). This brochure is for use in: DE, DC, KY, MD, NC, OH, SC, TN, VA Allstate Benefits is the marketing name used by American Heritage Life Insurance Company, a subsidiary of The Allstate Corporation Allstate Insurance Company. or allstatebenefits.com Page 6 of 6 ABJ

51 heart/stroke HeartCare Plus HOSPITALIZATION AND RELATED BENEFITS LOW PLAN HIGH PLAN Hospital Confinement (daily) $100 $200 Physician s Attendance (daily) $12.50 $25 Inpatient Drugs and Medicine (daily) $12.50 $25 Private Duty Nursing Services (daily) $50 $100 Physiotherapy (daily) $25 $50 Oxygen $100 $200 Cardiograms $50 $100 Cerebral or Carotid Angiogram $75 $150 SURGERY AND RELATED BENEFITS LOW PLAN HIGH PLAN Blood, Plasma and Platelets $100 $200 Cardiac Catheterization $250 $500 Pacemaker Insertion $500 $1,000 Thromboendarterectomy $1,250 $2,500 Heart Transplant $50,000 $100,000 Coronary Angioplasty $375 $750 Coronary Artery Bypass Graft Operation $1,250 $2,500 Second Surgical Opinion $50 $100 Surgery and Anesthesia 1. Surgery 1. $2,500 max. 1. $5,000 max. 2. Anesthesia 2. 25% 2. 25% 3. Ambulatory Surgical Center 3. $ $250 TRANSPORTATION AND LODGING BENEFITS LOW PLAN HIGH PLAN Ambulance Non-Air Ambulance $100 $200 Air Ambulance $200 $400 Non-Local Transportation $100 $200 Family Member Lodging (daily) $25 $50 Family Member Transportation $100 $200 RIDER BENEFIT LOW PLAN HIGH PLAN Cancer Initial Diagnosis Rider 1 $5,000 $10,000 PACKAGES Low Plan Heart/Stroke + Cancer Initial Diagnosis Rider High Plan Heart/Stroke + Cancer Initial Diagnosis Rider 1 One time benefit. premiums MODE PLAN EMPLOYEE FAMILY Weekly Low $3.65 $7.14 Monthly Low $15.78 $30.92 Weekly High $7.29 $14.27 Monthly High $31.56 $61.84 Issue Ages: This insert is for use in: DE, DC, KY, OH, TN, VA This insert is part of brochure ABJ23234 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. ABJ23234-Insert-GLT-B 49 Page 2a (B)

52 Peace of Mind and Real Cash Benefits GROUP CRITICAL ILLNESS Includes Cancer and Wellness This brochure is a brief description of coverage and is not a contract. Read your certificate carefully for exact terms and conditions. Definitions, waiting period, pre-existing condition limitation, limitations and exclusions, benefits, termination, portability, etc., may vary based on your employer's home office. Please 50 see your agent for the plan details specific to your employer. CI G CAI2875 IC(3/10)

53 CI G GROUP Critical Illness Policy Series CAI2800 This brochure is a brief description of coverage and is not a contract. Read your certificate carefully for exact terms and conditions. You can win the battle against a critical illness, but can you handle the added costs? A g rou p cri tica l illne ss pla n he lps pr ep ar e y ou f or th e ad d ed costs o f ba ttling a spe cific cr it ical illn es s. The good news is that many people with a critical illness survive these lifethreatening battles. Unfortunately, as the recovery process begins, people become aware of the medical bills that have piled up. Y ou r recov ery do e sn t ha ve to be spo iled b y m ed ical b ills. With this plan, our goal is to help you and your family cope with and recover from the financial stress of surviving a critical illness. COVERAGE WORK SHEET Employee Benefit: $ Spouse Benefit: $ Child Benefit: $ Total Weekly Deduction: $ (25 percent of the primary insured amount) This work sheet is for illustration purposes only. It does not imply coverage. 51

54 B E N E F ITS This brochure is a brief description of coverage and is not a contract. Read your certificate carefully for exact terms and conditions. Cov e r e d Cr iti c a l Ill n es s es : 1 CANCER (Internal or Invasive) HEART ATTACK (Myocardial Infarction) STROKE (Apoplexy or Cerebral Vascular Accident) MAJOR ORGAN TRANSPLANT 100% 100% 100% 100% RENAL FAILURE (End-Stage) CARCINOMA IN SITU2 CORONARY ARTERY BYPASS SURGERY2 100% 25% 25% FIRST - O C C URREN CE B ENE FIT RE - OC C U RREN C E B ENE F IT After the waiting period, a lump sum benefit is payable upon initial diagnosis of a covered critical illness. Employee benefit amounts available from $5,000 to $50,000. Spouse coverage is also available in benefit amounts up to $25,000. If you are deemed ineligible due to a previous medical condition, you still retain the ability to purchase Spouse coverage. If an insured collects full benefits for a covered condition and is later diagnosed with the same condition, we will pay the full benefit again. The two dates of diagnosis must be separated by at least 12 months, or for cancer, 12 months treatment free. Cancer that has spread (metastasized) even though there is a new tumor, will not be considered an additional occurrence unless the Insured has gone treatment free for 12 months. ADDITIONA L O C C U RREN C E B ENE F IT If an insured collects full benefits for a critical illness under the plan and later has one of the remaining covered critical illnesses, then we will pay the full benefit amount for each additional illness. Occurrences must be separated by at least six months. C H I L D C OVERAGE AT NO ADDITIONA L C OST Each Dependent Child is covered at 25 percent of the primary insured amount at no additional charge. 1.4 $50 He alth Screening Benefit (Employee and Spouse only) OVER After the waiting period, an insured may receive a maximum of $50 for any one covered health screening test per calendar year. We will pay this benefit regardless of the results of the test. Payment of this benefit will not reduce the critical illness benefit payable under your certificate. There is no limit to the number of years the insured can receive the health screening benefit; it will be paid as long as the certificate remains in force. This benefit is payable for the covered Employee and Spouse. This benefit is not paid for Dependent Children. FAC T MILLION The number of new cancer cases that were expected to be diagnosed in Cancer Facts & Figures 2009, American Cancer Society. C o v e r e d h e a lt h s c r e e n i n g t e s t s i n clu d e : Mammography Colonoscopy Pap smear Breast ultrasound Chest X-ray PSA (blood test for prostate cancer) Stress test on a bicycle or treadmill Bone marrow testing CA 15-3 (blood test for breast cancer) CA 125 (blood test for ovarian cancer) CEA (blood test for colon cancer) Flexible sigmoidoscopy Hemocult stool analysis Serum protein electrophoresis (blood test for myeloma) Thermography Fasting blood glucose test Serum cholesterol test to determine level of HDL and LDL All covered conditions are subject to the definitions found in your certificate. If a benefit is paid for Carcinoma in Situ, the Internal Cancer benefit will be reduced by 25 percent. If a benefit is paid for Coronary Artery Bypass Surgery, the Heart Attack benefit will be reduced by 25 percent. 1 2 What is Not Covered, Limitations and EXCLUSIONS, AND TERMS YOU NEED TO KNOW If di agn os is o ccu r s a f t er t h e a g e o f 7 0, h a lf o f t h e ben efi t is p a ya ble. The plan contains a 30-day waiting period. This means that no benefits are payable for any insured who has been diagnosed before your coverage has been in force 30 days from the effective date. If an insured is first diagnosed during the waiting period, benefits for treatment of that critical illness will apply only to loss starting after 12 months from the Effective Date or the Employee can elect to void the coverage and receive a full refund of premium. The applicable benefit amount will be paid if: the date of diagnosis is after the waiting period; the date of diagnosis occurs while the certificate is in force; and the cause of the illness is not excluded by name or specific description. ex clu s i ons Benefits will not be paid for loss due to: Intentionally self-inflicted injury or action; Suicide or attempted suicide while sane or insane; Illegal activities or participation in an illegal occupation; 52

55 What is Not Covered, Limitations and EXCLUSIONS, AND TERMS YOU NEED TO KNOW W ar, whether declared or undeclared or military conflicts, participation in an insurrection or riot, civil commotion or state of belligerence; Substance abuse; or Pre-Existing Conditions (except as stated below). made after any applicable Waiting Period. We must receive evidence of the permanent neurological damage provided from computed axial tomography (CAT scan) or magnetic resonance imaging (MRI). Stroke does not mean head injury, transient ischemic attack, or chronic cerebrovascular insufficiency. Cancer (Internal or Invasive) means a malignant tumor characterized by the No benefits will be paid for diagnosis made or treatment received outside of the uncontrolled growth and spread of malignant cells and the invasion of distant tissue. Cancer includes leukemia. Excluded are Cancers that are noninvasive, United States. such as (1) Premalignant tumors or polyps; (2) Carcinoma in Situ; (3) Any Pre-exi s t in g C on dit io n L i m i t a t i o n skin cancers except melanomas; (4) Basal cell carcinoma and squamous cell Pre-Existing Condition means a sickness or physical condition which, within carcinoma of the skin; and (5) Melanoma that is diagnosed as Clark s Level I or the 12-month period prior to the Effective Date, resulted in the insured receiving II or Breslow thickness less than.77 mm. medical advice or treatment. Cancer is also defined as a disease which meets the diagnosis criteria of We will not pay benefits for any critical illness starting within 12 months of the malignancy established by The American Board of Pathology after a study of the Effective Date which is caused by, contributed to, or resulting from a Prehistocytologic architecture or pattern of the suspect tumor, tissue, or specimen. Existing Condition. A claim for benefits for loss starting after 12 months from the Effective Date will not be reduced or denied on the grounds that it is caused by a Carcinoma in Situ means Cancer that is in the natural or normal place, Pre-Existing Condition. A critical illness will no longer be considered pre-existing confined to the site of origin without having invaded neighboring tissue. at the end of 12 consecutive months starting and ending after the Effective Date. Renal Failure (Kidney Failure) means the end-stage renal failure presenting as chronic, irreversible failure of both of your kidneys to function. The Kidney Failure TERMS Y O U NEED TO K NO W The Effective Date of your insurance will be the date shown in your Certificate must necessitate regular renal dialysis, hemodialysis or peritoneal dialysis (at least weekly); or which results in kidney transplantation. Renal failure is covered, Schedule. provided it is not caused by a traumatic event, including surgical traumas. Employee means the insured as shown in the Certificate Schedule. Coronary Artery Bypass Surgery means undergoing open heart surgery to Spouse means an Employee's legal wife or husband. correct narrowing or blockage of one or more coronary arteries with bypass Dependent Children means your natural children, stepchildren, legally adopted grafts, but excluding procedures such as but not limited to balloon angioplasty, children, or children placed for adoption, who are unmarried, chiefly dependent laser relief, stents or other nonsurgical procedures. on you or your Spouse for support, and younger than age 25. A doctor, physician, or pathologist does not include an insured or a family However, if any child is incapable of self-sustaining employment due to mental member. retardation or physical handicap and is dependent on a parent(s) for support, P o r ta bl e C o v e r a g e the above age of 25 limitation shall not apply. Proof of such incapacity and When coverage would otherwise terminate because the Employee ends dependency must be furnished to the company within 31 days following such employment with the employer, coverage may be continued. The Employee will child s 25th birthday. continue the coverage that is in force on the date employment ends, including dependent coverage then in effect. Treatment means consultation, care, or services provided by a physician, including diagnostic measures and taking prescribed drugs and medicines. The Employee will be allowed to continue the coverage until the earlier of the date the Employee fails to pay the required premium or the date the group Major Organ Transplant means undergoing surgery as a recipient of a master policy is terminated. Coverage may not be continued if the Employee fails transplant of a human heart, lung, liver, kidney, or pancreas. to pay any required premium or the group master policy terminates. Myocardial Infarction (Heart Attack) means the death of a portion of the heart muscle (myocardium) resulting from a blockage of one or more coronary t erm i na t i on arteries. Heart Attack does not include any other disease or injury involving the Coverage will terminate on the earliest of: (1) The date the master policy is cardiovascular system. Cardiac arrest not caused by a Myocardial Infarction is terminated; (2) The 31st day after the premium due date if the required premium has not been paid; (3) The date the insured ceases to meet the definition of an not a Heart Attack. The diagnosis must include all of the following criteria: 1. New and serial eletrocardiographic (EKG) findings consistent with Myocardial Employee as defined in the master policy; or (4) The date the Employee is no Infarction; 2. Elevation of cardiac enzymes above generally accepted laboratory longer a member of the class eligible. levels of normal [in case of creatine phosphokinase (CPK), a CPK-MB Coverage for an insured Spouse or Dependent Child will terminate on the measurement must be used]; and 3. Confirmatory imaging studies such as earliest of: (1) The date the master policy is terminated; (2) The 31st day after thallium scans, MUGA scans, or stress echocardiograms. the premium due date if the required premium has not been paid; (3) The Stroke means apoplexy (due to rupture or acute occlusion of a cerebral artery), premium due date following the date the Spouse or Dependent Child ceases to be a dependent; or (4) The premium due date following the date we receive a or a cerebral vascular accident or incident which is first manifested on or written request to terminate coverage for a Spouse and/or Dependent Children. after your Effective Date. Stroke does not include transient ischemic attacks and attacks of vertebrobasilar ischemia. We will pay a benefit for Stroke that produces permanent clinical neurological sequela following an initial diagnosis No benefits will be paid for loss which occurred prior to the Effective Date. We ve got you under our wing. aflacgroupinsurance.com The certificate to which this sales material pertains is written only in English; the certificate prevails if interpretation of this material varies. Underwritten by: Continental American Insurance Company 2801 Devine Street Columbia, South Carolina This brochure is a brief description of coverage and is not a contract. Read your certificate carefully for exact terms and conditions. This brochure is subject to the terms, conditions, and limitations of Policy Form Series CAI

56 Portsmouth 20 pay Rate sheet prepared by Web User on 12/10/ :40:27 AM. Virginia Payroll Premium rates are 20pp/yr. Aflac Group coverage is underwritten by Continental American Insurance Company (CAIC) The rates shown on this insert page are for illustration purposes only; they do not imply coverage. For more information about policy/plan benefits and limitations, please refer to the accompanying product brochure for each insurance policy/plan listed below. CAIC GROUP CRITICAL ILLNESS Series NON- TOBACCO for Employee Age $5,000 $10,000 $15,000 $20,000 $25,000 $30,000 $35,000 $40,000 $45,000 $50, $2.16 $3.27 $4.38 $5.49 $6.60 $7.71 $8.82 $9.93 $11.04 $ $3.09 $5.13 $7.17 $9.21 $11.25 $13.29 $15.33 $17.37 $19.41 $ $5.19 $9.33 $13.47 $17.61 $21.75 $25.89 $30.03 $34.17 $38.31 $ $8.53 $16.01 $23.49 $30.97 $38.45 $45.93 $53.41 $60.89 $68.37 $ $13.05 $25.05 $37.05 $49.05 $61.05 $73.05 $85.05 $97.05 $ $ CAIC GROUP CRITICAL ILLNESS Series NON-TOBACCO for Spouse Age $5,000 $7,500 $10,000 $12,500 $15,000 $17,500 $20,000 $22,500 $25, $2.16 $2.72 $3.27 $3.83 $4.38 $4.94 $5.49 $6.05 $ $3.09 $4.11 $5.13 $6.15 $7.17 $8.19 $9.21 $10.23 $ $5.19 $7.26 $9.33 $11.40 $13.47 $15.54 $17.61 $19.68 $ $8.53 $12.27 $16.01 $19.75 $23.49 $27.23 $30.97 $34.71 $ $13.05 $19.05 $25.05 $31.05 $37.05 $43.05 $49.05 $55.05 $61.05 CAIC GROUP CRITICAL ILLNESS Series TOBACCO for Employee Age $5,000 $10,000 $15,000 $20,000 $25,000 $30,000 $35,000 $40,000 $45,000 $50, $2.91 $4.77 $6.63 $8.49 $10.35 $12.21 $14.07 $15.93 $17.79 $ $4.56 $8.07 $11.58 $15.09 $18.60 $22.11 $25.62 $29.13 $32.64 $ $9.75 $18.45 $27.15 $35.85 $44.55 $53.25 $61.95 $70.65 $79.35 $ $16.05 $31.05 $46.05 $61.05 $76.05 $91.05 $ $ $ $ $25.05 $49.05 $73.05 $97.05 $ $ $ $ $ $ CAIC GROUP CRITICAL ILLNESS Series TOBACCO for Spouse Age $5,000 $7,500 $10,000 $12,500 $15,000 $17,500 $20,000 $22,500 $25, $2.91 $3.84 $4.77 $5.70 $6.63 $7.56 $8.49 $9.42 $ $4.56 $6.32 $8.07 $9.83 $11.58 $13.34 $15.09 $16.85 $ $9.75 $14.10 $18.45 $22.80 $27.15 $31.50 $35.85 $40.20 $ $16.05 $23.55 $31.05 $38.55 $46.05 $53.55 $61.05 $68.55 $ $25.05 $37.05 $49.05 $61.05 $73.05 $85.05 $97.05 $ $ Rates include cancer benefit. Rates include $50 Health Screening Benefit. 54

57 LIMITED BENEFIT ACCIDENT ONLY Insurance Plan Underwritten by American Fidelity Assurance Company Wellness Benefit Benefits Paid Directly to You Excellent Customer Service Learn More»» Marketed by: First Financial Administrators, Inc. P.O. Box Houston, TX Local (281) Toll Free (800) Fax (866)

58 Accident Only Insurance Life Provides the Accidents, First Financial Offers a Solution! Whether you re a weekend warrior with an active lifestyle or just a busy family, accidents can happen to you anytime, anywhere without warning. First Financial is pleased to offer American Fidelity Assurance Company s (AFA) Limited Benefit Accident Only Insurance. Accident Only Insurance can offer a solution to help you and your family prepare for those rising medical costs if you have to receive medical treatment for an Accidental injury. Think It Couldn t Happen to You? Consider this... Know The Facts: Total costs of accidental injuries averaged $19,216 per injury in National Safety Council, Injury Facts, 2012 Edition, p $19,216 How Would You Cover Your Out-of-Pocket Costs? Just going for a walk around the block or heading to your driveway could lead to a twisted knee and torn meniscus, one of the more common claims submitted under this plan. EMERGENCY ACCIDENT - Hypothetical Example 1 Twisted knee in the parking lot resulting in a torn meniscus and treatment is received within 72 hours. ENHANCED PLAN BENEFITS Accident Emergency Treatment $200 Accident Follow-Up Treatment (4 visits) $200 Physical Therapy (8 treatments) $200 Medical Imaging $200 X-Ray $100 Appliances $100 Surgical Facility $250 Torn Knee Cartilage Repair $500 Anesthesia $200 Total $1,950 Paid Directly To You! 1 Hypothetical example of a covered accident based on policy AO-03 and rider AMDI

59 Marketed by: First Financial Group of America Solutions For Life s Accidents... The Accident Only Plan is the insurance policy that provides payments direct to you protecting you and your family from some of the expenses brought about by injuries suffered in an Accident, regardless of any additional coverage you may have. It s guaranteed renewable for as long as you pay your premiums. Accident Only Insurance Features:» No medical questions.» Benefits paid directly to you, to be used however you see fit.» Benefits regardless of other coverage.» Coverage for you and each covered family member 24 hours a day, 7 days a week.» Available conveniently through your employer with payroll deduction.» Policy is guaranteed renewable at the option of the primary insured for life as long as premiums are paid as required. Any additional insureds must meet eligibility as outlined in the policy. The company has the right to change premium rates by class. Currently participating in, or possibly moving to a High Deductible Health Plan? Health Savings Account (HSA) and qualified High Deductible Health Plan enrollments have quadrupled in the past six years and are on the rise 2. The Choice is Yours: Be prepared with either of American Fidelity s two plan options (Basic and Enhanced) that provide the benefit amounts you require. Plus, American Fidelity supplies the coverage you need with four choices of coverage including individual, individual and spouse, individual and child(ren), and family. Ready To Learn More? Contact your First Financial Account Representative for more details or to schedule an one-on-one appointment. [Account Rep Name Here First Financial Group of America N. Freeway, Suite 900 Houston, TX Local: (281) / Toll Free: (800) ] 2 AHIP: January 2012 Census Shows 13.5 Million People covered by HSA/High-Deductible Health Plans, May 2012, p.3. 57

60 3 Schedule of Benefits Emergency Accident Benefits Basic Enhanced Emergency Accident Treatment Emergency Accident Treatment $150 $200 Emergency Accident Follow-up Treatment (up to four visits) $50 $50 Accident Injury Benefits Benefit amounts for the following Benefits are the same for Basic and Enhanced Plans for all Persons: Primary, Spouse, and Child(ren). Basic / Enhanced Injury Treatment Fractures Benefit (Depending on open or closed reduction, bone involved, or chip fracture). $25 to $3,000 Lacerations Benefit Not requiring sutures Sutured lacerations up to two inches Sutured lacerations totaling two to six inches Sutured lacerations totaling over six inches $25 $100 $200 $400 Appliances Benefit (crutches, leg braces, etc.) $100 Torn Knee Cartilage or Ruptured Disc Benefit $500 Eye Injury Benefit Injury with surgical repair, for one or both eyes. Removal of foreign body by a Physician, for one or both eyes. Dislocations Benefit Depending on open or closed reduction, with or without anesthesia and joint involved. No other amount will be paid under this benefit. $250 $50 $25 to $3,000 Concussion Benefit $200 2nd & 3rd Degree Burns(Skin grafts are 25% of benefit) $100 to $10,000 Internal Injuries Benefit Resulting in open abdominal or thoracic surgery $1,000 Paralysis Benefit: Paraplegia / Quadriplegia $5,000 / $10,000 Tendons, Ligaments and Rotator Cuff Benefit One Tendon, Ligament or Rotator Cuff More than One Tendon, Ligament or Rotator Cuff $500 $750 Blood, Plasma and Platelets $250 Exploratory Surgery without Surgical Repair $250 Physical Therapy (per treatment up to eight treatments) $25 Prosthesis $500 Emergency Dental Work Broken teeth repaired with crown Extraction of broken teeth (regardless of number) Refer to Plan Benefit Highlights for complete Benefit Descriptions and limits on the Accident Only Insurance Plan. 58 $150 $50

61 A Highlight of Benefits Available Under The Plan Wellness Benefit Basic Enhanced Wellness Annual Routine Physical Exam (Requires a 12-month waiting period before use and one exam per policy per calendar year.) $50 $75 Accidental Death & Dismemberment Benefit Accidental Death & Dismemberment Basic Primary Spouse Child Common Carrier $50,000 $50,000 $25,000 Other Accident $15,000 $15,000 $7,500 Dismemberment $1,000 to $15,000 $1,000 to $15,000 $500 to $7,500 Enhanced Primary Spouse Child Common Carrier $100,000 $100,000 $50,000 Other Accident $30,000 $30,000 $15,000 Dismemberment $1,500 to $30,000 $1,500 to $30,000 $750 to $15,000 Additional Accident Benefits Basic Enhanced Non-Emergency Accident Treatment Non-Emergency Accident Treatment $75 $100 Non-Emergency Follow-up Treatment (up to two visits) $50 $50 Hospital Confinement Hospital Admission $500 $1,000 Intensive Care Unit (up to 15 days) $300 $600 Hospital Confinement (up to 365 days) $100 $200 Medical Imaging MRI, CT, CAT, PET, US $200 $200 X-Rays $50 $100 Ambulance Ground $300 $300 Air $1,500 $1,500 Treatment Outpatient Hospital or Ambulatory Surgical Center $150 $250 Anesthesia $150 $200 Transportation Benefits Transportation (Patient Only) (per round trip for up to three round trips per calendar year) Family Member Lodging and Meals (per day per Accident; up to 30 days per confinement) 59 $300 $300 $100 $100

62 Plan Benefit Highlights A Covered Person (thereafter referred to as Person ) under American Fidelity s Limited Benefit Accident Only Policy can expect the following benefits when a Covered Accident (thereafter referred to as Accident ) happens. All benefits are paid once per Person per Accident unless otherwise specified. All benefits are only paid as a result of Injuries received in an Accident that occurs while coverage is in force. Benefits are not be paid for loss from sickness. All treatment, procedures, and medical equipment must be diagnosed, recommended and treated by a Physician. These references are not intended to change or modify any definitions in the AO-03 policy series. Accident Emergency Treatment Benefit Payable for receiving emergency treatment in a Physician s office or emergency room within 72 hours, including physician fees and emergency services. Accident Follow-up Treatment Benefit Payable for necessary follow-up treatment of Injuries in addition to the emergency treatment administered within 72 hours for up to four treatments. Not payable for a visit in which a Physical Therapy Benefit or Non-Emergency Follow-Up Benefit is paid. Accidental Death and Dismemberment Benefit The applicable benefits apply when a Accidental Death or Dismemberment occurs within 90 days of an Accident. Or, if Accidental Death or Dismemberment occurs within one year from the date of the Covered Person s accident and during a period of continuous total disability resulting from the Accident and commencing within 30 days of the date of the Accident, we will pay the applicable benefit. Total Disability as used in this benefit means that the Person is: unable to work at any job for which (s)he is qualified by education, training or experience; and not working at any job for pay or benefits; and under the care of a Physician. Ambulance Benefit If air and ground transportation is required for the same Accident, only the highest benefit will be paid. Anesthesia Benefit Pays the amount shown in the Schedule of Benefits for the services of an anesthesiologist for a surgery performed due to an Accident. Hospital Confinement is not required to receive this benefit. We will only pay one Anesthesia Benefit per Person in a 24-hour period even if more than one surgical procedure is performed. This benefit is not payable for local anesthesia. Appliances Benefit Payable for one of the following: crutches, leg braces, back braces, walkers, or wheel chairs. Not payable for Prosthetic Devices. Blood, Plasma and Platelets Benefit Payable for blood, plasma and platelets. This benefit does not provide benefits for immunoglobulins. Burns Benefit Payable for burns when treated by a Physician within 72 hours. Concussion Benefit Payable for a Person who sustains a concussion and is diagnosed by a Physician within 72 hours using any type of medical imaging. Dislocations Benefit Amount payable varies by the joint involved, type of treatment, and type of anesthesia. If a Person receives more than one Dislocation in an Accident, we will pay for all Dislocations up to two times the amount shown in the Schedule of Benefits for the Dislocation involved that has the highest benefit amount. No other amount will be paid under this benefit. Benefits are payable only for the first dislocation of a joint which occurs while this policy is in force. Emergency Dental Work Benefit Payable for repair to natural teeth when treated by a Physician or dentist. Initial dental treatment must be received within 72 hours. Exploratory Surgery Benefit Payable when an exploratory surgical operation without surgical repair is performed. Eye Injury Benefit Payable for one or both eyes requiring treatment. Family Member Lodging and Meals Benefit Payable for lodging and meals for a family member to be near a Person who is Confined in a non-local Hospital. The Hospital must be at least 50 miles one way from the Person s residence or site of the Accident. Fractures Benefit Varies based on the bone involved, type of fracture and type of treatment. If the Person fractures more than one bone, payment is made for all fractures up to two times the amount for the bone involved that has the highest benefit amount. Hospital Admission Benefit Pays per admission for confinement to a Hospital. This benefit does not pay for outpatient treatment, emergency room treatment, or a stay of less than 18 hours in an observation unit. Hospital Confinement Benefit Payable for a one-time Hospital Admission Benefit due to accidental Injuries (does not include emergency room and outpatient treatment). You will also receive a daily benefit for a Hospital Confinement that is longer than 18 hours for up to 365 days and an additional daily benefit for Confinement in an Intensive Care Unit up to 15 days. Intensive Care Unit Benefit Payable for each day of confinement in an Intensive Care Unit, as defined in the policy, up to 15 days. This benefit is paid in addition to the Hospital Confinement Benefit amount. Internal Injuries Benefit Payable for an open abdominal or thoracic surgery performed within 72 hours. Lacerations Benefit This benefit varies based on the severity of the laceration. Medical Imaging Benefit Payable for a Magnetic Resonance Imaging (MRI), a Computed Tomography (CT) scan, a Computed Axial Tomography (CAT) scan, a Positron Emission Tomography (PET) scan or an ultrasound. 60

63 Non-Emergency Accident Initial Treatment Benefit Payable for initial medical treatment when treatment is received more than 72 hours after the Accident. Initial medical treatment must: (1) be received in a Physician s office or emergency room; and (2) be the first treatment; and (3) occur within 30 days. Non-Emergency Accident Follow-up Treatment Benefit Payable only if the Non-Emergency Accident Initial Treatment Benefit is payable and later requires additional treatment: we will pay over and above the initial medical treatment administered. We will pay for up to two treatments. Not payable for the same visit that the Physical Therapy Benefit or the Accident Follow-Up Benefit is paid. Outpatient Hospital or Ambulatory Surgical Center Benefit When a surgical procedure is performed on an outpatient basis in a Hospital or at an Ambulatory Surgical Center, we will pay the indemnity amount shown in the Schedule of Benefits for the facility fee charged by such Hospital or Ambulatory Surgical Center. We will only pay one Outpatient Hospital or Ambulatory Surgical Center Benefit in a 24-hour period even if more than one surgical procedure is performed. This benefit will not be paid for surgery performed in a Hospital emergency room or in a Physician s office. Paralysis Benefit The duration of the Paralysis must be a minimum of 3 consecutive months. Paid once per lifetime per Person. Physical Therapy Benefit Payable for one treatment per day for up to eight treatments by a caregiver licensed in physical therapy. This benefit is not payable for the same visit that the Accident Follow-up Treatment Benefit or Non- Emergency Follow-Up Benefit. Prosthesis Benefit Payable for the use of a Prosthesis. This benefit is not payable for hearing aids; dental aids; eyeglasses; false teeth; or for cosmetic aids such as wigs. Tendons, Ligaments and Rotator Cuff Benefit Payable for the repair of one or more tendons, ligaments, or rotator cuffs. The tendons, ligaments, or rotator cuff must be repaired through surgery. Torn Knee Cartilage or Ruptured Disc Benefit Payable for surgical repair. Transportation Benefit Payable for the transportation when specialized treatment and Hospital Confinement in a non-local Hospital is required. A non-local Hospital must be at least 50 miles away, one way, using the most direct route, from the closer of the Person s residence or site of the Accident. Travel must be by scheduled bus, plane, train, or by car. Ambulance service does not qualify for this benefit. The treatment must be prescribed by a Physician and not be available locally. Wellness Benefit After coverage is in force for the waiting period shown, you can receive a benefit for an annual routine physical exam, including immunizations and preventive testing. Services must be supervised by a Physician and a charge must be incurred for the service. The benefit does not apply to dental or eye exams and is payable once per policy per calendar year. Limitations and Exclusions Base Policy No benefits will be provided for an Accident that is caused by or occurs as a result of: (1) intentionally self-inflicted bodily injury, suicide or attempted suicide, whether sane or insane; (2) participation in any form of flight aviation other than as a farepaying passenger in a fully licensed/passenger-carrying aircraft; (3) any act that was caused by war, declared or undeclared, or service in any of the armed forces; (4) participation in any activity or event while under the influence of any narcotic unless administered by a Physician or taken according to the Physician s instructions; (5) participation in, or attempting to participate in, a felony, riot or insurrection. (A felony is as defined by the law of the jurisdiction in which the activity takes place.). Benefits will not be provided for medical treatment for an Accident received outside the United States or its territories. Benefits will not be paid for services rendered by a member of the immediate family of a Person. An Accident is defined as a sudden, unexpected and unintended event, which results in bodily injury, which is independent of disease or bodily infirmity or any other cause. The policy will not pay benefits for injuries received prior to the Effective Date of coverage that are aggravated or re-injured by any event that occurs after the Effective Date. A hospital is not an institution, or part thereof, used as: a hospice unit, including any bed designated as a hospice or a swing bed; a convalescent home; a rest or nursing facility; a rehabilitative facility; an extended-care facility; a skilled nursing facility; or a facility primarily affording custodial, educational care, or care or treatment for persons suffering from mental diseases or disorders, or care for the aged, or drug or alcohol addiction. You cannot be singled out for a rate increase for any reason. The Insurer has the right to increase premium rates only if rates for all policies in this class change. This is a brief description of the coverage. For actual benefits, limitations, exclusions and other provisions, please refer to the policy, AO-03, and Accident Only Benefit Enhancement Rider, AMDI-258 Series. This coverage does NOT replace Workers Compensation Insurance. This product is inappropriate for people who are eligible for Medicaid coverage. 61

64 Accident Only Insurance Premiums Monthly Premiums Basic Enhanced Individual $19.90 $26.10 Individual & Spouse $28.30 $34.90 Individual & Child(ren) $31.50 $41.00 Family $39.90 $ The premium and amount of benefits provided vary based upon the plan selected. Plan Options» Individual Plan The Insured, age 18 through 64, at the date of policy issue, is the only Person.» Individual and Lawful Spouse Plan Covers you and your Lawful Spouse (ages 18 to 64 at Policy Issue).» Individual and Child(ren) Plan Covers you (ages 18 to 64 at Policy Issue) and each Eligible Child, as defined in the policy, under the age of 21 or 25 if attending school full-time.» Family Plan Covers you, your Lawful Spouse (ages 18 to 64 at Policy Issue) and each Eligible Child, as defined in the policy, under the age of 21 or 25 if attending school full-time. Underwritten and administered by: 2000 N. Classen Boulevard Oklahoma City, Oklahoma SB-25787(VA)-0113 AO-03 Series and AMDI-258 Series 62

65 Portsmouth Public Schools Focus Eye Care Highlight Sheet Focus Plan Summary Comprehensive Plan VSP Network Out of Network Deductibles Exam $15 $15 Eye Glass Lenses See materials See materials Materials $15 $15 Annual Eye Exam Covered in full Up to $45 Lenses (per pair) Single Vision Covered in full Up to $35 Bifocal Covered in full Up to $50 Trifocal Covered in full Up to $70 Lenticular Covered in full Up to $90 Contacts Fit & Follow Up Exams 15% discount No benefit See Additional Focus Features. Elective Up to $105 Up to $105 Medically Necessary Covered in full Up to $210 Frames $120 Up to $50 Frequencies (months) Exam/Lens/Frame 12/12/24 12/12/24 Based on date of service Based on date of service Rates 20 Pay Employee Only (EE) $5.82 Family $14.26 Additional Focus Features Contact Lenses Elective Additional Glasses Laser VisionCare Low Vision Cost of the fitting and evaluation is deducted from the allowance and any amount left is deducted from the material allowance. Allowance can be applied to disposables, but the dollar amount must be used all at once (provider will order 3 or 6 month supply). Applies when contacts chosen in lieu of glasses. 20% discount off the retail price on additional pairs of prescription glasses (complete pair). VSP offers an average discount of 15% on LASIK and PRK. The maximum out-of-pocket per eye for members is $1,800 for LASIK and $2,300 for custom LASIK using Wavefront technology, and $1,500 for PRK. In order to receive the benefit, a VSP provider must coordinate the procedure. With prior authorization, 75% of approved amount (up to $1,000 is covered every two years). Eye Care Plan Member Service Focus eye care from Ameritas Group features the money-saving eye care network of VSP. Customer service is available to plan members through VSP's well-trained and helpful service representatives. Call or go online to locate the nearest VSP network provider, view plan benefit information and more. VSP Call Center: Service representative hours: 9 a.m. to 10 p.m. EST Monday through Friday Interactive Voice Response available 24/7 Locate a VSP provider at: ameritasgroup.com/provider View plan benefit information at: vsp.com If you would like a complete copy of your vision insurance certificate, please visit our website at This document is a highlight of plan benefits provided by Ameritas Life Insurance Corp. as selected by your employer. It is not a certificate of insurance and does not include exclusions and limitations. For exclusions and limitations, or a complete list of covered procedures, contact your benefits administrator. 63