Customer Service Life Insurance

The Essential StaffCARE Fixed Indemnity Medical, Prescription Drug, Accidental Loss of Life, Limb & Sight, Dental and Vision Plans are underwritten by BCS Insurance Company, Oakbrook Terrace, Illinois under Policy Series Numbers 25.1204, 26.1801, 26.212, and 26.213. The Term Life and Short-Term Disability Plans are underwritten by 4 Ever Life Insurance Company, Oakbrook Terrace, Illinois under Policy Series Number 62.200. For questions or assistance, please call Essential StaffCARE Customer Service at 1-866-***-****. Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony. THE FIXED INDEMNITY MEDICAL PLAN IS A SUPPLEMENT TO HEALTH INSURANCE. IT IS NOT A SUBSTITUTE FOR ESSENTIAL HEALTH BENEFITS COVERAGE AS DEFINED IN FEDERAL HEALTH LAW. The MEC Wellness/Preventive Plan is an employer-sponsored, self-funded plan that has been deemed to be in compliance with ACA rules and regulations. More information about Preventive Services may be found on the government website at: https://www.healthcare.gov/coverage/preventive-care-benefi ts. For questions or assistance, please call Essential StaffCARE Customer Service at 1-866-***-****.

Voluntary Electronic Availability of Summary Health Information for MEC/Wellness Preventive Plan A sample copy of the Summary of Benefi ts and Coverage (“SBC”) from Essential StaffCARE (“ESC”) is available at the following link: www.enrollment.care/info/sbcmec.

While you may have other health plans, this is the link for your MEC plan with ESC. This important document explains the terms and conditions of your Health Plan, including eligibility, coverage amounts and exclusions along with your rights and responsibilities. At any time, you may request paper copies or revoke your consent to electronic delivery, free of charge, by calling 1-866-***-****.

For Enrollees of California: In order to enroll in the Fixed Indemnity Medical Benefi t, you and any dependent must have minimum essential coverage and be enrolled in major medical coverage. 1. You MUST complete the Enrollment Form as part of your New Hire Process. 2. Elect or decline all benefi ts on the Enrollment Form. 3. You MUST Sign and Date the bottom of the form, even if you decline coverage. 4. Return the Enrollment Form to your Branch Manager. 5. Keep the Benefi ts at a Glance page for your records. Fixed Indemnity Medical, Ancillary Products, and Self-Funded Minimum Essential Coverage (MEC) Enrollment Form

Complete the Enrollment Form to Elect or Decline Coverage IMPORTANT PLAN INFORMATION: You have two medical plan options. You may enroll in one or both. Additional benefi ts are available to add if you enroll in the Fixed Indemnity Medical Plan. IMS ESC/MEC SC P1M v24.1

ESC/MEC SC P1M v24.1

A. REQUIRED EMPLOYEE INFORMATION B. MEDICARE INFORMATION PRINT USING BLACK or BLUE INK (Must Be Filled Out) Do you or any of your dependents receive Medicare benefits?

Yes No. If Yes:

Name Phone

Social Security # Date of Birth

/ /

Gender

M F

Medicare Health Insurance Claim Number (HICN)

Address Apt. # Medicare Effective Date

City Zip State Name of Covered Person(s):

1. 2.

C. LIMITED BENEFIT PLAN SELECTION Payroll Deducted Weekly Rates You MUST enroll in the Fixed Indemnity Medical Insurance Plan before adding any additional benefits in Section C. Your coverage level for the additional benefits in Section C will be identical to your fixed indemnity medical plan selection. These plans are underwritten by BCS Insurance Company and 4 Ever Life Insurance Company. FIXED INDEMNITY

MEDICAL 1 DENTAL 1 VISION 1 TERM LIFE 1 SHORT-TERM DISABILITY 1,2

Employee Only $19.98 $5.40 $2.42 $0.60 $4.20

Employee + 1 $40.54 $10.80 $4.92 $0.90

Employee + Family $54.14 $17.82 $6.56 $1.80

NO to ALL Benefits Yes No Yes No Yes No Yes No

1 This coverage is not available to residents of NH, HI, or PR. 2 STD is not available to persons who reside in CA, HI, NH, NJ, NY, or RI. For Term Life / Accidental Loss of Life, Limb & Sight, please write in your beneficiary information. Accidental Loss of Life, Limb & Sight is part of the Fixed Indemnity Medical Benefit. Name Relationship

D. REQUIRED DEPENDENT INFORMATION

Name Social Security # Date of Birth

/ /

Gender

M F

Relationship

Spouse Child Domestic Partner

Name Social Security # Date of Birth

/ /

Gender

M F

Relationship

Spouse Child Domestic Partner

Name Social Security # Date of Birth

/ /

Gender

M F

Relationship

Spouse Child Domestic Partner

E. OPTIONAL MEC WELLNESS/PREVENTIVE BENEFIT SELECTION Direct Payment Monthly Rates Enrolling in the Optional MEC Wellness/Preventive Benefit may DISQUALIFY you from receiving a subsidy from the health insurance exchange. The MEC Wellness/Preventive Benefit is NOT underwritten by BCS Insurance Company. It is a benefit offered and provided by your employer. Note: The Patient Protection and Affordable Care Act (PPACA) individual mandate no longer imposes a penalty at the federal level; however, please check with your state for any state specific individual mandate requirements or penalties. Rates for the MEC Wellness/Preventive Benefit are billed monthly.

$58.19 Employee Only $69.53 Employee + 1 $80.87 Employee + Family NO to MEC Wellness/Preventive F. REQUIRED SIGNATURE YOU MUST SIGN AND DATE EVEN IF YOU DECLINE COVERAGE By signing below, I confirm I have read the Benefits Summary and the Limitations and Exclusions for the recommended benefit plans; I’ve been offered self-funded ACA compliant coverage (MEC Wellness/Preventive) and open enrollment is only available for a limited time. I also understand that making no benefit selection is a declination of benefit coverage and benefit coverage is only available to employees who are over the age of 18 with a valid SSN. DATE __ __ /__ __ /__ __ __ __ SIGNATURE

ENROLLMENT FORM

VSI 206301-IMS OFFICE USE ONLY LOCATION Rehire Date __ __ /__ __ /__ __ __ __ 82063010-M-IMS

SAMPLE

FIXED INDEMNITY MEDICAL BENEFIT

The Fixed Indemnity Medical Plan pays a flat amount for a covered event caused by an accident or illness. If the covered event costs more, you pay the difference. But if the covered event costs less, you keep the difference. Outpatient Benefits1 Inpatient Benefits

Physician Office Visit

(Virtual or In-Person)

$115 per day Standard Care $300 per day

Diagnostic (Lab) $90 per day Intensive Care Unit Maximum 5 $400 per day Diagnostic (X-Ray) $250 per day Inpatient Surgery $2,000 per day Ambulance Services $350 per day Anesthesia $400 per day Physical, Speech, or Occupational Therapy $50 per day Skilled Nursing 6 $100 per day Emergency Room Benefit—Sickness $250 per day First Hospital Admission (1 per year) $300 Emergency Room Benefit—Accident 2 $500 per day Annual Inpatient Maximum 7 No Limit Outpatient Surgery $500 per day Accidental Loss of Life, Limb & Sight Anesthesia $200 per day Employee/Spouse $20,000

Annual Outpatient Maximum $2,200 Dependent (6 months to 26 years) $5,000 Prescription Drugs (via reimbursement) 3, 4 Dependent (15 days to 6 months) $2,500 Annual Maximum $600 Wellness Care

Per Day $30 Wellness Care (one per year) $100

1 all outpatient benefits are subject to the outpatient maximum 2 covers treatment for off the job accidents only 3 not subject to outpatient maximum 4 To file a claim for reimbursement, save your receipt and remit to Planned Administrators, Inc. 5 pays in addition to standard care benefit 6 for stays in a skilled nursing facility after a hospital stay 7 subject to internal limits of plan

GROUP TERM LIFE BENEFIT

Employee Amount $10,000 (reduces to $7,500 at 65; $5,000 at 70) Child Amount (6 mos to 26 yrs old) $5,000 Spouse Amount $5,000 (terminates at age 70) Infant Amount (15 days to 6 mos) $1,000 Policy Number

WEEKLY LIMITED BENEFITS PREMIUM Medical Dental Vision Term Life STD Employee Only $19.98 $5.40 $2.42 $0.60 $4.20

Employee + 1 $40.54 $10.80 $4.92 $0.90 -

Employee + Family $54.14 $17.82 $6.56 $1.80 -

OPTIONAL MEC WELLNESS/PREVENTIVE BENEFIT 1

The optional MEC Wellness/Preventive Benefit DOES NOT cover medical services. This plan provides coverage for preventive services such as immunization and routine health screening. It does not cover conditions caused by accident or illness. Benefit In-Network Non-Network MONTHLY MEC PREMIUM MEC Preventive Services for Adults 100% 40% Employee Only $58.19 Preventive Services for Women 100% 40% Employee + 1 $69.53 Covered Preventive Services for Children 100% 40% Employee + Family $80.87 1 For more information about preventive services, please visit www.healthcare.gov. SHORT-TERM DISABILITY BENEFIT

Benefit Amount 60% of base pay up to $150 per week Waiting Period/Maximum Benefit Period 7 days for injury or sickness / up to 26 weeks DENTAL BENEFIT Waiting Period/Coinsurance Annual Maximum Benefit $750 Deductible $50 Coverage A None / 80% Exams, Cleanings, Intraoral Films, and Bitewings Coverage B 3 Months / 60% Fillings, Oral Surgery, and Repairs for Crowns, Bridges and Dentures Coverage C 12 Months / 50% Periodontics, Crowns, Endodontics, Bridges and Dentures Policy Number

LIMITED BENEFITS SUMMARY

For more details, please see your Summary Plan Description. VISION BENEFIT In-Network Out-of-Network

You Pay Plan Pays You Pay3 Plan Pays

Eye Exam 1 (including dilation) $10 Copay 100% 100% $35 Standard Contact Lens Fit Exam (includes follow up) Up to $55 $0 100% $0 Premium Contact Lens Fit Exam (includes follow up) 100%, after 10% discount $0 100% $0 Frames (once every 24 months) 80%, after $110 allowance 20% plus $110 allowance 100% $55 Standard Plastic Lenses (single, bifocal, trifocal) 1, 2 $25 Copay 100% 100% $25-$55 Contact Lenses (Conventional) (materials only) 1 85%, after $110 allowance 15% plus $110 allowance 100% $88 Contact Lenses (Disposable) (materials only) 1 100%, after $110 allowance $110 allowance 100% $88 Contact Lenses (Medically Necessary) (materials only) 1 $0 Copay 100% 100% $200 1 Once every 12 months 2 $15 higher in AK, CA, HI, OR, WA 3 After plan payment 206301-IMS

82063010-M-IMS

LIMITED BENEFIT EXCLUSIONS AND LIMITATIONS

These are the standard limitations and exclusions. As they may vary by state, please see your summary plan description (SPD) for a more detailed listing.

FIXED INDEMNITY MEDICAL AND ACCIDENTAL LOSS OF

LIFE, LIMB OR SIGHT BENEFIT

No benefi ts will be paid for loss caused by or resulting from:

• Intentionally self-infl icted injuries, suicide or any attempt while sane or insane

• Declared or undeclared war

• Serving on full-time active duty in the armed forces

• The covered person’s commission of a felony

• Work-related injury or sickness, whether or not benefi ts are payable under workers’ compensation or similar law or

• With regard to the accidental loss of life, limb or sight benefi t

- sickness, disease, bodily or mental infi rmity or medical or surgical treatment thereof, or bacterial or viral infection regardless of how contracted. This does not include bacterial infection that is the natural and foreseeable result of an accidental external bodily injury or accidental food poisoning. No benefi ts will be paid for:

• Eye examinations for glasses, any kind of eye glasses, or vision prescriptions

• Hearing examinations or hearing aids

• Dental care or treatment other than care of sound, natural teeth and gums required on account of injury to the covered person resulting from an accident that happens while such person is covered under the policy, and rendered within 6 months of the accident

• Services rendered in connection with cosmetic surgery, except cosmetic surgery that the covered person needs for breast reconstruction following a mastectomy or as a result of an accident that happens while such person is covered under the policy. Cosmetic surgery for an accidental injury must be performed within 90 days of the accident causing the injury and while such person’s coverage is in force

• Services provided by a member of the covered person’s immediate family.

PRESCRIPTION DRUGS

No benefi ts will be paid for over-the-counter products or medications or for drugs and medications dispensed while you are in a hospital.

DENTAL

The plan will pay only for procedures specifi ed on the Schedule of Covered Procedures in the group policy. Many procedures covered under the plan have waiting periods and limitations on how often the plan will pay for them within a certain time frame. For more detailed information on covered procedures or limitations, please see your summary plan description. TERM LIFE

No Life Insurance benefi ts will be payable under the policy for death caused by suicide or self-destruction, or any attempt at it within 24 months after the person’s coverage under the policy became effective.

VISION

No benefi ts will be paid for any materials, procedures or services provided under worker’s compensation or similar law; non-prescription lenses, frames to hold such lenses, or non- prescription contact lenses; any materials, procedures or services provided by an immediate family member or provided by you; charges for any materials, procedures, and services to the extent that benefi ts are payable under any other valid and collectible insurance policy or service contract whether or not a claim is made for such benefi ts.

The Fixed Indemnity medical/Rx, accidental loss of life, limb, or sight, dental, term life, and vision plans are not available to residents of Hawaii, New Hampshire, or Puerto Rico. SHORT-TERM DISABILITY

No benefi ts are payable under this coverage in the following instances:

• Attempted suicide or intentionally self-infl icted injury

• Voluntary taking of poison; voluntary inhalation of gas; voluntary taking of a drug or chemical. This does not apply to the extent administered by a licensed physician. The physician must not be you or your spouse, you or your spouse’s child, sibling or parent, or a person who resides in your home

• Declared or undeclared war or act of war

• Your commission of or attempt to commit a felony, or any loss sustained while incarcerated for the felony

• Your participation in a riot

• If you engage in an illegal occupation

• Release of nuclear energy

• Operating, riding in, or descending from any aircraft (including a hang glider). This does not apply while you are a passenger on a licensed, commercial, nonmilitary aircraft; or

• Work-related injury or sickness.

Short-Term Disability benefi ts are not available to persons who reside in California, Hawaii, New Hampshire, New Jersey, New York, or Rhode Island.

Member Services:

For frequently asked questions and network information for the Fixed Indemnity Medical Plan, visit https://enrollment.care/info/bcs/ind. For questions and a full list of preventive services covered by the MEC Wellness/ Preventive Plan, as well as the MEC SBC, please visit https://enrollment.care/info/bcs/mmdp. A paper copy is also available, free of charge, by calling Essential StaffCARE Customer Service 1-866-***-****. PLEASE NOTE: To make changes or cancel coverage by telephone call 800-***-****. Your pin code for enrolling/making changes is + _ _ _ _ (last four digits of your SSN). Your Company has chosen to take your payroll deductions on a Post-Tax basis. Essential StaffCARE Customer Service: 1-866-***-****

• Once enrolled, members can call this number for questions regarding plan coverage, ID card, claim status, and policy booklets and to add, change, or cancel coverage.

• Customer Service Call Center hours are M - F, 8:30 a.m. to 8 p.m. Eastern Standard Time. Bilingual representatives are available.

• Members can also visit www.paisc.com and click on “Members.” 140

Contact this candidate