Employee Benefits Enrollment Packet

Employee Benefits Enrollment Packet Enrollment Forms Due By: Return Enrollment Forms To: Date of Hire: Effective Date: Enrollment forms must be turned into our HR Department prior to the due date

A letter from FleetMasters, Inc. To our valuable company member, Welcome to FleetMasters, Inc. and congratulations on your new position. We are delighted to have you as a member of our team. As with anyone starting a new job, we are sure you have many questions. There are many details about employee benefits provided in this packet but if there is something not included that you are curious about, please let me know. We are so excited to have you on our team and will do our best to help you become a productive member of our staff through orientation and training. As you learn different aspects of your job and are introduced to coworkers and supervisors, please be open about questions you may have. You are always welcome to contact me with any questions or concerns that arise now or in the future. We are looking forward to our long-term relationship and your success. Sincerely,

Table of Contents Enrollment Checklist Medical Vision Dental Life / AD&D Provider Search Enrollment Employee Monthly Cost COBRA Affordable Care Act Employee Market Exchange Notice Frequently Asked Questions Meet Our Broker

Enrollment Checklist Review entire Employee Benefits Enrollment Packet, including benefit plan summaries and employee payroll deductions and benefit elections you must select. Check the physician/facility network to make sure you visit providers that are in network with the plan you select. Please see the How to Find an In-Network Physician/Facility instructions provided on the Provider Search page. Enroll in benefits. See enrollment section of this Employee Benefits Enrollment Packet for instructions on how to enroll in benefit plans. Enrollment Deadline is 15 Days before your eligibility date Once your elections have been made: If you are enrolling in benefits for the first time, you may receive new ID cards. Please check your ID cards to make sure the coverage you elected is correct. You may receive new ID cards for each line of coverage you elected (Medical, Dental, and/or Vision). Check your benefit deductions on your paycheck to make sure they are correct. It is important that you understand the way your health plan works. Please take a few minutes to review the materials in this enrollment kit. You will find helpful information, including benefit descriptions, costs, answers to frequently asked questions, and website services. As a member, it is your responsibility to understand and follow all guidelines. Our Human Resources Department, Broker, and Insurers are available to provide benefit interpretation, instructions on accessing your benefits and assistance in resolving any issues that may arise.

Medical Name of Carrier: Associated Industries Management Services (AIMS) Underwritten By: Regence BlueShield Group Number: 95700772 Medical Plan: Traverse 1500 Provider Network: Regence Preferred PPO Network Customer Service: 888-370-6156 Renewal Date: October 1 st

Vision Name of Carrier: Associated Industries Management Services (AIMS) Underwritten By: Vision Service Plan Group Number: Employees use Social Security # Vision Plan: Plan A Provider Network: Vision Service Plan PPO Customer Service: 800-877-7195 Renewal Date: October 1 st

Dental Name of Carrier: Delta Dental of Washington Group Number: 10838 Dental Plan: Plan 1 Provider Network: Delta Dental PPO Network Customer Service: 800-554-1907 Renewal Date: July 1 st

Provider Search For easy access to provider search pages, visit our Benefits Website. To access our employee benefits website log on to: www.psgwa.com Go to the Benefits Login at the top right side of the menu bar Enter our password: FMI2012 (the password is case sensitive) Medical Network: Regence BlueShield Preferred PPO Please visit: www.regence.com Select the Find a Doctor tab on the menu bar From there, a variety of different search options are available Vision Network: Vision Service Plan PPO Network Please visit: www.vsp.com Select the Find a Doctor tab on the menu bar From there, a variety of different search options are available Dental Network: Delta Dental PPO Network Please visit: www.deltadentalwa.com Select the Patients tab from the menu bar Select the Find A Dentist link From here a variety of different search options are available

Enrollment

Employee Enrollment & Change Form 2016 Medical Group Number: 1. GROUP INFORMATION (to be completed by the group) Please Be Sure To Fill Out All Sections Effective Date: Rate of Pay and Amount: $ per Group Name: FleetMasters Date of Hire: Yr Mo Bi-Wk Wk Hr New Change (Mark Reason Below) COBRA carry-over election must use COBRA carryover application to enroll Hire/Rehire Open Enrollment Loss of Prior Coverage Address/Name Change Add or Remove Dependent(s) Effective Date of Change: Reason Termination: Last day Worked Last day Compensated Date Coverage Ends Voluntary Involuntary of Coverage 2. EMPLOYEE INFORMATION (employee to complete sections 2 through 5) Please print legibly and sign Application Employee Name: (Last, First, MI) Social Security #: - - Date of Birth: Male Female Married Unmarried Home Phone: ( ) - Mailing Address: City State Zip Employee Email Address: Worksite Location (State): 3. ENROLLMENT INFORMATION: Please note that an incomplete application will delay processing. Please make sure to print legibly and sign application. By providing your email address, you are agreeing to receive plan documents via electronic delivery. I choose to WAIVE Medical/Rx coverage due to Medicare Supplement, but elect any ancillary coverage chosen by my employer (i.e. dental, vision). Basic Life not available. I choose to WAIVE the Medical/Rx coverage for myself and my dependents. Reason for Waiving: I choose to WAIVE dental coverage. Medical Plan Choice (Underwritten by Regence BlueShield): I choose to ELECT medical coverage. Plan Selection: (Your employer has selected the options available to you. See your benefit administrator for details. Compulsory $15,000 Life/AD&D is included with all medical. Beneficiary is required. See Section 4.) Dental Plan Choice (Underwritten by Delta Dental of Washington): Only available if chosen by your employer. I choose to ELECT dental coverage. Plan Selection: (Your employer has selected the options available to you. See your benefit administrator for details.) Vision Plan Choice (Underwritten by VSP, Vision Care Inc.): Only available if chosen by your employer. I choose to ELECT vision coverage. Plan Selection: (Your employer has selected the options available to you. See your benefit administrator for details.) Services and Access provided by AIMS 6201E Retail Employee Enrollment Form 11.19.2015 Program Management provided by

Supplemental Employee and Dependent Life and AD&D Underwritten by Standard Insurance Company (Only available if chosen by your employer) Supplemental Employee Life/AD&D coverage. Yes No If YES for Employee Coverage: Supplemental Dependent Life/AD&D for Spouse Only Yes No Supplemental Life for Dependent Child(ren) Yes No Amount of Coverage Requested (Please see your benefit administrator for allowed increments) Employee: Spouse: NOTE: In order for dependents to qualify for a benefit selection, the employee must select the same benefit. Please indicate each member s name as you would like it to appear on the ID Card. ID cards are limited to 26 characters and spaces. If dependent has separate mailing address, please attach. Add Drop Relationship Last Name First Name Spouse Domestic Partner * M I Social Security No. - - Date of Birth Gender Benefit Selection M F Med Dent Vis - - - - - - - - - - For individuals who are eligible for enrollment in an employer group health plan: If you are declining enrollment for yourself or your dependents (including your spouse) because of other health insurance or employer group health plan coverage, you may be able to enroll yourself and your dependents in this plan if you or your dependents lose eligibility for that other coverage (or if, in the case of employer group health plan coverage, the employer stops contributing toward you or your dependents other coverage.) However, the request for enrollment should be received by AIMS within 60 Days after you or your dependents other coverage ends (or after the employer stops contributing toward the other coverage). In addition, if you gain a new dependent as a result of marriage, birth, adoption, or placement for adoption, you may be able to enroll yourself and your dependents. However, we encourage enrollment within 60 days after the marriage, birth, adoption or assumption of a legal obligation for total or partial support of the child in anticipation of adoption. *Non-registered Domestic Partners must submit an Affidavit of Qualifying Domestic Partnership. Proof of registration is not required for state-registered domestic partners when an enrollment form is submitted, however Membership may ask for proof during the course of a standard audit. Services and Access provided by AIMS 6201E Retail Employee Enrollment Form 11.19.2015 Program Management provided by

4. DESIGNATION OF BENEFICIARY Mandatory to complete for designation of benefit provided with ALL Life Products, including the $15,000 Life Policy included with your Medical Coverage EMPLOYEE BENEFICIARY: Primary Beneficiary Name and Relationship* for Basic life/ad&d & Supp. Life/AD&D Primary Beneficiary Address EMPLOYEE BENEFICIARY: Contingent Beneficiary Name and Relationship** for Basic life/ad&d & Supp. Life/AD&D Contingent Beneficiary Address * If more than one primary beneficiary is named, the primary beneficiaries shall share equally unless otherwise indicated above. ** Contingent Beneficiary(ies) will only receive proceeds if all Primary Beneficiaries have predeceased the Insured. If you are naming more than one Contingent Beneficiary at 100% each, please indicate them in order of precedence. 5. SIGNATURE I hereby apply for enrollment or change of enrollment as indicated on this application. I understand that the Trust and the Health Carriers or Insurers may collect, use and disclose protected health information about each individual enrolled under this application in order to carry out their routine business functions, including but not limited to, determining eligibility for benefits, paying claims, coordinating benefits with other insurance carriers or payer, underwriting and conducting case management care management and quality reviews. The Trust and the Health Carriers and Insurers may also disclose protected health information to state and federal agencies, or other third parties, as required by law. I understand that information collected in connection with administration of the benefit plan may be used to bring to my attention health products or services that might be valuable to me and otherwise as permitted by law. I agree to accept and/or access all plan documents and notices via electronic delivery. This does not include documents sent directly from the Health Carrier. I understand that the health benefit plan that I have selected provides reimbursement for certain medical costs, which are more fully described in the current Certificate of Coverage. I understand there may be instances where treatment decisions made by my physician or me or medical expenses which I have incurred may not be covered by my health benefit plan. The undersigned understands that it is a crime to knowingly provide false, incomplete, or misleading information to a health carrier or insurance company for the purposes of defrauding the company. Penalties include imprisonment, fines and denial of health coverage or other insurance benefits. The changes on this form supersede all previous forms submitted. I authorize my employer to deduct from my earnings the amount, if any, for the coverage selected. Please note: Incomplete applications will delay processing. Employee Signature (required) Date: Employer Signature (required) Date: Effective 1/1/16 HSA members will have the option of selecting whether or not they would like to authorize claims integration with HealthEquity. The option to opt-in or opt-out will be administered through the application process, by calling customer service or available through the member preferences section of the member dashboard under My account through Regence.com. Please return form to: AIMS 1206 North Lincoln, Suite 200 Spokane, WA 99201-2559 fax to: (509) 777-2690 or email to aims@aiin.com Regence BlueShield 1800 Ninth Avenue Seattle, WA 98101 Standard Insurance Company 920 SW 6 th Avenue Portland, OR 97204 Delta Dental of Washington 9706 Fourth Ave NE Seattle, WA 98115-2157 VSP, Vision Care Inc. 3333 Quality Dr. Rancho Cordova, CA 9567 Magellan Health Services 14100 Magellan Plaza Drive MO-10 Maryland Heights, MO 63043 Services and Access provided by AIMS 6201E Retail Employee Enrollment Form 11.19.2015 Program Management provided by

PO Box 75688 Seattle WA 98175-0688 (206) 528-5335 or (800) 572-7835 x 5335 Delta Dental of Washington Enrollment Form DDWA Small Business Plans New Change Open Enrollment COBRA Reinstate Other (Check One) Employer or Group Name Group Number Subgroup Hire Date Effective Date FleetMasters Inc 10838 Social Security Number First Name Middle Initial Last Name Birthdate Gender Address City State Zip Phone Number Email Address Dependents Please list all dependents to be covered: Middle Add/ Dependent Over First Name Initial Last Name Birthdate Gender Remove Limiting Age Verification* Spouse or Domestic Partner** M Add Remove F Dependent M Add Remove Incapacitated*** F Dependent M Add Remove Incapacitated*** F Dependent M F Add Remove Incapacitated*** Dependent Coordination of Benefits M F Add Remove Do any of your dependents have other dental coverage? Yes No If yes, please complete the section below. Incapacitated*** Employer Group Number and Name Effective Date Name and Address of Other Insurance Carrier Social Security Number First Name Middle Initial Last Name Birthdate Gender COBRA Enrollment Only Indicate Qualifying Date Indicate Qualifying Event Termination Reduction in Hours Divorce Widowed/Surviving Dependent Dependent Child No Longer Eligible Other SMBUSENROLL-2013 Page 1 of 2 Continued on back

Enrollment Form DDWA Small Business Plans Waiver Dental Coverage I certify that I have been advised of the features and benefits of the dental plan offered to me through my employer and after due consideration, I have chosen: Not to enroll my spouse in the group dental plan being offered by my employer. Not to enroll my children in the group dental plan being offered by my employer Not to enroll myself and my dependents in the group dental plan being offered by my employer. I understand that by taking this action, I waive all benefits payable thereunder for myself and/or my dependents. It is a crime to knowingly provide false, incomplete, or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits (R.C.W. 48.135.080). * The minimum limiting age is through age 25 for all children; coverage shall not terminate for children over the age of 25 who are both (1) incapable of self-sustaining employment by reason of developmental disability or physical handicap and (2) chiefly dependent upon the employee or member for support and maintenance ** Domestic partners include state-registered partnerships and/or other domestic partners if specifically covered by group. *** Documentation is required (pursuant to R.C.W. 48.44.210). To download the proof of incapacity and dependency form, visit the Delta Dental of Washington website at www.deltadentalwa.com/forms. X Signature Date SMBUSENROLL-2013 Page 2 of 2

Employee Monthly Cost

Employee Cost Per Pay Period AIMS Traverse 1500 + Signature Plan A Vision Employee Enrollment Tier Medical Plan Vision Plan Total Cost Employer Contributes Employee Cost Employee Only $191.92 $1.80 $193.72 $143.94 $49.78 Employee + Spouse $469.07 $3.60 $472.67 $143.94 $328.73 Employee + Child(ren) $397.10 $3.85 $400.95 $143.94 $257.01 Employee + Family $658.24 $6.17 $664.40 $143.94 $520.46 Rates Effective Until October 2017 Delta Dental of Washington Dental Plan Employee Enrollment Tier Dental Plan Employer Contributes Employee Cost Employee Only $21.72 $16.29 $5.43 Employee + Spouse $45.30 $16.29 $29.01 Employee + Child(ren) $47.52 $16.29 $32.23 Employee + Family $71.10 $16.29 $54.81 Rates Effective Until July 2017 Created by PSG Washington Inc for the employees of FleetMasters Inc

COBRA Continuation Coverage Rights Introduction You are receiving this notice because you have recently become covered under our group health plan. This notice contains important information about your right to COBRA continuation coverage, as well as other health coverage alternatives that may be available to you through the health insurance marketplace. This notice generally explains COBRA continuation coverage, when it may become available to you and your family, and what you need to do to protect the right to receive it. The right to COBRA continuation coverage was created by a federal law, the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA). COBRA continuation coverage can become available to you when you would otherwise lose your group health coverage. It can also become available to other members of your family who are covered under the plan when they would otherwise lose their group health coverage. For additional information about your rights and obligations under the plan and under federal law, you should review our plan s summary of benefits. What is COBRA Continuation Coverage? COBRA continuation coverage is a continuation of plan coverage when coverage would otherwise end because of a life event known as a qualifying event. Specific qualifying events are listed later in this notice. After a qualifying event, COBRA continuation coverage must be offered to each person who is a qualified beneficiary. You, your spouse, and your dependent children could become qualified beneficiaries if coverage under the plan is lost because of the qualifying event. Under the plan, qualified beneficiaries who elect COBRA continuation coverage must pay for COBRA continuation coverage. If you are an employee, you will become a qualified beneficiary if you lose your coverage under the plan because either one of the following qualifying events happens: Your hours of employment are reduced, or Your employment ends for any reason other than your gross misconduct. If you are the spouse of an employee, you will become a qualified beneficiary if you lose your coverage under the plan because any of the following qualifying events happens: Your spouse dies; Your spouse s hours of employment are reduced; Your spouse s employment ends for any reason other than his or her gross misconduct; Your spouse becomes entitled to Medicare benefits (under Part A, Part B, or both); or You become divorced or legally separated from your spouse. Your dependent children will become qualified beneficiaries if they lose coverage under the plan because any of the following qualifying events happens: The parent-employee dies; The parent-employee s hours of employment are reduced; The parent-employee s employment ends for any reason other than gross misconduct; The parent-employee becomes entitled to Medicare benefits (Part A, Part B, or both); The parents become divorced or legally separated; or The child stops being eligible for coverage under the plan as a dependent child.

Frequently Asked Questions 1. When do I become eligible to enroll in benefits? You are eligible to enroll at Open Enrollment, as a New Hire or after a Qualifying Event. 2. What and when is Open Enrollment? Open Enrollment is the annual event where you and your eligible dependents can make changes to your election and apply for coverage. 3. When is the next opportunity to enroll or make changes in my benefits? Employees and/or dependents may enroll in the plan during the Open Enrollment period. Outside of Open Enrollment, you or your eligible dependents can only enroll or make changes as a Special Enrollee within 30 days under the following Qualifying Events: Divorce or legal separation results in you losing coverage under your spouse s health insurance; A dependent, due to age, work, or school status, is no longer a covered "dependent" under parent s plan; Your spouse s death leaves you without coverage under his or her plan; Your spouse s employment ends, as does coverage under his employer s health plan; Your employer reduces your work hours to the point where you are no longer covered by the health plan; Your plan decides it will no longer offer coverage to a certain group of individuals (for example, part time); You no longer live or work in the HMO s service area 4. Can I add or drop benefits at any time? Benefits for employees and dependents can be dropped at anytime but can ONLY be added during the Open Enrollment period or if an eligible Qualifying Event occurs. 5. What if I want to learn more about the plan benefits? See enclosed plan summary, visit our Benefits Website or ask our HR representative or our PSG broker to assist you. A certificate booklet with more detailed plan benefits is also available to you. 6. Until what age are dependents covered? Until age 26. 7. What are the wellness benefits with my carrier? Log on to our carrier s website and click on the Wellness Section to learn more. 8. Will I receive new ID cards? If switching to a new carrier, making a plan change, or enrolling in benefits for the first time, you will receive new ID cards. Please check with our HR Department to find out if you will receive ID cards for each line of coverage elected (e.g., Medical, Dental, Vision)

Frequently Asked Questions 9. How do I order an ID card replacement? Establish your personal online access at our carrier website and order an ID card replacement, call the carrier customer service telephone number, or ask your HR representative to assist you. 10. How do I find an in-network doctor, dentist or vision provider if applicable? Visit our Benefits Website, see enclosed Find a Physician/Facility Instructions or ask our HR team. 11. Will I have deductible credit from my previous carrier? Each carrier has specific rules regarding deductible credit from a prior group carrier. Please contact our PSG broker or HR team to confirm. If deductible credit applies, you will be required to provide your most recent Explanation of Benefits from your previous carrier and submit to your new carrier showing the deductible met for you and any dependents. 12. If I am currently seeking medical treatment for a serious condition (such as dialysis, chemotherapy, radiation therapy, pain management, or pregnancy) under my current carrier plan, how will that be managed with my new carrier? You will likely need to complete a Continuation of Care Form with the new carrier. Contact our HR representative or our PSG broker for assistance. 13. Do I need to pre-certify a surgery or inpatient hospital care? It is ultimately your responsibility to make sure your care has been pre-certified. Although most physicians will do this for you, make sure you confirm your surgery or hospital stay has been pre-certified as penalties may apply if it has not been approved by your insurance carrier. 14. Do I have to obtain prior authorization for a prescription drug? There may be select medications that require prior authorization and quantity limits. Visit the carrier website or our Employee Benefits Website for more information. 15. If I currently have a mail-order prescription drug with my current carrier, how do I transition this prescription to the new carrier s mail order? You will need to complete the appropriate mail order form. Download the form from our Employee Benefits Website or contact the customer service number listed on your ID card.

Meet Our Broker PSG Washington strives to bring their clients the very best in value, options and service when it comes to employee benefits and personal insurance. With over 30 years of industry experience, they work hard to develop lasting relationships with their clients, while providing the best insurance products available throughout the Pacific Northwest. As a client of PSG Washington, we receive free, unlimited access to our Employee Benefits Website. This website can be accessed 24/7 and has plan information including plan summaries, links to providers, claim assistance and more. Below is the login information to our company benefits website. To access our employee benefits website log on to: www.psgwa.com Go to the Benefits Login at the top right side of the menu bar Enter our password: FMI2012 (the password is case sensitive) For additional questions, contact our dedicated benefit consultant: Randy K Hansen 800-586-9088 ext 112 randy@psgwa.com