Blue Cross Blue Shield of LA

Plan Options Plan 1 Employee Share Plan 1 Employer Share Plan 2 Employee Share Plan 2 Employer Share
Employee $109.37 $532.26 $41.25 $455.18
Employee w/Spouse $416.89 $816.75 $202.28 $728.06
Employee w/Children $281.60 $697.91 $127.55 $601.26
Employee w/Family $570.83 $926.91 $336.56 $820.20
(2) Employees $202.19 $1,001.09 $80.30 $833.01
(2) Employees/Family $288.65 $1,063.87 $162.05 $886.59

Ascension Parish School Board

Outline of Benefits

Welcome to AlwaysCare! We are pleased to offer Dental benefits for you and your family effective 11/1/2017.

Selection of Providers: Members may choose any licensed dental provider. Members have access to our national network of over 270,000 participating access points where they can take advantage of discounts AlwaysCare has negotiated on their behalf. Further, in areas with relatively few participating providers, members have access to our list of an additional 46,000+ “certified” providers who, according to an independent resource, despite not participating in our network, offer excellent value for their customers. Members using participating providers will eliminate balance billing and reduce out-of-pocket expenses. No claim forms needed with participating providers. Visit www.AlwaysCareBenefits.com or call 1-888-729-5433, Ext. 2013 for a list of participating providers.

Deductible: Maximum 3 per family. Applies to Basic (Class B) and Major (Class C) Services. $50 per calendar year
Coinsurance: The plan pays the following percentages of maximum allowable charges for each class: Class A Preventive 100% Class B Basic 80% Class C Major 50% Class D Orthodontics 50%
Benefit Maximums: (Class A, B, and C benefits). $2000 per calendar year; Separate $1000 Lifetime Maximum for Orthodontia (Class D) Services.
Carryover Benefit: $400, Threshold Limit $800, Carryover Account Maximum $1500.
Monthly Premium Employee Deductions *: *Rates valid from 11/1/2017 to11/1/2018. Employee Only $0.00 Employee & One $29.14 Employee & Two or more $57.28

Covered Procedures and Waiting Periods:

Preventive Services (Class A): No waiting period. Routine exams (2 per 12 months) Prophylaxis (2 per 12 months)

o (1 additional cleaning or periodontal maintenance per 12 months if member is in 2nd or 3rd trimester of pregnancy)

Bitewing x-rays (maximum of 4 films) (2 per 12 months) Full mouth / panoramic x-rays (1 per 24 months) Fluoride treatment for children up to age 18 (1 per 12 months) Sealants for children up to age 16 (permanent molars 1 per 36 months) Space maintainers for children up to age 16 (1 per 24 months) Adjunctive Pre-Diagnostic Oral Cancer Screening (1 per 12 months for age 40+)

Basic Services (Class B): No waiting period.

Emergency treatment (1 per 12 months)

Simple restorative services (Fillings) (Benefit allowed for amalgam restorations on posterior teeth)

Simple extractions

Repair of Crown, Denture, or Bridge

Simple Periodontics

Major Services (Class C): No waiting period.

Surgical Periodontics

Endodontics (Root Canals)

Oral surgery (extractions and impacted teeth) & Anesthesia (subject to review, covered with complex oral surgery)

Inlays and Onlays

Crowns, Bridges, Dentures and Endosteal Implants (in lieu of an approved 3-unit Bridge)

Orthodontics (Class D): No waiting period.

Maximum lifetime benefit: $1000

Up to 25% of lifetime allowance may be payable on initial banding.

Adult coverage

Dependent children to age 26 only.

AlwaysHearingsm Savings Plan

Available at no cost to all AlwaysCare Members Material discounts between 30%-60% on all major name brand hearing instruments and accessories Battery program discounts up to 40% off retail pricing

To access call 1-888-729-5433, ext 2013

Dental Carryover Benefit

Members who take care of their teeth, but use only part of their annual maximum benefit during a benefit period are rewarded with extra benefits in future years! If an Insured submits qualifying claims for covered expenses during a benefit year and, in that benefit year,

receives benefits that are less than their group’s Threshold Limit, the

Insured will be credited a Carryover Benefit. Carryover Benefits will be

accrued and stored in the Insured’s Carryover Account to be used in

the next benefit year. If an Insured reaches his or her Certificate Year

Maximum Benefit, we will pay a benefit from the Insured’s Carryover Account up to the amount stored in the Insured’s Carryover Account.

The accrued Carryover Benefits stored in the Carryover Account may

not be greater than the Carryover Account Limit. The Limits for this Policy/Certificate are: Carryover Benefit $400, Threshold Limit $800, Carryover Account Limit $1500.

Other Specifications:

An Insured’s Carryover Account will be eliminated, and the accrued Carryover Benefits lost, if the Insured has a break in coverage of any length of time, for any reason.

Eligibility for a Carryover Benefit will be established or reestablished at the time the first Qualifying Claim in a benefit year is received for Covered Expenses incurred during that benefit year.

In order to be eligible to accumulate the Carryover Benefit, an Insured must be enrolled in the plan at least four months prior to the start of the new policy year. Example: If the plan effective date is January 1st, the Insured must be enrolled by September 1st.

Only claims incurred on or after the start of the next Policy Year will count toward the Threshold Limit.

Carryover Benefits will not be applied to an Insured’s Carryover

Account until the Policy Year that starts one year from the date the rider first applies.

If charges for Class C Services are not payable for an Insured due to a benefit waiting period for certain covered procedures, this rider will not apply to the Insured until the end of such waiting period. And, if the waiting period ends within the three months prior to the

start of this plan’s next benefit year, this rider will not apply to the

Insured until the next benefit year.

Carryover Benefits will not be applied to an Insured’s Carryover Account until the benefit year that starts one year from the date the rider first applies.

Definitions: “Benefit Year” means Calendar Year or Policy Year, according to

the type of plan applicable under the Policy/Certificate to which this rider is attached.

“Carryover Account” means the amount of an Insured’s accrued

Carryover Benefits.

“Carryover Account Limit” means the maximum amount of

cumulative Carryover Benefits that an Insured can store in his or her Carryover Account.

“Carryover Benefit” means the dollar amount, which will be added to an Insured’s Carryover Account when he or she receives

benefits in a benefit year that do not exceed the Threshold Limit. Qualifying Claim means a claim under Procedure Classes A, B, C, and Class D, Orthodontia and must include 1 exam & 1 cleaning.

“Threshold Limit” means the maximum amount of benefits for all

procedure classes A, B, C and D that an Insured can receive during a benefit year and still be entitled to receive the Carryover Benefit.

Dependent Children: Dependent age guidelines vary by state. Please refer to your policy certificate or contact customer service at 888-729-5433, Ext. 2013.

Services Not Listed: If you expect to require a dental or vision service not included on this brochure, it may still be covered. Please contact customer service at 1-888-729-5433 Ext. 2013 to confirm your exact benefits.

Alternate Treatment: AlwaysCare Benefits, Inc. covers the least expensive most commonly used and accepted American Dental Association treatments. Plan members may elect a more expensive treatment, but will be responsible for the cost difference resulting from the more expensive procedure.

Exclusions/Limitations: AlwaysCare Members whose dental plan includes coverage of crowns and bridges will have the option of choosing an endosteal implant to replace a missing tooth instead of a conventional fixed 3-unit bridge, when a 3-unit bridge is approved for coverage. Crowns placed on implants will also be covered. Other implants or implant related services are not covered.

The following dental services are not covered:

any treatment which is elective or primarily cosmetic in nature and not generally recognized as a generally accepted dental practice by the American Dental Association, as well as any replacement of prior cosmetic restorations;

the correction of congenital malformations; the replacement of lost, discarded, or stolen appliances; replacement of bridges, dentures, crowns, inlays, onlays or

dentures unless more than [5] years old and cannot be made serviceable;

appliances, services or procedures relating to: (i) the change or maintenance of vertical dimension; (ii) restoration of occlusion; (iii) splinting; (iv) correction of attrition, abrasion, erosion or a fraction;

(v) bite registration; or (vi) bite analysis;

services provided for any type of temporomandibular joint (TMJ) dysfunctions, muscular, skeletal deficiencies involving TMJ or related structures, myofascial pain;

charges for implants (except noted above), removal of implants, precision or semi-precision attachments, denture duplication, overdentures and any associated surgery, or other customized services or attachments, and related procedures;

dentures for teeth missing prior to effective date of coverage; some exceptions apply and are detailed in the Certificate of Coverage;

multiple x-rays done on same date of service will be combined to a full-mouth x-ray; cosmetic restorations on posterior permanent teeth and all primary teeth will be given alternate benefit; Anesthesia is covered with complex oral surgery only. Charges are subject to review. Pre-treatment estimate is recommended.

Takeover Benefits:

Takeover benefits apply if we are taking over a comparable benefits plan from another carrier and only if there is no break in coverage between the original plan and the takeover date. Takeover is available

to those individuals insured under the employer’s dental plan in effect at the time of the employer’s application. If takeover benefits are

included in your benefits, then waiting periods for service will be

waived for the individuals currently insured under the employer’s

previous plan during the month prior to coverage moving to us.

Application of takeover benefits is subject to Underwriting review and approval.

New hires with prior-like dental coverage (lapse in coverage must be less than 63 days) will receive takeover credit for the length of time they had with the prior carrier and must provide proof of coverage (including coverage dates) to receive takeover credit (i.e. one page benefit summary, certificate of creditable coverage, etc.).

Late entrants: Employees that waive coverage at initial enrollment (within 31 days of effective date) or in the new employee eligibility period and/or terminate coverage with AlwaysCare will have a twelve

(12) month waiting period applied to basic and major services and orthodontia upon re-applying.

The prior carrier is responsible for reimbursement of costs for procedures begun prior to the effective date.

This brochure is a brief overview of the AlwaysCareSM dental plan. It does not list all benefits, nor does it list all exclusions and limitations. For more complete information, please refer to the Certificate, or the employer’s Master Policy, which will be issued when coverage becomes effective.

Underwritten by: Starmount Life Insurance Company Administered by: AlwaysCare Benefits, Inc. (a Starmount Life Insurance company), The Starmount Building,8485 Goodwood Boulevard Baton Rouge, LA 70806; PH: 1-888-729-5433 ext 2013. Policy Forms: Dental DN 2002 and DN 2007

40%

OFF

Complete pair of prescription eyeglasses

20%

OFF

Non-prescription sunglasses

20%

OFF

Remainingbalance beyond plancoverage

Thesediscountsare for in-networkprovidersonly

  • You’re ontheSELECT Network
  • For a complete listof in-network providers near you, use our Enhanced Provider Locator on www.eyemed.com or call 1-866-299-1358.
  • For Lasik providers, call 1-877-5LASER6.

AscensionParishSchoolBoard

VisionCare Services

Exam With Dilationas Necessary

Frames

StandardPlastic Lenses

SingleVision Bifocal Trifocal StandardProgressiveLens Premium Progressive Lens Lenticular

In-Network Out-of-Network
MemberCost Reimbursement
_________________________________________ _________________
$10 Co-pay Up to $30
$0 Co-pay; $100 allowance; 80% of charge over $100 Up to $45
$25 Co-pay Up to $25
$25 Co-pay Up to $40
$25 Co-pay Up to $55
$90 Up to $40
$90, 80% of charge less $120 allowance Up to $40
$25 Co-pay Up to $55

LensOptions(paidbythe memberandaddedtothe baseprice ofthe lens)

UV Treatment $15 N/A Tint(SolidandGradient) $15 N/A StandardPlasticScratchCoating $15 N/A StandardPolycarbonate $40 N/A StandardPolycarbonate -$40 N/A StandardAnti-ReflectiveCoating $45 N/A Polarized 20%offretailprice N/A OtherAdd-OnsandServices 20%offretailprice N/A

ContactLens Fitand Follow-Up (Contactlens fitandtwofollow upvisitsareavailableonce a comprehensiveeye exam hasbeencompleted)

StandardContactLens Fit& Follow-Up Premium ContactLensFit&Follow-Up

ContactLenses

Conventional Disposable MedicallyNecessary

Laser VisionCorrection

LasikorPRKfromU.S. Laser Network

Frequency

Examination Lenses or Contact Lenses Frame

Up to $40 10% off retail N/A N/A
$0 Co-pay; $115 allowance; 85% of charge over $115 $0 Co-pay; $115 allowance; plus balance over $115 $0 Co-pay, Paid-in-Full Up to $100 Up to $100 Up to $200
15% off the retail price or 5% off the promotional price N/A
Once every 12 months Once every 12 months Once every 24 months

Benefitsarenotprovided fromservices or materialsarisingfrom:1) Orthopticorvision training, subnormalvisionaidsand anyassociatedsupplementaltesting; Aniseikonic lenses; 2) Medicaland/orsurgical treatment of theeye, eyes orsupporting structures; 3)Any eyeorVisionExamination, orany corrective eyewearrequired bya Policyholder as aconditionof employment; Safetyeyewear;4)ServicesprovidedasaresultofanyWorkers’Compensationlaw,orsimilarlegislation,orrequiredbyanygovernmentalagencyorprogramwhether federal,stateorsubdivisionsthereof;5)Plano(non-prescription)lenses;6)Non-prescriptionsunglasses;7)Twopairofglassesinlieuofbifocals; 8)Servicesormaterialsprovidedbyany other group benefitplanproviding visioncare9)Servicesrendered afterthe dateanInsuredPersonceasesto becoveredunder thePolicy,exceptwhen Vision Materials orderedbefore coverage endedaredelivered,and theservices renderedto theInsured Person are within 31 daysfromthe dateof such order. 10)Lostor brokenlenses, frames,glasses,orcontact lenses willnotbereplacedexceptinthenextBenefitFrequencywhenVisionMaterialswouldnextbecomeavailable. Benefitsmaynotbecombinedwithanydiscount,promotionaloffering,or other group benefitplans.Standard/Premium Progressivelens notcovered-fund as aBifocal lens.StandardProgressivelenscovered-fund Premium Progressiveasa Standard. Underwritten byFidelity Security LifeInsuranceCompanyof KansasCity, Missouri,exceptin New York. The Certificateof Insurance is onfilewithyouremployer. Benefitallowanceprovides noremainingbalance for futureusewithinthe samebenefit year. Feeschargedfora non-insuredbenefit mustbe paidin fulltothe Provider. Suchfees ormaterialsarenot covered.

AH2015

Out-of-Network

Benefits Snapshot

WithEyeMed Reimbursement

Examwith dilationas necessary (Onceevery12months) $10 Co-pay Up to $30

Frames (Once every 24 months) $0Co-pay;$100allowance;80%ofchargeover$100 Upto$45

Single Vision Lenses (Onceevery12months) $25 Co-pay Up to $25

Or

Contacts (Onceevery12months) $0Co-pay;$115allowance;plusbalanceover$115 Upto$100

Here’s an example of what you might pay for a pair of glasses with us vs. what you’d pay without vision coverage. So, let’s say you get an eye exam and choose a frame that costs $163 with single vision lenses that have UV and scratch protection. Now let’s see the difference...

WithEyeMed WithoutInsurance**

Exam $10Co-pay Exam $106

Frame $163 Frame $163 -$100allowance $63

71%

-$12.60(20%discountoffbalance) $50.40

SAVINGS

Lens $25Co-pay Lens $78

with us*

$15UVtreatmentadd-on $23UVtreatmentadd-on +$15Scratchcoatingadd-on +$25Scratchcoatingadd-on $55 $126

Total $115.40 Total $395

*Thisisasnapshotofyourbenefits.Actualsavingswilldependonprovider,frameandlensselections. **Basedonindustryaverages.

Dear Employees:

We are excited to tell you about a great benefit your company is offering to its employees. It’s called a Section 125 Cafeteria Plan or Flexible Benefits Plan. By using the Flexible Spending Account (FSA) available through the plan, you can save a great deal of money. The savings is achieved by not paying taxes on the amount you put into your account for health care and dependent care expenses.

Your Flexible Benefits Plan includes three components:

Health Care Spending Account pre-tax dollars set aside to cover out-of-pocket medical expenses not covered by your plan.

Dependent Care Spending Account pre-tax dollars that can be used to pay for day care for tax dependents.

Premium Conversion allows you to have your benefit premiums deducted pretax from payroll.

Here’s how it works. Each payroll, your company places the amount you designate from your pay into your personal health and/or dependent care spending accounts. The money

which is put aside without being taxed is earmarked for out-of-pocket expenses. Those expenses might include your day care bill, a co-pay for a visit to the doctor or a prescription.

The money you can save by using your FSA can be significant. For example, Employee A earns $1,700 per month. She elects to place $60 in her Health FSA, $260 in her Dependent Care FSA and also has her $50 health plan contribution taken out before tax each month. By taking care of these necessary expenses on a pre-tax basis, she could save over $100 in taxes per month, money she will surely be happy to spend elsewhere.

Every employee’s situation is a little different, but there is a reason this plan is called a Flexible Benefits Plan. It can be used to suit your needs and will save you money.

Participation is easy. Just review the enrollment materials provided for all the rules, calculate your expenses to determine your annual election, fill out the enrollment form and start saving.

If you have questions about your plan, please contact your HR representative.

15 E; Washington St; • PO Box 488 • Coldwater, MI 49036-0488 • 866-370-3040 • Fax: 800-379-5670 • E-mail: fsa@infinisource.com Copyright © 2013 Infinisource, Inc. All rights reserved. 0208 1013

FSA worksheet Estimated unreimbursed health care expenses

Medical Annual amount Dependent Day Care Annual amount
Deductible (necessary for you and your spouse to work)
Coinsurance payment After-school care
Contraceptives Care of other dependents
Doctor’s office visits Child care/day care center
Immunizations Child care in home
Insulin Preschool
Laboratory tests
Other expenses TOTAL2
Over-the-counter medicine1
Physicals/annual checkups
Prescription drugs
Splints, supports, corrective
devices
Therapy treatments
(medical reasons only)
Well-baby care
SUBTOTAL
Dental
Deductible
Coinsurance payment
Cleaning
Dentures
Fillings/crowns/bridges
Fluoride treatments
Orthodontia
(based on expenses incurred for
upcoming plan year)
X-rays
SUBTOTAL
Vision
Deductible
Coinsurance payment
Contact lenses and
solutions
Examinations
Frames
Laser eye surgery
Lenses
SUBTOTAL
TOTAL

Unreimbursed health care expenses cannot exceed your plan’s maximum.

NOTE: any coordination of benefits with another group plan may reduce your out-of-pocket expenses.

1Effective January 1, 2011, over-the-counter medicines or drugs are not eligible for reimbursement under Health Flexible Spending Accounts (FSA) or health Reimbursement Arrangements (HRA) without a doctor’s prescription. 2Cannot exceed $5,000 ($2,500 if married, filing separately), per calendar year or earned income of employee or spouse, whichever is less.

15 E; Washington St; • PO Box 488 • Coldwater, MI 49036-0488 • 866-370-3040 • Fax: 800-379-5670 • E-mail: fsa@infinisource.com Copyright © 2013 Infinisource, Inc. All rights reserved. 0208 1113

Know your FSA/HRA Eligible and Ineligible Expenses Maximize the Value of Your Reimbursement Account

Your Health Flexible Spending Account (FSA) and/or Health Reimbursement Account (HRA) dollars can be used for a variety of out-of-pocket health care expenses. The following list is based on eligible and ineligible

expenses used by federal employees.

Eligible Expenses

BABY/CHILD TO AGE 13 MEDICAL EQUIPMENT/SUPPLIES MEDICATIONS

Lactation consultant*

Air purification equipment* Insulin Lead-based paint removal

Arches and orthotic inserts Special formula*

Contraceptive devices Tuition: special school/teacher for

Crutches, walkers, wheel chairs OBSTETRICS

disability or learning disability* Exercise equipment* Doulas*

Well baby/well child care

Hospital beds* Lamaze class

Mattresses* OB/GYN exams

DENTAL

Medic alert bracelet or necklace

OB/GYN prepaid maternity fees Dental x-rays

Nebulizers (reimbursable after date of birth) Dentures and bridges

Orthopedic shoes* Exams and teeth cleaning

Oxygen* Extractions and fillings

Post-mastectomy clothing PRACTITIONERS Oral surgery

Prosthetics Allergist

SyringesOrthodontia Chiropractor

Wigs*Periodontal services

Christian Science Practitioner Dermatologist

MEDICAL PROCEDURES/SERVICES

EYES

Homeopath Eye exams

Acupuncture Naturopath* Eyeglasses and contact lenses

Alcohol and drug/substance Optometrist Laser eye surgeries

abuse (inpatient treatment and

Osteopath

outpatient care) PhysicianPrescription sunglasses Ambulance Psychiatrist or PsychologistRadial keratotomy

Fertility enhancement and treatment

Hair loss treatment*

THERAPYHEARING

Hospital services Alcohol and drug addictionHearing Aids and Batteries Immunization Counseling (not marital or career)Hearing Exams

In Vitro fertilization Exercise programs*

Physical examination (not

Hypnosis

LAB EXAMS/TESTS

employment-related)

Massage* Blood tests and metabolism tests

Reconstructive surgery (due to a

OccupationalBody ccans

congenital defect, accident, or

PhysicalCardiograms medical treatment) Smoking cessation programs*Laboratory fees Service animals SpeechX-Rays

Sterilization/sterilization reversal

Weight loss programs* Transplants (including organ donor)

Transportation*

HRA ELIGIBLE

Insurance premiums Long-term care premiums

Note: This list is not meant to be all-inclusive, as other expenses not specifically mentioned may also qualify. Also, expenses marked with an asterisk (*) are potentially eligible expensesthat require a note of medical necessity from your health care provider to qualify for reimbursement. For additional information, check your Summary Plan Document or contact Infinisource.

15 E; Washington St; • PO Box 488 • Coldwater, MI 49036-0488 • 866-370-3040 • Fax: 800-379-5670 • E-mail: fsa@infinisource.com Copyright © 2013 Infinisource, Inc. All rights reserved. 0208 1113

The IRS does not allow the following expenses to be reimbursed under Health FSAs or HRAs, as they are not prescribed by a physician for a specific ailment.

Ineligible Expenses

Insurance premiums and interest Personal trainersContact lens or eyeglass insurance (FSA ineligible only) Sunscreen (SPF less than 30)Cosmetic surgery/procedures Long-term care premiums Swimming lessonsElectrolysis

(FSA ineligible only) Marriage or career counseling

Note: This list is not meant to be all-inclusive.

Please note: The IRS will not allow OTC medicines or drugs to be purchased with Health FSA or HRA funds unless accompanied by a prescription.

Eligible Over-the-Counter Items Note: Product categories are listed in bold face; common examples of products are listed in regular face.

The following is a high level list of over-the-counter (OTC) items that clearly are not medicine or drugs and are eligible for purchase with Health FSA or HRA dollars. You can use your benefits card for these items

Antiseptics, wound cleansers Alcohol, peroxide, Epsom salt Baby electrolytes Diagnostic products Thermometers, blood pressure monitors, cholesterol testing
Pedialyte, Enfalyte Elastics/athletic treatments ACE,
Denture adhesives, repair Futuro, elastic bandages, braces,
and cleansers hot/cold therapy, orthopedic
PoliGrip, Benzodent, Efferdent supports, rib belts
Diabetes testing and aids Eye care
Insulin, Ascencia, One Touch, Contact lens care
Diabetic Tussin, insulin syringes, Family planning
glucose products Pregnancy and ovulation kits

First aid dressings and supplies

Band Aid, 3M Nexcare, non-sport

tapes

Hearing aid/medical batteries

Incontinence products Attends, Depend, GoodNites for juvenile incontinence

Reading glasses and maintenance accessories

For additional information, please contact:

Infinisource, Inc. Phone: 866.370.3040
PO Box 488 Fax: 800.379.5670
Coldwater, MI 49036-0488 Email: fsa@infinisource.com

15 E; Washington St; • PO Box 488 • Coldwater, MI 49036-0488 • 866-370-3040 • Fax: 800-379-5670 • E-mail: fsa@infinisource.com Copyright © 2013 Infinisource, Inc. All rights reserved. 0208 1113

Savings Snapshot

You can increase the money you take home each pay period by using a Flexible Benefits Plan. Here is an example of the tax savings an employee earning $2,200 a month can experience using

this great benefit.
Without 125 Plan With 125 Plan
Monthly income before taxes $2,200.00 $2,200.00
Pre-tax salary deductions
Health FSA contribution $.00 $60.00
Dependent Care FSA contribution $.00 $260.00
Employee contribution to health plan $.00 $50.00
Total $.00 $370.00
Payroll taxes
FICA (7.65%) $168.30 $140.00
Federal income tax (12.16%) $267.52 $222.53
State income tax (4%) $88.00 $73.20
Total $523.82 $435.73
After tax expenses
Health care expenses $60.00 $.00
Dependent care expenses $260.00 $.00
Employee contribution to health plan $50.00 $.00
Total $370.00 $.00
Spendable income $1,306.18 $1,394.27
Employee’s spendable income increases
$22.03 each week
$88.09 each month
$1,057.08 each year

Frequently Asked Questions

General Information

Why should I participate in the Flexible Benefits Plan?

There are some great advantages to using a Flexible Benefits Plan!

Reduced taxes -the money contributed to an FSA is not subject to taxes (federal income and FICA taxes and

most state and local income taxes).

Increase your take-home pay less taxes, more money in your pocket

The Benny Card pay for expenses at point of purchase

A Flexible Benefits Plan applies to out-of-pocket expenses you cover with your spendable income, but allows you to pay for these expenses with income before you are taxed.

Another advantage to participating in the Plan is the opportunity it offers for you to budget for health care expenses by withholding a small amount from each paycheck; With proper planning, you won’t be faced with having to come up with large amounts of money at one time. This is especially advantageous if you are scheduling a surgery, anticipating maternity expenses or if you do not have other coverage for dental and vision expenses. Even those with coverage for medical, dental and vision usually have deductibles, co-pays and other out-of-pocket expenses to cover.

Where do I call with questions about my Flexible Benefits Plan?

If you have any questions about putting a Flexible Benefits Plan to work for you, how to sign up or how to determine your election amounts, etc., please call a Customer Service Representative at 866-370-3040.

Enrollment

How do I enroll?

To enroll in either or both the Health and Dependent Care FSA, you simply need to fill out the Enrollment Form/Direct Deposit Form before the beginning of each Plan Year.

Do I have to keep the same election each year?

No. Each year, you will have to re-enroll before the beginning of the Plan Year. At that time, you will have the opportunity to evaluate the need to participate in the Plan as well as budget for all health care and/or dependent care expenses. You may decide to keep the same election, change your election or in some cases waive participation.

Do I have to elect both the Health and Dependent Care FSAs?

No. You may choose to participate in one or both depending on your individual needs.

Health FSAs

What is a Health Flexible Spending Account (FSA)?

You may set aside pre-tax dollars to cover eligible medical expenses that are not covered by any other type of insurance. The account helps you budget for planned expenses such as deductibles, co-payments and prescriptions. You may refer to the FSA Worksheet for a list of some eligible and ineligible expenses.

Are insurance premiums an eligible expense?

No, insurance premiums are not reimbursable from a Health FSA. However, you may pay your required premium contributions (for coverage under the employers health plan) on a pre-tax basis outside of the Health FSA.

15 E; Washington St; • PO Box 488 • Coldwater, MI 49036-0488 • 866-370-3040 • Fax: 800-379-5670 • E-mail: fsa@infinisource.com Copyright © 2013 Infinisource, Inc. All rights reserved. 0208 1013

What are some examples of OTC drugs that are eligible for reimbursement from my Health FSA?

Antiseptics, diabetes testing aids, bandages and contact lens care. For a more inclusive list, please see the OTC expenses list available at www.infinisource.com.

If I terminate employment or retire, can I receive the remaining balance in my Health FSA?

No. However, you can continue to submit claims incurred prior to your termination date before the end of the run-out period (defined in your Summary Plan Description).

Example: Your plan has a 90-day run-out period following termination. Your termination date is September 13. Your physician sees you on September 12, but you do not receive the Explanation of Benefits from your insurance carrier until October 31. You can still submit this expense as it was incurred prior to your termination date, and prior to the end of the 90-day run-out period following your date of termination. Any expense incurred after September 13 is not eligible.

If I terminate employment or retire can I be reimbursed for expenses incurred after my termination date?

No. In order to be considered an eligible expense, the expense must be incurred prior to your termination date. However, you may be able to continue your Health FSA coverage under COBRA.

Dependent Care FSAs

What is a Dependent Care FSA?

You can use pre-tax dollars to cover eligible work-related dependent care expenses for qualified dependents, or if you are married, while you and your spouse work or your spouse attends school full-time.

Who is a qualified dependent under the Dependent Care FSA?

Dependent under the age of 13 Dependent or spouse of employee who is mentally or physically disabled and whom the employee claims as a dependent on his or her federal income tax return

Can an adult be a qualified dependent?

Yes, an adult may qualify as a dependent provided that the employee is providing more than half of that individuals support for the year and the dependent lives with the employee.

Do I have to use a day care facility?

No. You can be reimbursed for expenses of an individual providing care for your dependent in your home as long as the expenses are incurred for you and your spouse (if married), to work, look for work or attend school full-time.

Does my day care provider have to be licensed?

No. However, you are required to submit their Tax Identification Number or Social Security Number when filing your federal income tax return.

Does my day care provider have to be 18?

No, but the individual must claim the money as income on their tax return.

My child attends camp during the summer. Is this eligible?

Generally, no; however, if the camp is day camp and your dependent attends to allow you and your spouse (if married), to work, look for work or attend school full-time, then yes this would be an eligible expense. Overnight camps are specifically excluded.

15 E; Washington St; • PO Box 488 • Coldwater, MI 49036-0488 • 866-370-3040 • Fax: 800-379-5670 • E-mail: fsa@infinisource.com Copyright © 2013 Infinisource, Inc. All rights reserved. 0208 1013

When can I be reimbursed for dependent care expenses?

Expenses are eligible for reimbursement when they have been incurred, not when you are billed or when you pay for the services.

Example: Your day care provider requires you to pay for the month of September on September 1. You can be reimbursed as the services are incurred, not when you paid for the services. You can submit claims after each week, every two weeks or on October 1.

Changing Your Election

What if I discover that I elected too much for the Health and/or Dependent Care FSA, can I change my election?

Generally, your election is irrevocable unless you experience an IRS Change in Status. Your election change must be consistent with the Change in Status event:

Change in legal marital status (marriage, death of spouse, divorce, legal separation, annulment)

Change in number of tax dependents (birth, death of dependent, adoption or placement for adoption)

Change in dependents eligibility

Change in employment status of employee, spouse or dependents

Other changes that may permit an election change under the Dependent Care FSA are:

  1. o Change of dependent care provider
  2. o Change of rate charged by unrelated dependent care provider
  3. o Child attaining age 13

Election changes must be consistent with the event. If you experience a Change in Status, please review your Summary Plan Description, as it will provide you with important information on the deadline for reporting this event.

If I elected too much in my Health FSA but not enough in my Dependent Care FSA, can I move money from one account to the other?

No, Health and Dependent Care FSA elections are separate. You cannot move contributions from one account to another. Also, it is very important to note that the elections you make are for the entire year. Your elections cannot be changed unless you experience an IRS Change in Status as noted above.

What happens if I don’t use all the money elected in my FSA?

The IRS has issued guidance that allows a Health FSA to carry over up to $500 to the next plan year by plan design based on the plan sponsor’s decision; AHealthFSAcannothavebothacarryoverandagraceperiodofuptotwomonthsand15days. Youalso havea run-out period following the end of the plan year to submit expenses that were incurred during the plan year. It is important to estimate your expenses carefully before making your elections.

Infinisource will assist you in monitoring your Flexible Spending Accounts by providing you with a statement at the beginning of the fourth quarter of your plan year. You can minimize possible forfeitures by scheduling routine exams, purchasing glasses or contact lenses and scheduling dental appointments, etc., at the end of the plan year to use up your election amounts.

Submitting Claims for Reimbursement

How do I submit a claim for the Health or Dependent Care FSA?

You can file your claim online or via mobile app and upload your receipts. You can complete an FSA Request for Reimbursement Form for each Health or Dependent Care FSA claim you file. Remember to attach supporting documentation for the claim. This information can be faxed to 800-379-5670.

You may also submit your claim by mail: Infinisource, Inc. PO Box 488, Coldwater, MI 49036-0488

15 E; Washington St; • PO Box 488 • Coldwater, MI 49036-0488 • 866-370-3040 • Fax: 800-379-5670 • E-mail: fsa@infinisource.com Copyright © 2013 Infinisource, Inc. All rights reserved. 0208 1013

May I submit expenses for my spouse and children for reimbursement through my Health FSA?

Yes, you may be reimbursed for expenses incurred for you, your spouse and any IRS dependents, regardless of where you are insured. It could be that you are not covered through your employers health plan, but have coverage through your spouses employers plan. You may still submit your family out-of-pocket expenses to be reimbursed under the Health FSA.

What supporting documentation must I file with each Health FSA claim?

Each time you submit claims to your health insurance carrier, you will receive an Explanation of Benefits (EOB) detailing what the health plan will pay and what you must pay. For expenses that are partially covered under another insurance plan, you must attach a copy of both EOBs.

For expenses that are not submitted to another insurance plan, you must attach a copy of an itemized billing containing the

following information:

Name of patient

Name and address of provider

Description of service

Date of service

Amount of service

The documentation requirements are also listed on the FSA Request for Reimbursement Form to assist you in properly filing your claim. Following these guidelines will ensure you receive your reimbursement without unnecessary delays.

What supporting documentation must I file with each Dependent Care claim?

Complete the Dependent Care section of the Request for Reimbursement Form and have your day care provider sign and date.

The receipt must include the following information:

Name and address of provider

From/through dates of service

Amount of charge

How long after the end of the Plan year do I have to submit claims?

Claims must be submitted prior to the end of the run-out period for the Plan. The run-out period is defined in your Summary Plan Description.

Will I receive reimbursement for claims that are greater than the current balance of my Health FSA?

Yes, the annual amount is available to you from the beginning of the Plan year.

Will I receive reimbursement that is greater than the current balance of my Dependent Care FSA?

No, you will only receive reimbursement for the amount that has been contributed at the time you submit your claim.

Can I submit claims for dependent care expenses that are greater than the current balance of my Dependent Care FSA?

Yes, however, you will only receive reimbursement for the amount that you have contributed to your Dependent Care FSA. For example, if you contribute $150 each month to your Dependent Care FSA, then you will only receive $150 in reimbursement each month. The excess amount of expenses will be pended and automatically paid to you as contributions are posted to your account.

What happens if a claim exceeds the amount currently available in my Dependent Care FSA?

The claim will be processed and approved. The amount that is currently available will be disbursed and the remaining portion will be pended until you make another contribution.

15 E; Washington St; • PO Box 488 • Coldwater, MI 49036-0488 • 866-370-3040 • Fax: 800-379-5670 • E-mail: fsa@infinisource.com Copyright © 2013 Infinisource, Inc. All rights reserved. 0208 1013

How do I know that you received my claim and whether or not it was paid?

Generally, within two business days of submitting a claim, you can view your account to check on the status of the claim at www.infinisource.com. Simply choose Flexible Spending Account /Health Reimbursement under employee/participant and follow the on-screen instructions.

When can I expect to receive my reimbursement?

Claims are generally processed within two business days of receipt. Reimbursements are then processed and released according to the disbursement schedule and funding option of the employer. Generally, disbursement schedules are daily. This means that reimbursements are processed each day and include any claims that were processed the previous day. The release of your reimbursement depends upon the funding option chosen by the employer.

How do I know what my account balance is?

You can use one of the following methods to check your account balance: You can view your account at www.infinisource.com. Simply choose Flexible Spending Account/ Health Reimbursement

under Employee/Participants and follow the on-screen instructions. You can view your balance on the mobile app. Your account balance will be displayed on the reimbursement check or direct deposit notification each time you submit

a claim. You will receive a Balance Statement quarterly during the Plan year. This statement provides a summary of your remaining balance in the Health FSA and/or the Dependent Care FSA as well as claims paid to date.

How do I know why my claim was denied?

You will receive a letter indicating the reason for the denial along with instructions for submitting the requested documentation.

Why may the amount of my reimbursement differ from the amount of my request?

There are reasons that you may see a different reimbursement amount. For example:

1. If the request was for more than the balance of your account.

Annual election $1,000.00 Total amount disbursed to date $700.00 Available balance $300.00 Total amount of request $500.00

You will only be reimbursed $300.00, as this is your available balance.

2. If the request was for a dependent care claim, you may only be reimbursed for the total amount that you have contributed.

Annual election $5,000.00 Total amount contributed $3,000.00 Total amount of request $4,250.00

You will only be reimbursed $3,000.00, as this is the amount that you have contributed to the account. The entire request of $4,250.00, will be processed and the remaining $1,250.00 will be disbursed as contributions are made.

15 E; Washington St; • PO Box 488 • Coldwater, MI 49036-0488 • 866-370-3040 • Fax: 800-379-5670 • E-mail: fsa@infinisource.com Copyright © 2013 Infinisource, Inc. All rights reserved. 0208 1013

Dependent Care FS! F!Q

A Dependent Care FSA allows participants to use pre-tax dollars to cover eligible work-related dependent care expenses for qualified dependents, or if you are married, while you and your spouse work or your spouse attends school full-time.

Who is a qualified dependent under the Dependent Care FSA?

  • Dependent under the age of 13
  • Dependent or spouse of employee who is mentally or physically disabled and whom the employee claims

as a dependent on their federal income tax return

Can an adult be a qualified dependent?

Yes, an adult may qualify as a dependent provided that the employee is providing more than half of that individual’s support for the year and the dependent lives with the employee.

Do I have to use a day care facility?

No. You can be reimbursed for expenses of an individual providing care for your dependent in your home as long as the expenses are incurred for you and your spouse (if married), to work, look for work or attend school full-time.

Does my day care provider have to be licensed?

No. However, you are required to submit their Tax Identification Number or Social Security Number when filing your federal income tax return.

Does my day care provider have to be 18?

No, but the individual must claim the money as income on their tax return.

My child attends camp during the summer. Is this eligible?

Generally, no; however, if the camp is day camp and your dependent attends to allow you and your spouse (if married), to work, look for work or attend school full-time, then yes this would be an eligible expense. Overnight camps are specifically excluded.

When can I be reimbursed for dependent day care expenses?

Expenses are eligible for reimbursement when they have been incurred, not when you are billed or when you pay for the services.

Example: Your day care provider requires you to pay for the month of September on September 1. You can be reimbursed as the services are incurred, not when you paid for the services. You can submit claims after each week, every two weeks or on October 1.

V1.0/4-14 All ideas and information contained within these documents are the intellectual property rights of Infinisource. These documents are not for general distribution and are meant for use only by Infinisource participants. Unauthorized distribution of these documents, in any form or means including electronic, mechanical, photocopying or otherwise is prohibited.

Dependent Care FS! F!Q

What supporting documentation must I file with each Dependent Care claim?

Complete the Dependent Care section of the Request for Reimbursement Form and have your day care provider sign and date. The receipt must include the following information:

  • Name and address of provider
  • From/through dates of service
  • !mount of charge

Can I submit claims for dependent care expenses that are greater than the current balance of my Dependent Care FSA?

Yes, however, you will only receive reimbursement for the amount that you have contributed to your Dependent Care FSA. For example, if you contribute $150 each month to your Dependent Care FSA, then you will only receive $150 in reimbursement each month. The excess amount of expenses will be pended and automatically paid to you as contributions are posted to your account.

What happens if a claim exceeds the amount currently available in my Dependent Care FSA?

The claim will be processed and approved. The amount that is currently available will be disbursed and the remaining portion will be pended until you make another contribution.

V1.0/4-14 All ideas and information contained within these documents are the intellectual property rights of Infinisource. These documents are not for general distribution and are meant for use only by Infinisource participants. Unauthorized distribution of these documents, in any form or means including electronic, mechanical, photocopying or otherwise is prohibited.

Consumer Portal

Quick Start Guide

Welcome to your Infinisource Benefits Accounts Consumer Portal. This portal gives you anytime access to view information and manage your account.

It enables you to:

File a claim online

Upload receipts

View up-to-minute account balances

View your account activity, claim history and payment (reimbursement) history

Update your personal profile information

Change your login ID and/or password

Download plan information, forms and notifications

Note: If your employer is providing you with the Infinisource prepaid benefits cards, The Benny Card, please review the following information.

Since you’ve enrolled in the Flexible Spending !ccount you may be receiving two prepaid benefits cards at your home address for you and your family members to use. The cards will arrive in a special envelope that looks like this – so please don’t throw it out!

AllideasandinformationcontainedwithinthesedocumentsaretheintellectualpropertyrightsofInfinisource. Thesedocumentsarenotfor general distribution and are meant for use only by Infinisource participants. Unauthorized distribution of these documents, in any formor means including electronic, mechanical, photocopying or otherw ise is prohibited.

Consumer Portal

Quick Start Guide

With the card, you don’t have to pay cash up front, file claims and wait for reimbursement. !ccessing your account is …

Easy a simple swipe of the card makes it hassle free! Automatic funds are immediately transferred from your FSA at the time you incur the expenses

Convenient there are nomanualclaimforms tosubmit

Simple to track your current balance is available 24/7 at www.infinisource.com

Note: The Benny Cardexpires afterfive years. There isa$5.00replacement feeifthe cardisdestroyed prior to the expiration date, lost/stolen, additional cards requested or not received.

Participants frequently contact Infinisource requesting information on when their debit card will be

mailed to them. Participants now have the ability to set up to receive a text message when their debit card is mailed.

To add this feature, participants will access the Participant Online Portal (see below for more information for first-time users logging into the site), select Statements and Notifications, Update Notification Preference and check the box to receive alerts under Debit Card Alerts.

Participants can also set up to receive a text message for claim information including when it has been filed, processed or denied.

To login to your home page, follow these steps:

  1. Navigate to the Infinisource login page.
  2. Enter your Username and Password. First time users will login using lower case first initial, last name and last four digits of your Social Security Number as both Username and Password.

AllideasandinformationcontainedwithinthesedocumentsaretheintellectualpropertyrightsofInfinisource. Thesedocumentsarenotfor general distribution and are meant for use only by Infinisource participants. Unauthorized distribution of these documents, in any formor means including electronic, mechanical, photocopying or otherw ise is prohibited.

Consumer Portal

Quick Start Guide

  1. Enter your First Name, Last Name, Zip Code and SSN or Employee ID. Click Next.
  2. You will be prompted to answer security questions when you login and change your username and password. (You will only be asked these questions upon logging in to the website the first time.) Answers to security questions are case sensitive.
  3. Set up your Username and new Password. Your username may contain alphanumeric characters and any of these special characters: period (.), at sign (@), underscore (_) and dash(-).

Your password must have a minimum of six characters, not be one of your last three passwords, contain at least one upper and lowercase letter, contain at least one number and at least one special symbol (-+=!@#$%^&*_).

AllideasandinformationcontainedwithinthesedocumentsaretheintellectualpropertyrightsofInfinisource. Thesedocumentsarenotfor general distribution and are meant for use only by Infinisource participants. Unauthorized distribution of these documents, in any formor means including electronic, mechanical, photocopying or otherw ise is prohibited.

Consumer Portal

Quick Start Guide

The Home Page is easy to navigate: The top section shows messages from your employer and links to employee information. The Message Center section displays alerts and relevant links to keep current on your accounts. The Available Balance section has a link to account balances and activity details. File a claim directly from the Home Page. Get your money faster (direct deposit), under Message Center click on get your money faster. This will direct you to enter your bank information and click submit.

AllideasandinformationcontainedwithinthesedocumentsaretheintellectualpropertyrightsofInfinisource. Thesedocumentsarenotfor general distribution and are meant for use only by Infinisource participants. Unauthorized distribution of these documents, in any formor means including electronic, mechanical, photocopying or otherw ise is prohibited.

Consumer Portal

Quick Start Guide

How do I file a claim and upload documentation?

Important: Itemized receipts or an Explanation of Benefits (EOB) is required. Charge slips or check copies are not eligible documentation. Claims can be submitted online or via the Mobile App for iPhone and Androids.

Consumer Portal

Quick Start Guide

4. When all claims are entered in the Claims Basket, check the box next to I have read and agree to

Terms and Conditions. Click Submit Claims to send the claims for processing.

5. The Claim Confirmation page will the display. Print the Claim Confirmation Form as a record of your submission. Ifyou didnotupload yourreceipt, printanotherClaimConfirmation Form, attachthe required receipts and submit to the administrator. If a receipt is required, you will see the Upload

Receipt link. Click on it and the Receipts Needed screen displays.

Note: If you see Receipts Needed link in the Message Center section of your Home Page, click on it. A listing of the claims requiring receipts will appear.

AllideasandinformationcontainedwithinthesedocumentsaretheintellectualpropertyrightsofInfinisource. Thesedocumentsarenotfor general distribution and are meant for use only by Infinisource participants. Unauthorized distribution of these documents, in any formor means including electronic, mechanical, photocopying or otherw ise is prohibited.

Consumer Portal

Quick Start Guide

How do I view current account balance and activity?

  1. For the current Account Balance only, on the Home Page, under Available Balance shows the available amount next to the applicable account.
  2. For an Account Summary of your account(s) that includes current Account Balance(s), click on Available Balance link or click on the Accounts link on the top menu, which will take you to Account Summary.

AllideasandinformationcontainedwithinthesedocumentsaretheintellectualpropertyrightsofInfinisource. Thesedocumentsarenotfor general distribution and are meant for use only by Infinisource participants. Unauthorized distribution of these documents, in any formor means including electronic, mechanical, photocopying or otherw ise is prohibited.

Consumer Portal

Quick Start Guide

3. On your iPhone/Android, download the iFlex app and view your account information.

How do I view my claims history?

1. On the Home Page, click on Accounts,

a.
Click Claims
b.
Click on any claim to view more details

How do I view my payment (reimbursement) history?

  1. On the Home Page, click on Accounts, then on the left menu click on Payments. You will see reimbursement payments made to date, including debit card transactions.
  2. Click on any claim to see claim details.

AllideasandinformationcontainedwithinthesedocumentsaretheintellectualpropertyrightsofInfinisource. Thesedocumentsarenotfor general distribution and are meant for use only by Infinisource participants. Unauthorized distribution of these documents, in any formor means including electronic, mechanical, photocopying or otherw ise is prohibited.

Consumer Portal

Quick Start Guide

Consumer Portal

Quick Start Guide

How do I change my login and/or password?

  1. On the Home Page, click on Profile, click on Login Information from the left menu.
  2. You can change your password, username or security questions from this area
  3. Follow the instructions on the screen. (For a new account, the first time you log in, you will be prompted to change the password that was assigned by your plan administrator. Follow the instructions.)

How do I view or access ...

Statements and Notifications

  1. On the Home Page, click on Statements & Notifications from top menu
  2. Click any link of your choice: Account Statements, Advice of Deposits, Denial Letters, Denial Letters with Repayments or Receipt Reminder are a few options.

AllideasandinformationcontainedwithinthesedocumentsaretheintellectualpropertyrightsofInfinisource. Thesedocumentsarenotfor general distribution and are meant for use only by Infinisource participants. Unauthorized distribution of these documents, in any formor means including electronic, mechanical, photocopying or otherw ise is prohibited.

Consumer Portal

Quick Start Guide

Plan information

  1. On the Home Page, click on Accounts from top menu then Account Summary from the left menu.
  2. Click on the applicable account
  3. Plan Rules open in another browser

Questions?

Contact Infinisource Customer Service Representatives at 866-370-3040 or email at fsa@infinisource.com .

AllideasandinformationcontainedwithinthesedocumentsaretheintellectualpropertyrightsofInfinisource. Thesedocumentsarenotfor general distribution and are meant for use only by Infinisource participants. Unauthorized distribution of these documents, in any formor means including electronic, mechanical, photocopying or otherw ise is prohibited.

Download the iFlex !pp

Infinisource provides all Flexible Spending Account (FSA) and Health Reimbursement Arrangement (HRA) participants with an online portal that provides anytime access to view and manage account information. Participants can also download the iFlex App to access account information from an iPhone, iPad or Android device.

Follow these steps to Download the iFlex App

  1. Visit the iTunes App Store or the Android Market to download the Infinisource app on your iPhone, iPad or Android.
  2. Once installed, enter the same Username and Password to log into your account at www.infinisource.com.

The iFlex app saves time and hassles while making the most of your HSA, HRA and FSA health benefit accounts by checking your balances and details. Our secure app makes managing your health benefits easy by providing real time, convenient access to all your important account information on the go!

Powerful features of the app:

Easy, convenient & secure

Simply login to the app using your same health benefits website username and password (or follow

alternative instructions if provided to you)

No sensitive account information is ever stored on your mobile device; secure encryption is used to protect all transmissions

V1.0/4-14 All ideas and information contained within these documents are the intellectual property rights of Infinisource. These documents are not for general distribution and are meant for use only by Infinisource participants. Unauthorized distribution of these documents, in any form or means including electronic, mechanical, photocopying or otherwise is prohibited.

Download the iFlex !pp

Connects you with the details

  • Quickly check available balances 24/7
  • !ccess account details
  • View charts summarizing account(s)
  • Click to call or email Customer Service

Provides additional time-saving options (if supported or applicable to your account[s])

  • View claims requiring receipts
  • Submit medical FS! and HR! claims
  • Take a picture of a receipt and submit for a new or existing claim
  • View HSA transaction details
  • Using Expense Tracker, enter medical expense information and

supporting documentation to store for later use in paying claims via your health benefits website

Report a lost or stolen debit card

V1.0/4-14 All ideas and information contained within these documents are the intellectual property rights of Infinisource. These documents are not for general distribution and are meant for use only by Infinisource participants. Unauthorized distribution of these documents, in any form or means including electronic, mechanical, photocopying or otherwise is prohibited.

Plan Highlights

Voluntary Group Long Term Disability Insurance

Ascension Parish School Board

Who iS eligiBle?

All full-time employees

When do my BenefitS Begin?

You may select from the following elimination period

options: option 1 – 14 days for injury, 14 days for sickness option 2 – 30 days for injury, 30 days for sickness* option 3 – 60 days for injury, 60 days for sickness option 4 – 90 days for injury, 90 days for sickness

*If you are hospital confined as an inpatient for your disability and have selected an elimination period of 30 days, benefits begin immediately. Inpatient means an individual who is physically confined for an overnight stay, as a registered bed patient in a hospital or institution, as defined in the policy or plan.

WhAt iS the Benefit Amount?

You may elect a monthly benefit in increments of $100 from a minimum of $200, up to a maximum benefit of $7,500, not to exceed 66.67% of your covered salary. If at any time the monthly benefit you have chosen exceeds 66.67% of your covered salary, your benefit amount will be reduced to the highest increment for which you are eligible.

Will my BenefitS ever Be reduced?

After 12 months of benefit payments, the amount of benefit you receive or are eligible to receive from various sources will reduce your benefit amount.

hoW long Will i receive BenefitS?

If disabled due to a covered sickness, and disability occurs at age 68 or less, for 5 years; for a disability occurring at age 69 or more, 1 year.

Benefits will not extend beyond the longer of: Social Security Normal Retirement Age or Duration of Benefits below for Injury:

Age at disablement duration of Benefits (in years)
age 61 or less To Age 65
62
63 3
64
65 2
66
67
68
69 or older 1

Or Employee’s Normal Retirement Age

WhAt feAtureS Are included in my PlAn?

  • Conversion Privilege
  • Extended Disability Benefit
  • Limited Benefit Period for Other Specific Conditions –

24 months

  • FMLA Continuation
  • Mental/Nervous Illness Limitation – 2 year
  • Own Occupation - 24 months
  • Pre-Existing Condition Limitation – 3/12
  • Specific Indemnity Benefit
  • Substance Abuse Limitation – 2 year
  • Survivor Benefit – 3 times your gross monthly benefit
  • Work Incentive and Child Care Expense Benefit
  • Worksite Modification
  • Residual and Partial Disability
  • Living Benefit
  • Minimum Benefit Payable – $100
  • Pre-Existing Condition Benefit
  • Non-occupational coverage

Are there Any AdditionAl ServiceS AvAilABle under thiS PlAn?

  • Travel Assistance Service
  • Employee Assistance Program
  • Identity Theft Recovery Services

This Plan Highlights is a brief description of the key features of the RSL

insurance plan. The availability of the benefits and features described may vary by state. It is not a certificate of insurance or evidence of coverage.

Insurance is provided under group policy form LRS-6564,et al.

www.RelianceStandard.com

EF-0003 (7/13)

Reliance Standard Voluntary Plans Voluntary Group Disability Insurance Premium Table Plan Holder: Ascension Parish School Board

Scheduled Benefit: Each eligible employee may elect an amount of insurance, in increments of $100 from a minimum of $200 to a maximum of $7,500 per month up to 67% of covered earnings.

You may select any benefit amount from $200 up to your maximum monthly benefit. Locate your monthly earnings to determine your maximum monthly benefit amount. If your covered month earnings fall between ranges, the lesser benefit amount will apply.

Monthly Premiums
Min. Annual Earnings Min. Monthly Earnings Monthly Benefit Option 1 14 day EP Option 2 30 day EP Option 3 60 day EP Option 4 90 day EP
3,600.00 $ 300.00 $ 200.00 $ 4.72 $ 3.30 $ 2.34 $ 1.90 $
5,400.00 $ 450.00 $ 300.00 $ 7.08 $ 4.95 $ 3.51 $ 2.85 $
7,200.00 $ 600.00 $ 400.00 $ 9.44 $ 6.60 $ 4.68 $ 3.80 $
9,000.00 $ 750.00 $ 500.00 $ 11.80 $ 8.25 $ 5.85 $ 4.75 $
10,800.00 $ 900.00 $ 600.00 $ 14.16 $ 9.90 $ 7.02 $ 5.70 $
12,600.00 $ 1,050.00 $ 700.00 $ 16.52 $ 11.55 $ 8.19 $ 6.65 $
14,400.00 $ 1,200.00 $ 800.00 $ 18.88 $ 13.20 $ 9.36 $ 7.60 $
16,200.00 $ 1,350.00 $ 900.00 $ 21.24 $ 14.85 $ 10.53 $ 8.55 $
18,000.00 $ 1,500.00 $ $ 1,000.00 23.60 $ 16.50 $ 11.70 $ 9.50 $
19,800.00 $ 1,650.00 $ $ 1,100.00 25.96 $ 18.15 $ 12.87 $ 10.45 $
21,600.00 $ 1,800.00 $ $ 1,200.00 28.32 $ 19.80 $ 14.04 $ 11.40 $
23,400.00 $ 1,950.00 $ $ 1,300.00 30.68 $ 21.45 $ 15.21 $ 12.35 $
25,200.00 $ 2,100.00 $ $ 1,400.00 33.04 $ 23.10 $ 16.38 $ 13.30 $
27,000.00 $ 2,250.00 $ $ 1,500.00 35.40 $ 24.75 $ 17.55 $ 14.25 $
28,800.00 $ 2,400.00 $ $ 1,600.00 37.76 $ 26.40 $ 18.72 $ 15.20 $
30,600.00 $ 2,550.00 $ $ 1,700.00 40.12 $ 28.05 $ 19.89 $ 16.15 $
32,400.00 $ 2,700.00 $ $ 1,800.00 42.48 $ 29.70 $ 21.06 $ 17.10 $
34,200.00 $ 2,850.00 $ $ 1,900.00 44.84 $ 31.35 $ 22.23 $ 18.05 $
36,000.00 $ 3,000.00 $ $ 2,000.00 47.20 $ 33.00 $ 23.40 $ 19.00 $
37,800.00 $ 3,150.00 $ $ 2,100.00 49.56 $ 34.65 $ 24.57 $ 19.95 $
39,600.00 $ 3,300.00 $ $ 2,200.00 51.92 $ 36.30 $ 25.74 $ 20.90 $
41,400.00 $ 3,450.00 $ $ 2,300.00 54.28 $ 37.95 $ 26.91 $ 21.85 $
43,200.00 $ 3,600.00 $ $ 2,400.00 56.64 $ 39.60 $ 28.08 $ 22.80 $
45,000.00 $ 3,750.00 $ $ 2,500.00 59.00 $ 41.25 $ 29.25 $ 23.75 $
46,800.00 $ 3,900.00 $ $ 2,600.00 61.36 $ 42.90 $ 30.42 $ 24.70 $
48,600.00 $ 4,050.00 $ $ 2,700.00 63.72 $ 44.55 $ 31.59 $ 25.65 $
50,400.00 $ 4,200.00 $ $ 2,800.00 66.08 $ 46.20 $ 32.76 $ 26.60 $
52,200.00 $ 4,350.00 $ $ 2,900.00 68.44 $ 47.85 $ 33.93 $ 27.55 $
54,000.00 $ 4,500.00 $ $ 3,000.00 70.80 $ 49.50 $ 35.10 $ 28.50 $
55,800.00 $ 4,650.00 $ $ 3,100.00 73.16 $ 51.15 $ 36.27 $ 29.45 $
57,600.00 $ 4,800.00 $ $ 3,200.00 75.52 $ 52.80 $ 37.44 $ 30.40 $
59,400.00 $ 4,950.00 $ $ 3,300.00 77.88 $ 54.45 $ 38.61 $ 31.35 $
61,200.00 $ 5,100.00 $ $ 3,400.00 80.24 $ 56.10 $ 39.78 $ 32.30 $
63,000.00 $ 5,250.00 $ $ 3,500.00 82.60 $ 57.75 $ 40.95 $ 33.25 $
64,800.00 $ 5,400.00 $ $ 3,600.00 84.96 $ 59.40 $ 42.12 $ 34.20 $
66,600.00 $ $ 5,550.00 $ 3,700.00 $ 87.32 $ 61.05 $ 43.29 $ 35.15
68,400.00 $ $ 5,700.00 $ 3,800.00 $ 89.68 $ 62.70 $ 44.46 $ 36.10
70,200.00 $ $ 5,850.00 $ 3,900.00 $ 92.04 $ 64.35 $ 45.63 $ 37.05
72,000.00 $ $ 6,000.00 $ 4,000.00 $ 94.40 $ 66.00 $ 46.80 $ 38.00
73,800.00 $ $ 6,150.00 $ 4,100.00 $ 96.76 $ 67.65 $ 47.97 $ 38.95
75,600.00 $ $ 6,300.00 $ 4,200.00 $ 99.12 $ 69.30 $ 49.14 $ 39.90
77,400.00 $ $ 6,450.00 $ 4,300.00 $ 101.48 $ 70.95 $ 50.31 $ 40.85
79,200.00 $ $ 6,600.00 $ 4,400.00 $ 103.84 $ 72.60 $ 51.48 $ 41.80
81,000.00 $ $ 6,750.00 $ 4,500.00 $ 106.20 $ 74.25 $ 52.65 $ 42.75
82,800.00 $ $ 6,900.00 $ 4,600.00 $ 108.56 $ 75.90 $ 53.82 $ 43.70
84,600.00 $ $ 7,050.00 $ 4,700.00 $ 110.92 $ 77.55 $ 54.99 $ 44.65
86,400.00 $ $ 7,200.00 $ 4,800.00 $ 113.28 $ 79.20 $ 56.16 $ 45.60
88,200.00 $ $ 7,350.00 $ 4,900.00 $ 115.64 $ 80.85 $ 57.33 $ 46.55
90,000.00 $ $ 7,500.00 $ 5,000.00 $ 118.00 $ 82.50 $ 58.50 $ 47.50
91,800.00 $ $ 7,650.00 $ 5,100.00 $ 120.36 $ 84.15 $ 59.67 $ 48.45
93,600.00 $ $ 7,800.00 $ 5,200.00 $ 122.72 $ 85.80 $ 60.84 $ 49.40
95,400.00 $ $ 7,950.00 $ 5,300.00 $ 125.08 $ 87.45 $ 62.01 $ 50.35
97,200.00 $ $ 8,100.00 $ 5,400.00 $ 127.44 $ 89.10 $ 63.18 $ 51.30
99,000.00 $ $ 8,250.00 $ 5,500.00 $ 129.80 $ 90.75 $ 64.35 $ 52.25
$ 100,800.00 $ 8,400.00 $ 5,600.00 $ 132.16 $ 92.40 $ 65.52 $ 53.20
$ 102,600.00 $ 8,550.00 $ 5,700.00 $ 134.52 $ 94.05 $ 66.69 $ 54.15
$ 104,400.00 $ 8,700.00 $ 5,800.00 $ 136.88 $ 95.70 $ 67.86 $ 55.10
$ 106,200.00 $ 8,850.00 $ 5,900.00 $ 139.24 $ 97.35 $ 69.03 $ 56.05
$ 108,000.00 $ 9,000.00 $ 6,000.00 $ 141.60 $ 99.00 $ 70.20 $ 57.00
$ 109,800.00 $ 9,150.00 $ 6,100.00 $ 143.96 $ 100.65 $ 71.37 $ 57.95
$ 111,600.00 $ 9,300.00 $ 6,200.00 $ 146.32 $ 102.30 $ 72.54 $ 58.90
$ 113,400.00 $ 9,450.00 $ 6,300.00 $ 148.68 $ 103.95 $ 73.71 $ 59.85
$ 115,200.00 $ 9,600.00 $ 6,400.00 $ 151.04 $ 105.60 $ 74.88 $ 60.80
$ 117,000.00 $ 9,750.00 $ 6,500.00 $ 153.40 $ 107.25 $ 76.05 $ 61.75
$ 118,800.00 $ 9,900.00 $ 6,600.00 $ 155.76 $ 108.90 $ 77.22 $ 62.70
$ 120,600.00 $ 10,050.00 $ 6,700.00 $ 158.12 $ 110.55 $ 78.39 $ 63.65
$ 122,400.00 $ 10,200.00 $ 6,800.00 $ 160.48 $ 112.20 $ 79.56 $ 64.60
$ 124,200.00 $ 10,350.00 $ 6,900.00 $ 162.84 $ 113.85 $ 80.73 $ 65.55
$ 126,000.00 $ 10,500.00 $ 7,000.00 $ 165.20 $ 115.50 $ 81.90 $ 66.50
$ 127,800.00 $ 10,650.00 $ 7,100.00 $ 167.56 $ 117.15 $ 83.07 $ 67.45
$ 129,600.00 $ 10,800.00 $ 7,200.00 $ 169.92 $ 118.80 $ 84.24 $ 68.40
$ 131,400.00 $ 10,950.00 $ 7,300.00 $ 172.28 $ 120.45 $ 85.41 $ 69.35
$ 133,200.00 $ 11,100.00 $ 7,400.00 $ 174.64 $ 122.10 $ 86.58 $ 70.30
$ 135,000.00 $ 11,250.00 $ 7,500.00 $ 177.00 $ 123.75 $ 87.75 $ 71.25
Ascension Parish School Board

ELIGIBILITY Employees: Each Active, Full-time employee working 30 or more hours per week, except any person working on a temporary or seasonal basis.

Dependents: You must be insured in order for Dependents to be covered. Dependentsare:

  • your legal spouse not legally separated or divorced from you.
  • unmarriedfinanciallydependentchildren,birthtoage26 *natural and adopted children; stepchildren and foster children in your custody.
  • A person may not have coverage as both an Employee and Dependent.
  • Only one insured spouse may cover Dependent children.

BENEFITAMOUNT Basic Life and AD&D

$50,000

Employee & Spouse Supplemental Life

Choose from a minimum of $25,000 to a maximum of $300,000 in $25,000 increments (spouse amount may not exceed 50% of the employee amount to a maximum of $150,000)

Supplemental Child(ren) Life:

Choice of: $5,000 or $10,000

Supplemental AD&D

Supplemental AD&D matches elected Supplemental Life benefit

subject to a maximum of $100,000.

GUARANTEE ISSUE (Initial Eligibility period only)

Employee: $100,000

Spouse: $50,000

Child: all child amounts are guaranteed issue

AGE Original Benefit Reduced To

65 75% 70 50%

CONTRIBUTIONREQUIREMENTS Basic Life (and AD&D):

Coverage is 100% employer paid.

SupplementalLife:

Coverage is 100% employee paid.

Spouse: Coverage is 100% employee paid.

Dependent Child(ren): Coverage is 100% employee paid.

AD&D SCHEDULE

For Accidental Loss of: AmountPayable:
Life 100%
Two or more Members 100%
Speech and hearing 100%
OneMember 50%
Speech or Hearing 50%
Thumb & Index Finger of Same Hand 25%
RATE

See attached Rate Sheet.

FEATURES
  • LivingBenefitRider(expressedasAcceleratedDeathBenefitinsome states and Imminent Death Benefit in PA)
  • AirBagBenefit
  • ConversionPrivilege
  • EducationBenefit
  • FMLA/MSLAContinuation
  • Portability
  • SeatBeltBenefit
  • WaiverofPremium
VALUE ADDED SERVICES
  • BereavementCounselingService
  • TravelAssistanceService
EXCLUSIONS

AD&D EXCLUSIONS: AD&D benefits will not be payable for a loss: caused by suicide or intentionally self-inflicted injuries; caused by or resulting from war or any act of war, declared or undeclared; to which sickness, disease or myocardial infarction, including medical or surgical treatment thereof, is a contributingfactor;

sustained during an insured’s commission or attempted commission of an assault or felony; to which the insured’s acute or chronic intoxication is a contributing factor;or to which the insured’s voluntary consumption of an illegal or controlled substance or a non-prescribed narcotic or drug is a contributingfactor.

For a comprehensive list of exclusions and limitations, please refer to the Certificate of Insurance. The Certificate also provides all requirements necessary to be eligible for coverage and benefits.

This Plan Highlights is a brief description of the key features of the RSL insurance plan. The availability of the benefits and features described may vary by state. It is not a certificate of insurance or evidence of coverage. Insurance is provided under group policy form LRS-6422, et al.

EF-0001 (GL) www.RelianceStandard.com

Reliance Standard Term Life

Scheduled Benefit: Employee-Each eligible employee may elect an amount of insurance, in increments of $25,000 from a minimum of $25,000 to a maximum of $300,000. Spouse-Each eligible employee may elect an amount of insurance, in increments of $25,000 from a minimum of $25,000 to a maximum of $150,000 not to exceed 50% of the employee elected amount.

Voluntary Life & AD&D Election Amount Age <24 Age 25 -29 Age 30 -34 Age 35 -39 Age 40 -44 Age 45 -49 Age 50 -54 Age 55 -59 Age 60 -64 Age 65 -69 Age 70+
$25,000 $2.13 $2.38 $2.88 $3.13 $3.38 $4.63 $6.63 $11.63 $17.38 $32.63 $52.38
$50,000 $4.25 $4.75 $5.75 $6.25 $6.75 $9.25 $13.25 $23.25 $34.75 $65.25 $104.75
$75,000 $6.38 $7.13 $8.63 $9.38 $10.13 $13.88 $19.88 $34.88 $52.13 $97.88 $157.13
$100,000 $8.50 $9.50 $11.50 $12.50 $13.50 $18.50 $26.50 $46.50 $69.50 $130.50 $209.50
$125,000 $9.75 $11.00 $13.50 $14.75 $16.00 $22.25 $32.25 $57.25 $86.00 $162.25 $261.00
$150,000 $11.00 $12.50 $15.50 $17.00 $18.50 $26.00 $38.00 $68.00 $102.50 $194.00 $312.50
$175,000 $12.25 $14.00 $17.50 $19.25 $21.00 $29.75 $43.75 $78.75 $119.00 $225.75 $364.00
$200,000 $13.50 $15.50 $19.50 $21.50 $23.50 $33.50 $49.50 $89.50 $135.50 $257.50 $415.50
$225,000 $14.75 $17.00 $21.50 $23.75 $26.00 $37.25 $55.25 $100.25 $152.00 $289.25 $467.00
$250,000 $16.00 $18.50 $23.50 $26.00 $28.50 $41.00 $61.00 $111.00 $168.50 $321.00 $518.50
$275,000 $17.25 $20.00 $25.50 $28.25 $31.00 $44.75 $66.75 $121.75 $185.00 $352.75 $570.00
$300,000 $18.50 $21.50 $27.50 $30.50 $33.50 $48.50 $72.50 $132.50 $201.50 $384.50 $621.50
Dependent Monthly
Child(ren) Premium
$5,000 $1.00
$10,000 $2.00

Rates are subject to change.

Coverage Options
Employee Employee & Employee & Employee,
Spouse Child Spouse, and Child
$13.78 $22.66 $26.04 $34.97
Covered Critical Illnesses Up to 100% of the benefit amount
Cerebral Palsy 100%
Cleft Lip or Palate 100%
Cystic Fibrosis 100%
Down Syndrome 100%
Spina Bifida 100%

Health Screening Benefit

  • Pays $50 per insured per calendar year if a covered health screening test is performed.
  • Benefits are payable for covered health screening tests performed. The benefit waiting period is 30 days for new employees and 0 days for present employees.
  • Covered health screening tests may vary by state.

Sample Monthly Rates

$10,000 Benefit $20,000 Benefit
Age Non Tobacco Tobacco Non Tobacco Tobacco
25 $6.28 $8.88 $11.00 $16.21
35 $11.00 $17.72 $20.41 $33.80
45 $20.02 $34.19 $38.39 $66.82
55 $33.58 $56.98 $65.61 $112.41

Follow these easy instructions to file a wellness claim and receive your wellness incentive.*

Covered wellness tests include:
Blood test for triglycerides
Bone marrow aspiration or biopsy
CA 15-3 (blood test for breast cancer)
CA-125 (blood test for ovarian cancer)
CEA (blood test for colon cancer)
Carotid Doppler
Chest X-ray
Colonoscopy
Echocardiogram
Electrocardiogram
Fasting blood glucose test
Fasting plasma glucose (FPG)
Flexible sigmoidoscopy
Hemoglobin A1C(HbA1c)
Hemocult stool analysis
Mammography**
Pap smear
PSA (blood test for prostate cancer)
Serum cholesterol test to determine HDL and LDL levels
Serum protein electrophoresis (blood test for myeloma)
Skin cancer biopsy
Stress test on a bicycle or treadmill
Thermography
Thin prep pap test
Two hour post-load plasma glucose
Virtual colonoscopy

Your plan includes benefits that cover annual wellness tests. You can receive valuable incentives for keeping an eye on your health. These step by step instructions make it easy to file a claim and receive your benefit.

Filing a wellness claim:

1.Call 1-800-635-5597. 2.Request to submit a wellness claim. 3.Simply be prepared to provide this information:

  • First and last name of the policyholder
  • Policyholder’s Social Security Number and/or policy number
  • First and last name of the claimant (may or may not be the policyholder)
  • Name and date of the test
  • Physician’s name and/or the facility name where the test was performed

4. If you do not want to file a claim over the telephone, you can request a paper claim form by calling 1-800-635-5597.

It’s that easy. Customer service representatives on the telephone will explain your benefits and answer any questions.

*The wellness benefit can reimburse each covered person a benefit as defined in your plan per calendar year for one

covered wellness test. **In CA, mammograms are not paid under the wellness benefit. GROUP CRITICAL ILLNESS INSURANCE IS A LIMITED POLICY. GROUP ACCIDENT IS A LIMITED POLICY

Insurance products are underwritten by the subsidiaries of Unum Group. unum.com

© 2011 Unum Group. All rights reserved. Unum is a registered trademark and marketing brand of Unum Group and its insuring subsidiaries.

Whole life insurance for children

Giveyour kidsastrong financialstart.

Unum’s whole life insurancefor children can help.

Teach your kids to start saving now.

Katie and Derek work hard for what they have. But they’re also smart financial planners who save their money — and they’re teaching their kids to do the same. By buying a life insurance policy that accumulates cash value, they can save for their children’s future. Now that’s a smart lesson.

Features that add value

1. Cash value — Accumulates at a rate of 4.5%.* You can borrow from the cash value if you choose, or use it to buy a reduced policy with no more premiums.

2. Policy amountsof$10,000to $25,000require no health questions if you apply when you are first eligible. If you wait, there will be a few medical questions. Coverage beyond $25,000 is available but requires health questions to determine eligibility.

3. At age 70, the policy is fully paid up.This means no more premiums must be paid. The benefit will be paid to the beneficiaries upon death.

How to Tolearn more,watchfor information fromyour employer.

apply )

Financial protection for your family

If an accident or illness were to claim the life of your child, this policy could provide the resources needed to deal with the financial strain of your loss — so you can take care of your family during this difficult time.

This coverage can be purchased without purchasing employee coverage. Each policy covers one child or grandchild;you can purchasecoverageforeachofyour children and grandchildren.

Child eligibility

Coverage is available to your:

  • Children (natural and legally adopted)
  • Stepchildren
  • Grandchildren Your child/grandchild is eligible from 14 days old until their 26th birthday. Children must reside in the U.S. to receive coverage.

Three reasons to buy this coverage at work

1.You get affordable rates when you buy this policy

through your employer, and the premiums are

conveniently deducted from your paycheck.

2.You own the policy so you can keep it even if you leave the company or retire. Unum will bill you directly for the same premium amount.

3.Coverage becomes effective on the first day of the month in which payroll deductions begin.

My child’s whole life coverage

$ ____________

AmountIappliedfor:

$ ____________

Cost per payperiod:

___/___/____

Date deductions begin:

(For your records — complete during your enrollment)

EN-1754 (6-13)

Get the coverage you need.

Amounts and values

$10,000 benefit amount $15,000 benefit amount $20,000 benefit amount $25,000 benefit amount $50,000 benefit amount
Issue age Premium amount Cash value at age 65* Premium amount Cash value at age 65* Premium amount Cash value at age 65* Premium amount Cash value at age 65* Premium amount Cash value at age 65*
0 $1.34 $4,637 $2.01 $6,956 $2.68 $9,274 $3.35 $11,593 $6.71 $23,186
1 $1.35 $4,634 $2.02 $6,951 $2.69 $9,268 $3.36 $11,584 $6.72 $23,169
2 $1.35 $4,630 $2.02 $6,945 $2.70 $9,260 $3.37 $11,575 $6.73 $23,150
3 $1.37 $4,626 $2.05 $6,939 $2.73 $9,251 $3.41 $11,564 $6.81 $23,128
4 $1.39 $4,621 $2.08 $6,932 $2.77 $9,242 $3.46 $11,552 $6.92 $23,105
5 $1.42 $4,616 $2.12 $6,924 $2.83 $9,232 $3.53 $11,540 $7.06 $23,080
6 $1.45 $4,611 $2.17 $6,916 $2.89 $9,222 $3.61 $11,528 $7.23 $23,055
7 $1.48 $4,606 $2.23 $6,908 $2.97 $9,211 $3.71 $11,514 $7.41 $23,028
8 $1.53 $4,600 $2.29 $6,900 $3.05 $9,200 $3.81 $11,500 $7.61 $22,999
9 $1.57 $4,594 $2.35 $6,891 $3.14 $9,188 $3.92 $11,484 $7.84 $22,969
10 $1.62 $4,588 $2.42 $6,881 $3.23 $9,175 $4.04 $11,469 $8.07 $22,938
11 $1.67 $4,581 $2.50 $6,871 $3.34 $9,162 $4.17 $11,452 $8.34 $22,904
12 $1.73 $4,574 $2.59 $6,861 $3.45 $9,148 $4.31 $11,435 $8.61 $22,870
13 $1.78 $4,567 $2.67 $6,850 $3.56 $9,134 $4.45 $11,417 $8.90 $22,834
14 $1.84 $4,559 $2.76 $6,839 $3.68 $9,119 $4.60 $11,398 $9.19 $22,796
15 $1.90 $4,552 $2.85 $6,827 $3.80 $9,103 $4.74 $11,379 $9.48 $22,758
16 $1.96 $4,544 $2.93 $6,815 $3.91 $9,087 $4.89 $11,359 $9.77 $22,718
17 $2.02 $4,535 $3.02 $6,803 $4.03 $9,071 $5.04 $11,338 $10.07 $22,676
18 $2.08 $4,527 $3.11 $6,790 $4.15 $9,053 $5.18 $11,317 $10.36 $22,634
19 $2.13 $4,518 $3.20 $6,777 $4.27 $9,035 $5.33 $11,294 $10.66 $22,588
20 $2.19 $4,508 $3.29 $6,762 $4.38 $9,016 $5.48 $11,270 $10.96 $22,541
21 $2.26 $4,498 $3.38 $6,747 $4.51 $8,997 $5.63 $11,246 $11.26 $22,492
22 $2.32 $4,488 $3.47 $6,732 $4.63 $8,975 $5.79 $11,219 $11.57 $22,438
23 $2.38 $4,477 $3.57 $6,715 $4.76 $8,953 $5.95 $11,192 $11.89 $22,383
24 $2.44 $4,465 $3.66 $6,697 $4.88 $8,930 $6.10 $11,162 $12.21 $22,324
25 $2.51 $4,452 $3.76 $6,678 $5.01 $8,905 $6.26 $11,131 $12.52 $22,262
26 $2.57 $4,439 $3.85 $6,659 $5.14 $8,878 $6.42 $11,098 $12.84 $22,196

* The policy accumulates cash value based on a non-forfeiture interest rate of 4.5% and the 2001 CSO mortality table. The cash value is guaranteed and will be equal to the values shown in the policy. Cash value will be reduced by any outstanding loans against the policy.

GetBenefitSmart.com

Finally, benefits made simple

Exclusions: If within two years (one year in Colorado, Missouri and North Dakota) from the date of issue of this policy the insured individual dies by suicide, while sane or insane, the amount payable by Unum in place of all other benefits shall be the sum of the premiums paid, without interest, less any debt secured by this policy.

Underwritten by: Provident Life and Accident Insurance Company, Chattanooga, Tennessee In NY, underwritten by: First Unum Life Insurance Company, New York, New York

The information is not intended to be a complete description of the insurance coverage available. The policies or their provisions may vary or be unavailable in some states. The policies have exclusions and limitations which may affect any benefits payable.

For complete details of coverage and availability, please refer to Policy Form L-21848 or

contact your Unum representative. Termination: Your coverage ends when any of the following occurs: the insured individual requests to terminate, premiums are not paid, the insured individual dies, the policy matures, the grace period ends.

Unum complies with all state civil union and domestic partner laws when applicable.

unum.com

© 2013 Unum Group. All rights reserved. Unum is a registered trademark and marketing brand of Unum Group and its insuring subsidiaries.

EN-1754 (6-13) FOR EMPLOYEES Volume Purchase Plan

Enroll in LifeLock Identity Theft Protection

In today’s world of online shopping, using public Wi-Fi and giving out Social Security numbers as a form of ID, our personal information can be exposed. Unfortunately, free credit monitoring simply alerts you to credit issues. LifeLock not only has proprietary technology to detect a variety of identity threats, if you do have an identity theft problem, our U.S.-based team of specialists can help fix it. It pays to have the comprehensive protection of LifeLock.

HOW TO ENROLL

  • Enroll through your employer during benefits enrollment.
  • Provide the name, Social Security number, date of birth, address, email and phone number for you and each dependent you wish to enroll.
  • Your LifeLock coverage will begin upon your benefit effective date.
  • You will receive a welcome email from LifeLock with instructions on how to take full advantage of your LifeLock membership.

No one can prevent all identity theft.

LifeLock does not monitor all transactions at all businesses. § Phone alerts made during normal local business hours. 1 2017 Identity Fraud Study, Javelin Strategy & Research 2 Based on a monthly online consumer survey (n=2,237) conducted for LifeLock by MSI International, Oct 2016 – Mar 2017..

Copyright © 2017 Symantec Corp. All rights reserved. Symantec, the Symantec Logo, the Checkmark Logo, LifeLock and the LockMan Logo are trademarks or registered trademarks of Symantec Corporation or its affiliates in the U.S. and other countries. Other names may be trademarks of their respective owners.

When a threat is detected†, LifeLock notifies members by phone§, text or email.

The Essential Employee Benefit

LIFELOCK BENEFIT ELITE (only available as a payroll deducted employee benefit) includes searching millions of transactions per second every day for potential threats to your identity and to financial assets – your 401(k) and investment accounts.†

Also includes scanning for misuse of your Social Security number, change of address and court records scanning for use of your identity to commit crimes.

LIFELOCK JUNIOR® (if dependents under age 18 are enrolled) protection helps safeguard your child’s Social Security number and good name with proactive identity theft protection designed specifically for children.†† To learn more about LifeLock Junior® service, please visit LifeLock.com/products/lifelock-junior.

*Indicates features included within the Million Dollar Protection™ Package††† 

No one can prevent all identity theft.

LifeLock does not monitor all transactions at all businesses.

Must agree to terms and conditions at LifeLock.com/terms. ‡

This 2017 complimentary feature requires you to create and access your LifeLock online portal to take advantage of this feature. 1 Credit reports, scores and credit monitoring may require an additional verification process and credit services will be withheld until such process is complete.

Children under the age of 18 will receive a product designed specifically for minors, LifeLock Junior service. Enrollment in LifeLock service is limited to employees and their eligible dependents.

**

LifeLock Junior® membership is available as an added membership to an adult LifeLock plan. Million Dollar Protection™ Package benefits are provided by a Master Policy issued by United Specialty Insurance Company, Inc. (State National Insurance Company, Inc. for NY State members). The Master Policy provides coverage for

††

†††

Stolen Funds Reimbursement and Personal Expense Compensation, each with limits of up to $1 Million for Benefit Elite members. If needed, LifeLock will provide lawyers and experts under the Service Guarantee. Please see the policy terms, conditions and exclusions at: LifeLock.com/legal. Copyright © 2017 Symantec Corp. All rights reserved. Symantec, the Symantec Logo, the Checkmark Logo, LifeLock, the LockMan Logo, LifeLock Junior, LifeLock Privacy Monitor, LifeLock Identity Alert and Million Dollar Protection are trademarks or registered trademarks of Symantec Corporation or its affiliates in the U.S. and other countries. Other names may be trademarks of their respective owners. MEB1568_BE_BIWK