Mexico School District # 59. All Eligible

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Questions? Concerns?

Helpline (888) 600-1600

Call weekdays, 7:00AM to 8:30PM, EST. And refer to

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Protect your family’s future, with life coverage

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Comprehensive dental care for all your needs

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High-quality vision care coverage

Benefits Plan

HIGHLIGHTS:

All Eligible

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Mexico School District # 59

Here is your new coverage. Make sure you return the completed form, if applicable, to your plan

administrator.

If you miss the deadline, the coverage may be delayed or you may not be eligible for enrollment this year and

proof of insurability

may be required.

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We’re ready to get working for you

If you’re like most employees, finding enough time in the day to accomplish your lengthy

to-do list can often be no easy task.

As your Guardian coverage begins, we want you to know that we’re here for you every step

of the way and are committed to providing you with the resources to obtain fast, accurate

answers to your benefits-related questions.

One way in which we do this is through our online member resource, Guardian Anytime

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which allows you to manage your benefits when it works best for you — day or night. Plus,

it offers helpful resources to ensure you get access to the quality care you need.

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Life Plans

COVERAGE OPTIONS

VOLUNTARY TERM LIFE

Employee Benefit Choice of 6 employer-specified amounts, from $25,000 to$150,000. See Cost Illustration page for details. Spouse‡benefit You may elect one of the following benefit options: $10,000.

See Cost Illustration page for details. Child benefit—children age 14 days

to 23 years (25 if full time student) You may elect one of the following benefit options: $10,000.Subject to state limits. See Cost Illustration page for details.

YOUR GUARDIAN

PLAN OFFERS:

Low group rates

Family coverage for spouse

and children

Reliable claims payments

Plan coverage begins

July 01, 2012

Did you know?

According to the National Safety

Council, someone dies in an

accident every six minutes.

Basic Life Your employer provides $10,000 Basic Term Life coverage for all full time employees. Your Basic Life coverage includes Accidental

Death and Dismemberment coverage equal to one times the employee’s life benefits.

Your spouse is eligible for coverage in the amount of $2,000. Your dependent children ages 14 days to 23 (25 if full time student) are eligible

for coverage in the amount of $1,000

**

_{. See enrollment form for details.}

You may elect Voluntary Term coverage.

Premiums will be deducted from your monthly payroll check.

Subject to coverage limits

‡_{Spouse coverage is based on employee age and terminates at age 70.}

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PLAN DETAILS

BASIC LIFE

VOLUNTARY TERM LIFE

Guarantee Issue Underwriting may be required, depending on amount

and/or age We Guarantee Issue coverage up to $150,000 peremployee, $10,000 for a spouse and $10,000 for dependent children

Premiums Covered by your company if you meet eligibility requirements

Increase on plan anniversary after you enter next 5 year age group

Portability Yes, with age and other restrictions, including evidence of insurability

Yes, with age and other restrictions

Conversion Yes, with restrictions; see certificate of benefits Yes, with restrictions; see certificate of benefits

Accelerated Life Benefit No Yes

Waiver of Premiums For employees disabled prior to age 60, with premiums

waived until age 65, if conditions are met For employees disabled prior to age 60, with premiumswaived until age 65, if conditions met Benefit Reductions 35% at age 65, 50% at age 70 35% at age 65, 60% at age 70, 75% at age 75, 85% at

age 80

A SUMMARY OF PLAN LIMITATIONS AND EXCLUSIONS For Basic Life:

You must be working full-time on the effective date of your coverage; otherwise, your coverage becomes effective after you have completed a specific waiting period.

Employees must be legally working in the United States in order to be eligible for coverage. Underwriting must approve coverage for employees on temporary assignment: (a) exceeding one year; or (b) in an area under travel warning by the US Department of State. Subject to state specific variations.

Dependent life insurance will not take effect if a dependent, other than a newborn, is confined to the hospital or other health care facility or is unable to perform the normal activities of someone of like age and sex.

Evidence of Insurability is required on all late enrollees.

This coverage will not be effective until approved by a Guardian underwriter. This proposal is hedged subject to satisfactory financial evaluation. Please refer to certificate of coverage for full plan description.

A SUMMARY OF PLAN LIMITATIONS AND EXCLUSIONS for Voluntary Term Life:

You must be working full-time on the effective date of your coverage; otherwise, your coverage becomes effective after you have completed a specific waiting period.

Employees must be legally working in the United States in order to be eligible for coverage. Underwriting must approve coverage for employees on temporary assignment: (a) exceeding one year; or (b) in an area under travel warning by the US Department of State. Subject to state specific variations.

We pay no benefits if the insured’s death is due to suicide within two years from the insured’s original effective date. This two year limitation also applies to any increase in benefit. This exclusion may vary according to state law

Dependent coverage will not take effect if a dependent, other than a newborn is confined to a hospital or other health care facility, or is unable to perform the normal activities of someone of like age and sex (may vary by state). Accelerated Life Benefit is not paid to an employee under the following circumstances: one who is required by law to use the benefit to pay creditors; is required by court order to pay the benefit to another person; is required by a government agency to use the payment to receive a government benefit; or loses his or her group coverage before an accelerated benefit is paid.

GP-1-R-EOPT-96.

Guarantee Issue/Conditional Issue amount applies for ages less than 65. Ages 65-69 maximum issue underwriting amounts $10,000 for employee and $5,000 spouse. Ages 70 and older must be individually underwritten for all amounts. Late entrants and benefit increases require underwriting approval.

A SUMMARY OF PLAN LIMITATIONS AND EXCLUSIONS for AD&D:

We pay no Accidental Death and Dismemberment (AD&D) benefits for an insured where death or dismemberment occurs:

As the result of a disease or a bodily infirmity; By declared or undeclared war or act of war or armed aggression, or while a member of any armed force. May vary by state; Through intentional self-injury; While driving without a valid driver's license; While legally intoxicated; While participating in civil disorder or committing a felony; Traveling on any type of aircraft while having any duties on that aircraft; While voluntarily using a non-prescription controlled substance; GP-1-R-ADCL1-00 et al.

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Life Cost Illustration

Monthly premiums displayed.

Policy Election Amount Policy Election Cost Per Age Bracket

Voluntary Life Cost Illustration

Employee < 25 25–29 30–34 35–39 40–44 45–49 50–54 55–59 60–64 65–69† $25,000 $1.25 $1.25 $1.75 $2.50 $4.00 $6.25 $9.25 $14.25 $23.75 $40.00 $50,000 $2.50 $2.50 $3.50 $5.00 $8.00 $12.50 $18.50 $28.50 $47.50 $80.00 $75,000 $3.75 $3.75 $5.25 $7.50 $12.00 $18.75 $27.75 $42.75 $71.25 $120.00 $100,000 $5.00 $5.00 $7.00 $10.00 $16.00 $25.00 $37.00 $57.00 $95.00 $160.00 $125,000 $6.25 $6.25 $8.75 $12.50 $20.00 $31.25 $46.25 $71.25 $118.75 $200.00 $150,000 $7.50 $7.50 $10.50 $15.00 $24.00 $37.50 $55.50 $85.50 $142.50 $240.00

Policy Election Amount

Spouse

$10,000 $.50 $.50 $.70 $1.00 $1.60 $2.50 $3.70 $5.70 $9.50 $16.00

Policy Election Amount

Child(ren)

$10,000 $1.90 $1.90 $1.90 $1.90 $1.90 $1.90 $1.90 $1.90 $1.90 $1.90

Guarantee Issue Amount: Employee $150,000; Spouse $10,000; Child $10,000

Estimated premiums; refer to your first paycheck deduction for final rates. Your company has selected Guardian to provide life coverage to eligible employees according to plan terms which have been mutually agreed upon. As an eligible employee, you can purchase this coverage at the group premium levels illustrated above. For more details see enrollment form.

Subject to coverage limits

Premiums for Voluntary Life Increase in 5 year increments

Spouse coverage is based on employee age and terminates at age 70.

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Tips for buying Life Insurance

Life insurance helps provide financial protection for your family and loved ones. If something were to ever happen to you, life insurance would provide

money so that your family and loved ones can continue to manage expenses if you were no longer around. Sample expenses include mortgage

payments, legal or medical expenses, childcare, college education and outstanding debts.

If someone depends on you, whether or not you work, chances are you need life insurance. Here are some things to keep in mind when you

buy life insurance:

Know how much

Life insurance you

need

A very broad rule of thumb is that your life insurance coverage should be 7 to 10 times your income. However, every person’s

life insurance needs are different. For example, you’ll need more insurance if you have four children compared to two or if you

have credit card debt versus none.

How do you stack up? For a personal estimate on how much life insurance you need, go to the Life and Health Insurance

Foundation for Education’s website at www.lifehappens.org. The online life insurance needs calculator is easy to use and

takes just minutes.

A good place to

start is at your

workplace

If your employer offers a life insurance benefit, think about enrolling in it. A workplace benefit is generally affordable (just a few

dollars a month in many cases) and easy to buy. You don’t typically need a medical exam to enroll and your employer has done

the legwork of finding a quality plan to offer its employees.

Think about

supplementing your

workplace benefit

Your workplace benefit is a good place to start but may not meet the needs of all people. Know how much your workplace

benefit covers. If it’s not enough based on your personal estimate, it might make sense for you to supplement it. Consider

talking to a financial advisor. Know that, unlike a workplace benefit, when you buy life insurance outside of work a medical exam

is usually required.

As things change in your life, your life insurance needs will too. Review your life insurance policy every year. If you’ve experienced a life milestone like

getting married, having a baby or buying a home in the last year, you’ll want to make sure your family and loved ones continue to be adequately

protected.

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Dental Plans

YOUR GUARDIAN

PLAN OFFERS:

No charge for preventive care

(subject to plan limits)

Maximum rollover If a

member submits at least

one claim and stays under

the claims threshold, a part

of the unused maximum

will be rolled over for use

in future years.

National PPO network of more

than 70,000 dentist locations

Reliable claims payment four

days on average

Plan coverage begins

July 01, 2012

Find out if your dentist is in

Guardian’s network at

www.guardianlife.com

Let Guardian put its 30-plus years

of dental benefits experience to

work for you and your family.

COMPARE THE PLANS

Option 1: Base Plan

Option 2: PPO In-Network

Option 3: Buy Up Plan

Network DentalGuard Preferred DentalGuard Preferred DentalGuard Preferred

Your Monthly premium

$26.48

$37.54

You and spouse $50.33 $72.77 $72.77

You and child(ren) $55.44 $79.73 $79.73

You, spouse and child(ren) $79.29 $114.48 $114.48

Calendar year deductible In-Network Out-Network In-Network Out-Network In-Network Out-Network

Individual $50 $50 $0 N/A $50 $50

Family limit 3 per family 3 per family 3 per family

Waived for Preventive Preventive Not applicable Not applicable Preventive Preventive

Charges covered for you (co-insurance) In-Network Out-Network In-Network Out-Network In-Network Out-Network

Preventive Care (e.g. cleanings) 100% 100% 100% Not Covered 100% 100%

Basic Care (e.g. fillings) 50% 50% 100% Not Covered 80% 80%

Major Care (e.g. crowns, dentures) 25% 25% 60% Not Covered 50% 50%

Orthodontia Not Covered Not Covered Not Covered

Annual Maximum Benefit $1000 $1000 $1000 N/A $1000 $1000

Maximum Rollover Yes No Yes

Rollover Threshold $500 $500

Rollover Amount $250 $250

Rollover In-network Amount $350 $350

Rollover Account Limit $1000 $1000

Lifetime Orthodontia Maximum Not Applicable Not Applicable Not Applicable Not Applicable

Dependent Age Limits 25 25 25

Option 1 or 3: With your Base Plan or Buy Up Plan plan, you can visit any dentist; but you pay less out-of-pocket when you choose a PPO dentist.

Option 2: With your PPO In-Network Only plan, you save money by visiting a PPO dentist. Out-of network visits are not covered.

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CATEGORY PLAN DETAILS

Option 1: Base Plan

Option 2: PPO In-Network

Option 3: Buy Up Plan

Plan pays (on average) Plan pays (on average) Plan pays (on average) In-network Out-of-network In-network Out-of-network In-network Out-of-network Preventive Care Cleaning (prophylaxis) 100% 100% 100% Not Covered 100% 100%

Frequency: Once Every 6 Months Once Every 6 Months Once Every 6 Months

Fluoride Treatments 100% 100% 100% Not Covered 100% 100%

Limits: No Age Limits No Age Limits No Age Limits

Oral Exams 100% 100% 100% Not Covered 100% 100%

Sealants (per tooth) 100% 100% 100% Not Covered 100% 100%

X-rays 100% 100% 100% Not Covered 100% 100%

Basic Care Anesthesia* 50% 50% 100% Not Covered 80% 80%

Fillings‡ _50% _50% _100% _{Not Covered} _80% _80%

Periodontal Maintenance 50% 50% 100% Not Covered 80% 80%

Frequency: Once Every 6 Months Once Every 6 Months Once Every 6 Months

(Standard) (Standard) (Standard)

Scaling & Root Planing (per quadrant) 50% 50% 100% Not Covered 80% 80%

Simple Extractions 50% 50% 100% Not Covered 80% 80%

Major Care Bridges and Dentures 25% 25% 60% Not Covered 50% 50%

Inlays, Onlays, Veneers** 25% 25% 60% Not Covered 50% 50%

Perio Surgery 25% 25% 60% Not Covered 50% 50%

Repair & Maintenance of

Crowns, Bridges & Dentures 25% 25% 60% Not Covered 50% 50%

Root Canal 25% 25% 60% Not Covered 50% 50%

Single Crowns 25% 25% 60% Not Covered 50% 50%

Surgical Extractions 25% 25% 60% Not Covered 50% 50%

This is only a partial list of dental services. Your certificate of benefits will show exactly what is covered and excluded. **Crowns, Inlays, Onlays and Labial Veneers are covered only when needed because of decay or injury and only when the tooth cannot be restored with amalgam or composite filing material. When Orthodontia coverage is for "Child(ren)" only, the orthodontic appliance must be placed prior to the age of 19; If full-time status is required by your plan in order to remain insured after a certain age; then orthodontic maintenance may continue as long as full-time student status is maintained. If Orthodontia coverage is for "Adults and Child(ren)" this limitation does not apply. The total number of cleanings and periodontal maintenance procedures are combined in a 12 month period. *General Anesthesia – restrictions apply. ‡Fillings – restrictions may apply to composite fillings.

Please note: The plan

details listed here are some

of the most common

services related to dental

coverage. The

co-insurance percentages for

the PPO plan options

correspond to the coverage

categories of Preventive,

Basic, Major and

Orthodontia listed in the

table above.

Some services may be paid

under a different category

than listed. The actual

co-insurance shown

reflects your plan's

coverage.

EXCLUSIONS AND LIMITATIONS

n Important Information about Guardian’s DentalGuard Indemnity and DentalGuard Preferred PPO plans: This policy provides dental insurance only. Coverage is limited to those charges that are necessary to prevent, diagnose or treat dental disease, defect, or injury. Deductibles apply. The plan does not pay for: oral hygiene services (except as covered under preventive services), orthodontia (unless expressly provided for), cosmetic or experimental treatments (unless they are expressly provided for), any treatments to the extent benefits are payable by any other payor or for which no charge is made, prosthetic devices unless certain conditions are met, and services ancillary to surgical treatment. The plan limits benefits for diagnostic consultations and for preventive, restorative,

endodontic, periodontic, and prosthodontic services. The services, exclusions and limitations listed above do not constitute a contract and are a summary only. The Guardian plan documents are the final arbiter of coverage. Contract # GP-1-DG2000 et al.

n Special Limitation: Teeth lost or missing before a covered person becomes insured by this plan. A covered person may

have one or more congenitally missing teeth or have lost one or more teeth before he became insured by this plan. We won’t pay for a prosthetic device which replaces such teeth unless the device also replaces one or more natural teeth lost or extracted after the covered person became insured by this plan. R3 – DG2000

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Maximum Rollover

®

Save Your Dental Annual Maximum Dollars For a Time When You Need Them Most!

With Maximum Rollover, Guardian will roll over a portion of your unused annual maximum into your personal Maximum Rollover Account (MRA). The

MRA can be used in further years, if you reach the plan’s annual maximum.

To qualify, you must submit a claim for covered services for which a benefit payment is issued, in excess of any deductible or co-pay, and you must not

exceed the paid claims threshold during the benefit year.

You and your insured dependents maintain separate MRAs based on your own claim activity. Each MRA may not exceed the MRA limit.

You can view your annual MRA statement detailing your account and those of your dependents on www.GuardianAnytime.com.

PLAN ANNUAL

MAXIMUM ** THRESHOLD MAXIMUM ROLLOVER AMOUNT

IN-NETWORK ONLY MAXIMUM ROLLOVER AMOUNT

MAXIMUM ROLLOVER ACCOUNT LIMIT

$1000

$500

$250

$350

$1000

** If a plan has a different annual maximum for PPO benefits vs. non-PPO benefits, ($1500 PPO/$1000 non-PPO for example) the non-PPO maximum determines the Maximum Rollover plan.

NOTES:

Cases on either a calendar year or policy year accumulation basis qualify for the Maximum Rollover feature. For calendar year cases with an effective

date in October, November or December, the Maximum Rollover feature starts as of the first full benefit year. For example, if a plan starts in November of

2009, the claim activity in 2010 will be used and applied to MRAs for use in 2011.

Under either benefit year set up (calendar year or policy year), Maximum Rollover for new entrants joining with 3 months or less remaining in the benefit

year, will not begin until the start of the next full benefit year.

Maximum Rollover is deferred for members who have coverage of Major services deferred. For these members, Maximum Rollover starts when coverage

of Major services starts, or the start of the next benefit year if 3 months or less remain until the next benefit year.

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Finding a dentist or vision care provider is easy

Go online – it just takes minutes!

The best way to save money through your dental or vision plan is by seeing a provider in your plan’s network. Guardian’s Find a

Provider site makes it easy for you to search for a dental or vision provider meets your needs.

Guardian’s Find a Provider site is available to you 24 hours a day, 7 days a week.

Here are just a few things you can do online:

• Customize your search by specialty, languages spoken and more

• Get side-by-side comparisons of provider information (ie. office status, distance)

• Create a quick-list of “favorite” providers — for easy reference online

• Get maps and directions to a providers office location

• View your results online or have them faxed or emailed to you

• Save your search criteria for easy access when you revisit the site

• Create a customized provider directory

• Nominate a dentist to be included in a network

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Vision Plans

Visit any doctor with your Full Feature plan, but save by visiting any of the 34,000 locations in the nation's largest vision network.

UNDERSTAND YOUR PLAN

Full Feature

Network VSP Network Signature Plan

Your Monthly premium

$ 12.39

You and spouse $ 20.85 You and child(ren) $ 21.26 You, spouse and child(ren) $ 33.65

Copay

Exams Copay $ 10

Materials Copay (waived for elective contact lenses)

$ 25

Service Frequencies

Exams Every 12 months

Lenses (for glasses or contact lenses)‡‡

Every 12 months

Frames Every 24 months

Network discounts (cosmetic extras, glasses and contact lens professional service)

Limitless within 12 months of exam.

Dependent Age Limits 25

1

‡‡Benefit includes coverage for glasses or contact lenses, not both.

Prepared for

Mexico School District # 59

Guardian Group Plan Number

405275

YOUR GUARDIAN

PLAN OFFERS:

Reduced prices

An average 15% to

30% discount off an extensive list of "cosmetic extras", including special lenses and scratch-resistant coatings.

No claims submission

for

in-network services and supplies.

Did you know?

"Two-thirds of employees would rather trade a vacation day for eyecare benefits." – Bests Review, 2006

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PLAN DETAILS

FULL FEATURE

You pay (after copay if applicable): In-network Out-of-network

Eye Exams $0 Amount over $46

Single Vision Lenses $0 Amount over $47

Lined Bifocal Lenses $0 Amount over $66

Lined Trifocal Lenses $0 Amount over $85

Lenticular Lenses $0 Amount over $125

Frames 80% of amount over

$120 Amount over $47 Contact Lenses (Elective) Amount over $105 Amount over $105 Contact Lenses (Medically Necessary) $0 Amount over $210 Contact Lenses (Evaluation and fitting) 15% off UCR No discounts Cosmetic Extras Avg. 30% off retail price No discounts Glasses (Additional pair of frames and lenses) 20% off retail price^ No discounts Laser Correction Surgery Discount Up to 15% off the usual

charge or 5% off promotional price

No discounts

This is only a partial list of vision services. Your certificate of benefits will show exactly what is covered and excluded.

^ For the discount to apply your purchase must be made within 12 months of the eye exam. In addition Full-Feature plans offer 30% off additional prescription glasses and nonprescription sunglasses, including lens options, if purchased on the same day as the eye exam from the same VSP doctor who provided the exam.

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Po lic y Am ou nt Yo u m us tb e en ro lle d to co ve ry Em plo ye e R $1 0,0 00 Ba sic Lif e fo rS po us e R $2 ,0 00 Th e am ou nt m ay no tb e m or e th an 50 % of th e em plo ye e am ou nt. Ba sic Lif e fo rC hild (re n) R $1 ,0 00 Th e am ou nt m ay no tb e m or e th an 10 % of th e em plo ye e am ou nt. If th is Ba sic Lif e po lic y w ill re pla ce yo ur ex ist in g life in su ra nc e po lic y un de ry ou rc ur re nt em plo ye r, pr ov id e th e am ou nt of th e pr ev io us po lic y $ __ __ N am e yo ur be ne fic ia rie s Pr im ary be ne fic iar ies m us Pr im ary Be ne fic iar y 1 Fir st, M id dle In itia l, La st N am e R ela tio ns hip to Em plo ye e Pe rc en t Pr im ary Be ne fic iar y 2 Co nti ng en tB en efic iar y In th e ev en tth e de sig na te d pr im ary be ne fic iar ies are de ce as ed ,th e co nti ng en tb en efic iar y w ill re ce ive th e be ne fit.

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Ch ec Em plo ye e Po lic y Am ou nt Yo u m us tb e en ro lle d to co ve ry ou rd ep en

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$2 5,0 00

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$5 0,0 00

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$7 5,0 00

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$1 00 ,0 00

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$1 25 ,0 00

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$1 *G ua ra nte e Is su e Am ou nt

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Iw aiv e th is co ve ra ge Ad d Vo lu nta ry Lif e fo rS po us e Ch ec k on e bo x on ly

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$1 0, 00 0* *G ua ra nte e Is su e Am ou nt

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Iw aiv e th is co ve ra ge Th e am ou nt m ay no tb e m or e th an 50 % of th e em plo ye e am ou nt fo rV olu nta ry Lif e. Ad d Vo lu nta ry Lif e fo rC hild (re n) Ch ec k on e bo x on ly

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$1 0, 00 0* *G ua ra nte e Is su e Am ou nt

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Iw aiv e th is co ve ra ge Th e am ou nt m ay no tb e m or e th an 10 % of th e em plo ye e am ou nt fo rV olu nta ry Lif e.

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A se pa ra te sh ee tfo rV olu nta ry Te rm Lif e be ne fic iar ies is att ac he d if th ey are no tth e sa m e as th os e na m ed fo rB as ic Lif e. Fo r Vo lu nta ry Lif e, an Ev id en ce of In su ra bil ity fo rm m us tb e co m ple te d fo r an y am ou nt ab ov e th e G ua ra nte e Is su e.

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n If yo u w aiv e life or dis ab ilit y co ve ra ge an d lat er de cid e to en ro ll, yo u w ill ha ve to pr ov id e, at yo ur ow n ex pe ns e, pr oo fo fe ac h pe rs on 's in su ra bili ty .G ua rd ian re se rv es th e rig ht to re jec ty ou rr eq ue st. n Ch ild re n w ill no tb e co ve re d un til th ey re ac h 14 da ys . n Ba se d on yo ur pla n be ne fits an d yo ur ag e, yo u m ay be re qu ire d to co m ple te an ad dit io na le vid en ce of in su ra bili ty fo rm fo rV olu nta ry Lif e an d/o rG ua rd ian U niv ers al Lif e.

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G ua rd ian G ro up Pla n N um be r:

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52

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Ple as e pr in te m plo ye e na m e:

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Ch ec k on e O pti on 1: Ba se Pla n O pti on 2: PP O In -N etw or k O nly O pti on 3: Bu y U p Pla n Yo ur m on th ly pr em iu m Em plo ye e alo ne

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$2

6.

48 q

$3

7.

54 q

$3

7.

54 q

Iw aiv e th is co ve Em plo ye e an d Sp ou se

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$5

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33 q

$7

2.

77 q

$7

2.

77 q

Iw aiv e th is co ve Em plo ye e an d Ch ild (re n)

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$5

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44 q

$7

9.

73 q

$7

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73 q

Iw aiv e th is co ve En tire fa m ily

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$7

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29 q

$1

14 .4

8 q

$1

14 .4

8 q

Iw aiv e th is co ve If yo u or yo ur fa m ily ha ve lo st de nta lc ov er ag e, ple as e ex pla in be lo w . La te en try pe na ltie s m ay ap ply . R ea so n fo rL os s of co ve ra ge : q Te rm in atio n of Em plo ym en tq D ivo rc e q D ea th of Sp ou se q Te rm in atio n or Ex pir atio n of co ve ra ge D ate of co ve ra ge lo / / If yo u are w aiv in g co ve ra ge ,a re yo u co ve re d un de ra no th er de nta lp lan ? q Ye s q N o If yo u are w aiv in g de pe nd en tc ov era ge ,a re yo ur de pe nd en ts co ve re d un de nta lp lan ? q Ye s q N o

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n N ew bo rn Ch ild re n: A ne w bo rn ch ild w ill be co ve re d fo rth e firs t3 1 da ys fro m th e m om en to fh is or he rb irth .T o co nti nu e co ve ra ge be yo nd th e firs t3 1 da ys yo u m us tn oti fy G ua rd ian w ith in 31 da ys of th e ne w bo rn ch ild ’s da te of bir th .G ua rd ian w ill th en pr ov id e an y ne ce ss ary fo rm s an d in str uc tio ns fo re nr ollm en Yo u m us te nr oll th e ch ild an d ag re e to m ak e an y ad dit io na lre qu ire d pa ym en ts ,w ith in 10 da ys of re ce ip to fth e fo rm s. If yo u fa ilt o do th is, th e ne w bo rn ch ild ’s co ve ra ge w ill ce as e at th e en d of th e firs t3 1 da ys .If yo u lat er en ro llt he ch ild ,h e or sh e w ill be co ns id ere d a lat e en ro lle e n Pr oo fo fin su ra bili ty do es no ta pp ly to de nta l, bu tif yo u w aiv e de nta lc ov era ge an d lat er de cid e to en ro ll, yo u m ay be su bje ct to a lat e en tra nt pe na lty an d yo de nta lb en efit s m ay be lim ite d fo ra pe rio d of tim e. G ua rd ian m ay w aiv e lat e-e ntr an tp en alt ies if yo u lo se de nta lc ov era ge du e to te rm in atio n of th e pla n, lo ss of em plo ym en t, de ath of sp ou se ,d ivo rc e or w he re a co ur th as or de re d co ve ra ge be pr ov id ed fo ra n elig ib le sp ou se or elig ib le ch ild re n, pr ov id ed yo u ap ply w ith in 30 da ys .

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Ch ec k on e Yo ur m on th ly pr em iu m Fu ll Fe atu re Em plo ye e alo ne

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$1

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39 q

Iw aiv e th is co ve ra Em plo ye e an d Sp ou se

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$2

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85 q

Iw aiv e th is co ve ra Em plo ye e an d Ch ild (re n)

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$2

1.

26 q

Iw aiv e th is co ve ra En tire fa m ily

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$3

3.

65 q

Iw aiv e th is co ve ra If yo u are w aiv in g co ve ra ge ,a re yo u co ve re d un de ra no th er vis io n pla n? q Ye s q N o If yo u are w aiv in g de pe nd en tc ov era ge ,a re yo ur de pe nd en ts co ve re d un de ra no th er vis io n pla n? q Ye s q N o

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n If Ih av e w aiv ed th e vis io n co ve ra ge ,a nd ele ct co ve ra ge at a lat er da te ,e nr ollm en td ela ys m ay ap ply . n Yo ur pla n in clu de s a O ne Ye ar Lo ck -In /L oc k-O ut Pr ov isio n -Y ou re lec tio n to en ro llin or w aiv e vis io n co ve ra ge m us tr em ain in eff ec tu nti ly ou rp lan 's ne xt an nu al vis io n en ro llm en tp eri od .

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n Ih ere by ap ply fo rth e gr ou p be ne fit( s) th at Ih av e ch os en ab ov e. n Iu nd ers ta nd th at Im us tm ee te lig ib ilit y re qu ire m en ts fo ra llc ov era ge s th at Ih av e ch os en ab ov e. n Iu nd ers ta nd Im us tb e ac tiv ely at w or k un til Ih av e co m ple te d a w ait in g pe rio d (a s de fin ed in th e gr ou p pla n) of fu llt im e se rv ice fo rm y life an d/o rd isa bili ty co ve ra ge .T his re qu ire m en td oe s no ta pp ly to elig ib le re tire es . n Iu nd ers ta nd th at m y de pe nd en t(s )c an no tb e en ro lle d fo ra co ve ra ge if I am no te nr olle d fo rth at co ve ra ge . n Iu nd ers ta nd th at life in su ra nc e co ve ra ge fo ra de pe nd en t, oth er th an a ne w bo rn ch ild ,w ill no tta ke eff ec tif th at de pe nd en tis co nfi ne d to a ho sp ita lo ro th er he alt h ca re fa cili ty ,o ris ho m e co nfi ne d, or is un ab le to pe rfo rm th e no rm al ac tiv itie s of so m eo ne of lik e ag e an d se x. n Ia gr ee th at m y em plo ye rm ay de du ct pr em iu m s fro m m y pa y or pr em iu m s to m y du es ;if th ey are re qu ire d fo rth e co ve ra ge Ih av ch os en ab ov e. n Iu nd ers ta nd th at th e pr em iu m am ou nts sh ow n ab ov e are es tim If th e pr em iu m am ou nts sh ow n ab ov e an d th e de du ctio ns fo rp re sh ow n on m y pa yc he ck stu b do no ta gr ee ,m y pa yc he ck stu b w pr ev ail. Iu nd ers ta nd th at th e pr em iu m am ou nts m ay be am en de n Ia tte st th at th e in fo rm ati on pr ov id ed ab ov e is tru e an d co rre ct be st of m y kn ow le dg e. n An y pe rs on w ho w ith in te nt to de fra ud or kn ow in g th at he /s he fa cil ita tin g a fra ud ag ain st an in su re r, su bm its an ap pli ca tio n a cla im co nta in in g a fa ls e or de ce pti ve sta te m en tm ay be gu ilty in su ra nc e fra ud .