BENEFIT CHANGE REQUEST FORM (Qualifying Life Event)

BENEFIT CHANGE REQUEST FORM (Qualifying Life Event) Please read the following information carefully If you experience a Qualifying Life Event as described below, you are allowed to make certain changes to your benefits. You are entitled to change a previous benefit election if your new election is on account of and corresponds with the "Change in Status". This is the only time that you are allowed to make a benefit change outside of the normal Open Enrollment period. Important: Completed forms must be received by the HR Service Center within 31 days of the qualifying life event. When adding a dependent, coverage will begin the first of the month following the event date or coverage will begin on the date of birth or adoption. When dropping a dependent, coverage will end the last day of the month following the event date. Please fill out the below completely. Specify Qualifying Life Event Marriage; Divorce or Legal Separation (Documentation needed); Birth, adoption or placement for adoption of a child Dependent reaches age 26 Death of a dependent (Documentation needed) Involuntary loss of other group benefits coverage Change in associate's employment status* Change in dependent's employment status* (Documentation needed if dropping coverage) *For example: Part-time to full-time, full-time to part-time, new hire, or termination of employement Information To Process Your Life Event Complete the attached Enrollment Form and return to the HR Service Center. Associate Name: Date of Birth: Date of Qualifying Life Event: S#: Care Site/Office: Phone Number:

Effective Date (Office Use Only): Associate Name: Benefit Change Request Form S#: Specify if you wish to add or drop dependent Complete the following table ONLY if you are adding new dependents* to and/or removing existing dependents from any plans. Dependent Full Name Relationship (Spouse, Child, or LDA**) Gender (M/F) SSN (Only for new dependents added) Date of Birth (MM/DD/YY) *Adding Dependent(s) to Coverage: Any newly added dependents must go through a dependent audit through HMS. HMS will contact you via your work email with instructions within 10 days after enrollment. Find the list of required documents at SCLHealthBenefits.org. **Legally Domiciled Adult (LDA): If you designate an LDA and/or LDA's child you are required to legally document the relationship. Find the LDA Affidavit and list of required documents at SCLHealthBenefits.org. Please check plan option for EACH benefit category. Check a coverage level option for medical, dental and vision. If you are experiencing a Qualifying LIfe Event and do not wish to change coverage for a current SCL Health benefit, you must select. MEDICAL OPTIONS CIGNA Consumer Driven Health Plan (CDHP) CIGNA PPO Kaiser EPO (Denver Only) DENTAL OPTIONS Delta Choice Delta Core VISION OPTION Eye Med Vision COVERAGE LEVEL Associate Associate & Spouse Associate & Child(ren) Associate & Family COVERAGE LEVEL Associate Associate & Spouse Associate & Child(ren) Associate & Family COVERAGE LEVEL Associate Associate & Spouse Associate & Child(ren) Associate & Family SUPPLEMENTAL LIFE and AD&D INSURANCE 1 X Salary 2 X Salary 3 X Salary 4 X Salary 5 X Salary Note: Supplemental Life and AD&D Insurance is in addition to the company-paid Basic Life and AD&D insurance coverage equal to 1 X Salary, which you automatically receive. Guaranteed issue amount for Basic is $500,000 and for Supplemental is also $500,000. Evidence of Insurability is required for greater amounts. Coverage reduces to 65% at age 65, 40% at age 70 and 20% at age 75. SPOUSE LIFE and AD&D $25,000 $50,000 $100,000 $150,000 $200,000 Guaranteed issue of $50,000. For amounts above $50,000, spouse coverage may not exceed associate supplemental life.

Associate Name: CHILD LIFE and AD&D $5,000 $10,000 LONG TERM DISABILITY 10% Buy Up Option Waive Buy Up Option $25,000 Guaranteed issue on all amounts. Coverage amount applies to each child. Benefits eligible associates automatically receive a Basic 50% LTD benefit. SHORT TERM DISABILITY - PHYSICIANS ONLY Buy-Up Option Waive Buy-Up Option HEALTH CARE FLEXIBLE SPENDING ACCOUNT Elect coverage Waive coverage No Change to Current Coverage Benefits eligible associates automatically receive a Basic 60% STD benefit with a weekly benefit maximum of $2,500. Physicians receive a Basic 70% STD benefit with an option to increase the weekly benefit from $3,800 to $5,000. Total Annual Contribution: $ (If currently enrolled, this will replace your existing contribution amount) Per pay period contribution: $ (Per Pay Period Contribution = Total Annual divided by 24) Annual maximum is $2,600 DEPENDENT CARE FLEXIBLE SPENDING ACCOUNT Elect Coverage Waive coverage Total Annual Contribution: $ (If currently enrolled, this will replace your existing contribution amount) Per pay period contribution: $ (Per Pay Period Contribution = Total Annual divided by 24) Annual maximum is $5,000 or $2,500 if married and filing separate tax returns. HYATT LEGAL PLAN Elect coverage Waive coverage All immediate family members are covered (spouse and dependent children). LIFE AND AD&D INSURANCE BENEFICIARY INFORMATION SCL Health has a paperless beneficiary designation process. You can enter or change your beneficiaries anytime through Lawson Employee Self Service (ESS). If you do not elect a beneficiary, your Life and AD&D Insurance benefits will be paid in the following order: 1. Your spouse 2. Your children 3. Your parents 4. Your brothers and sisters 5. Your estate By enrolling you agree to accept the following conditions: I authorize SCL Health to establish the benefits that I select and to deduct from my pay (before taxes, except for Dependent Life, Short-Term Disability or Legal plans) any amounts that are necessary to pay for my benefit elections, or any subsequent enrollments or changes in my benefits. If I do not work enough hours to cover my premium payments each payroll, I agree to write a personal check for the balance owed and submit it to Human Resources Services. Otherwise, I acknowledge my insurance coverage may be terminated for late payment. I understand that the benefits I elect will remain in effect until December 31, of the current plan year, as long as I remain eligible, unless these plans terminate or change earlier, or unless I make applicable changes to my coverage due to a qualified work or family status change as described in the plan document. I understand that I am responsible for completing the full enrollment process within the established enrollment period to have access to these benefits. I certify that the dependents I cover under a SCL Health plan are qualified, per the definition of dependents included in the current plan year enrollment guidebook. I understand that I am responsible for maintaining current information about me and my dependents with SCL Health and the companies that administer these plans. I also understand that if I have made any false statements or misrepresentations or have failed to disclose or have concealed any material fact, SCL Health will be entitled to deny benefits. I agree that any health care professional may furnish SCL Health with all information required to administer these plans. Signature Submit completed form along with any required documents to HR Service Center within your enrollment period. HR Service Center Contact Information: Phone: Toll Free 855-412-3701 / 303-813-5250 Fax: 303-813-5240 Email: SO-HRSupport@sclhs.net Please keep a copy of your submitted form for your records. Date

Tobacco-Use Surcharge Affidavit If you are enrolling in a SCL Health medical plan and: If there is only one adult covered on the medical plan who currently uses or has used tobacco products within the last six months, you will be charged $50 per month. There are two or more adults covered on the medical plan who currently use or have used tobacco products within the last six months, you will be charged $100 per month. The surcharge will be waived if all adult tobacco-users covered under your benefit plan successfully complete the SCL Health QuitLine tobacco cessation program or any other tobacco cessation program that may be offered at your local care site within the six-month period ending on the date you submit the Tobacco Use Affidavit. You will not have to complete the cessation program, and the surcharge will be waived, if the tobacco-user s personal physician believes quitting tobacco is not medically appropriate for that member. Contact the HR Service Center at 1-855-412-3701 for a copy of the Physician Affidavit or for information regarding the cessation programs. Outside of your open enrollment period, you are only eligible to remove or reduce the tobacco surcharge after certifying that the applicable covered tobacco users have been tobacco-free for the prior six months or have completed the reasonable alternative within the prior six months. NOTE: Tobacco products are defined as tobacco or tobacco-like products intended for human consumption, and when used orally or inhaled, produces smoke or smoke-like vapor. This includes but is not limited to: cigarettes, cigars, loose tobacco smoked via pipe or hookah, chewing tobacco, snuff, dip, electronic cigarettes and vaporizers. TOBACCO USE INFORMATION Please check the applicable boxes below. INFORMATION ABOUT YOU AND YOUR COVERED ADULT DEPENDENTS I certify that the Tobacco Surcharge does not apply to me because either: There are no adult tobacco-users covered on my medical plan who currently use or have used any tobacco products for at least six months; or All adult tobacco-users have completed a qualifying tobacco cessation program within the past six months such as the SCL Health QuitLine or another tobacco cessation program offered at a local SCL Health care sites. I understand that I may be asked to provide the certificate(s) of completion. There is one adult tobacco-user covered on my medical plan who currently uses or has used tobacco products within the past six months. I understand that as a result, I will be subject to the $50 Tobacco Surcharge. There are two or more adult tobacco-users covered on my medical plan who currently use or have used tobacco products within the past six months. I understand that as a result, I will be subject to the $100 Tobacco Surcharge. I am not enrolling in an SCL Health medical plan and therefore, the Tobacco Surcharge does not apply to me.

By signing this form, I certify the following: 1. I have truthfully checked the box above that accurately reflects the use of tobacco products by all adult members covered on my SCL Health medical plan within the past six months. 2. I understand that the Tobacco Surcharge will be automatically added to my medical plan contributions if I checked that I and/or any of my dependents use or have used tobacco products within the past six months and have not completed the cessation program within the past six months or submitted the Physician Affidavit described above. 3. I understand the Tobacco Surcharge will be automatically added to my medical plan contributions if I do not complete and submit this form by my enrollment deadline. 4. I understand that I will be eligible to have the Tobacco Surcharge waived or reduced (depending on the number of users outlined above) within two pay periods following receipt of a new Tobacco-Use Affidavit certifying that there has been a reduction in the number of covered tobacco-users due to the member(s) becoming tobacco-free for the past six months or the member(s) completing a qualifying SCL Health QuitLine or another tobacco cessation program offered at an SCL Health work site within the last six months. 5. I understand that if my Tobacco Surcharge status should change and I or my covered dependents begin using tobacco products subsequent to the submission of this Affidavit, I agree that I am subject to the Tobacco Surcharge and will complete an updated Tobacco-Use Affidavit. Failure to do so could result in repayment of the surcharge retroactively to the beginning of the plan year and/or disciplinary action. 6. I also understand knowingly and intentionally providing false, incomplete or misleading facts or information on any benefits form or other document for the purpose of defrauding or attempting to defraud SCL Health may result in disciplinary action including repayment of the premium surcharge. Print Name Employee ID (S-ID) Signature Date

Working Spouse Affidavit Associates choosing to cover a spouse who is offered coverage through their own employer will pay an additional $100 per month pre-tax ($1,200 per year) for coverage. SCL Health encourages working spouses to evaluate their own employer s medical plan before enrolling in SCL Health s plan. This form must be filled out by all associates electing to cover a spouse on an SCL Health Medical Insurance Plan. SCL Health reserves the right to request supplemental documentation to verify information provided. 1. Is your spouse employed? Yes No If you checked No, the working spouse surcharge does not apply. Please continue to question # 7. If you checked Yes, please continue to question #2. 2. Is your spouse employed by SCL Health? Yes No If you checked No, please continue to question #3. 3. Does your spouse s employer offer medical coverage for which he/she is eligible? Yes No If you checked No, the working spouse surcharge does not apply. Please continue to question # 7. If you checked Yes, please continue to question #4. 4. Is your spouse enrolled in his/her employer s medical plan? Yes No If you checked No, please continue to question #5. 5. Is your spouse s employer a branch of the U.S. Military by which they have Tricare benefits? Yes No If you checked No, please continue to question #6. 6. Does the medical coverage offered by your spouse s employer have an annual in-network out-of-pocket maximum more than $5,000 for individual coverage or more than $10,000 for all other coverage levels? Yes No If you checked No, the Working Spouse Surcharge applies. Please continue to question #7. 7. Does the Working Spouse Surcharge apply? Yes No If you checked Yes, you will be assessed a $100* monthly surcharge. This surcharge will be deducted from your pay on a pretax basis in $50 increments twice a month. *Associates enrolled in the Medical Premium Assistance program will have a prorated monthly surcharge of $25.

Status Change: If your spouse gains or loses employer coverage mid-year, the change should be reported to the HR Service Center within 31 days so the surcharge can be adjusted as necessary. Attestation: By signing this form, I certify that the information provided above is true and correct as of the date submitted. I agree to resubmit this form should my spouse s access to coverage change during the year. I understand that if I knowingly and intentionally provide false, incomplete or misleading facts or information on any benefits form or other document for the purpose of defrauding or attempting to defraud SCL Health, I may be disciplined up to and including repayment of premium subsidies under the program and/or termination of employment. Print Name Employee ID (S-ID) Signature Date