a l i f e t i m e o f c o m m i t m e n t

a c o m m o n s e n s e

d e n t a l p l a n

f o r g r o u p s o f 2 t h r o u g h 9 e m p l o y e e s

rate information

Dental Cents®

95076 REV. 10/17

Companion Life reviews premiums annually and rates are subject to change.

SIC Code Discount SIC FactorAgriculture 0100-0999 -15% .85Mining 1000-1499 -15% .85Construction 1500-1999 -15% .85Manufacturing 2000-3999 -10% .90Transportation 4000-4299 -10% .90 4400-4499 -10% .90Pipeline 4600-4699 -10% .90Transport Services 4700-4799 -10% .90Utilities 4900-4999 -10% .90

Standard Industry Code (SIC) FactorsFACTOR IS 1.00 IF SIC CODE IS NOT SHOWN BELOW

Industry Discount

SIC Code Surcharge SIC FactorBanking, Investments 6000-6299 +10% 1.10Insurance 6300-6499 +10% 1.10Real Estate 6500-6699 +10% 1.10Holding Companies 6700-6999 +10% 1.10Amusement Companies 7800-7999 +10% 1.10Health Services 8000-8049 +15% 1.15 8070-8099 +15% 1.15Legal Services 8100-8199 +15% 1.15Miscellaneous Services/Organizations 8300-8999 +15% 1.15Public Administration 9000-9999 +15% 1.15Education 8200-8299 +25% 1.25Dentists and Dental Labs (SIC 8021, 8072) Ineligible for Dental Coverage

Industry Surcharge

95076 REV. 10/17

See Dental “Cents” brochure (95067) for information on policy benefits and limitations. Orthodontia (optional – available with all plans – Monthly Base Rate $8.90 [All Areas])Orthodontia benefits apply to children under age 19 onlyAdd to Employee + Child(ren) Rates and Employee + Family RatesAdjustment for $1,500 annual maximum: (Adjustment: 1.10) Adjustment for $50 deductible: (Adjustment: 1.12)

Using Rates For M PLAN A M PLAN B

Proposed Effective Date Area

Monthly Annual Ann Deductible ual SIC Orthodontia Number Rate Maximum Adjustment Factor Rate Enrolling Cost Adjustment Employee Only $ x x x + N/A x = $ Employee + Spouse $ x x x + N/A x = $

Employee + Child(ren) $ x x x + x = $

Employee + Family $ x x x + x = $

Rate Formula

95076 REV. 10/17

Rates are Guaranteed for 12 Months. Effective for Issue January 2018 – December 2018

PLAN B Monthly Base RateDental Cents - Plan B - January 2018 – December 2018$100 lifetime deductible, 100/80/50, 12-month waiting period on Class III services, $1,000 maximum, no orthodontia Area A Area B Area C Area D Area E Area F Area G Area H

Rates for Flexible Dental Cents Plans A and B

PLAN A Monthly Base RateDental Cents - Plan A - January 2018 – December 2018$100 lifetime deductible, 100/80/50, 12-month waiting period on Class III services, $1,000 maximum, no orthodontia Area A Area B Area C Area D Area E Area F Area G Area H

Employee Only 36.82 38.74 40.69 43.07 45.47 47.85 50.25 55.99

Employee + Spouse 73.61 77.47 81.37 86.12 90.91 95.67 100.50 111.98

Employee + Child(ren) 77.11 81.01 85.24 90.15 94.87 99.94 105.15 116.97

Employee + Family 115.55 121.44 127.70 135.11 142.29 149.87 157.62 175.40

Employee Only 30.68 32.29 33.91 35.88 37.88 39.87 41.88 46.67

Employee + Spouse 61.34 64.56 67.81 71.76 75.76 79.73 83.75 93.31

Employee + Child(ren) 64.27 67.51 71.04 75.13 79.06 83.28 87.62 97.48

Employee + Family 96.29 101.20 106.42 112.59 118.58 124.90 131.34 146.16

Monthly Administration Fee + $ 15.00

Total Cost $

The rates above include the federally mandated ACA Health Industry Fee.

P.O. Box 100102, Columbia, SC 29202-3102

DENTAL EMPLOYER PARTICIPATION APPLICATION FOR THE JOINT EMPLOYER GROUP INSURANCE TRUST

EMPLOYER (APPLICANT) INFORMATION (Please Print or Type)

Legal Name of Employer: Type of Business (Sole Proprietorship, Partnership, Corporation, etc.):

Address: City: State: ZIP:

Telephone: ( ) Contact: Title: (Person to contact concerning coverages) No. of Eligible Employees: No. of Eligible Employees Enrolled:

Effective Date Requested: SIC Code and Nature of Business: (The firm’s effective date will be the first or the 15th of the month following written acceptance by Companion Life Insurance Company.)

How many years in this business? How many years at this location?

Tax I.D. Number: No. of Family Members in Organization:

PLAN DESCRIPTIONPLAN REQUESTED:

Are Takeover Benefits requested? M Yes M No If yes, please provide the following:

a. Name of Prior Carrier:

b. Effective Date of Prior Plan: c. Termination Date of Prior Plan: Also, submit a copy of your previous insurance carrier’s most recent billing statement as well as a certificate or letter of

acceptance that shows the effective date of your policy along with a copy of your previous carrier’s certificate, booklet or schedule of benefits. If prior carrier’s bill does not include the effective date of each employee’s coverage, please note this information next to each employee’s name so we can give the correct credit for transfer of benefits.

Employment Waiting Period: M 1 Month M Other: (or as allowed by state law) (No waiting period applies to those employed on the effective date.)Coverage following the completion of the waiting period selected will be effective on the first or the 15th of the month only.The employer agrees to contribute the following percentage of the cost of employee dental insurance for all covered employees % (25% required)

Participation Agreement (Administered and underwritten by Companion Life Insurance Company)The Participant hereby applies for Group Insurance Benefits as set forth in the above “Dental Employer Participation Application for the Joint Employer Group Insurance Trust” and subscribes to the Agreement and Declaration of Trust.Name of Trust: The Joint Employer Group Insurance TrustIt is understood and agreed by the undersigned that the Trustee is not an insurer, nor does the Trustee have any obligation under any policy of insurance and that all claims for and benefits provided by insurance being applied for herein shall be made to and payable by the Insurance Companies issuing group policy(ies) to the Trustees, but only to the extent and in strict accordance with the provisions of such policy(ies). The Trust agreement and the group policy(ies) held by the Trustee are available for inspection during regular business hours by the Participant at the office of the Administrator, Companion Life Insurance Company, located at 7909 Parklane Road, Suite 200, Columbia, SC 29223-5666.

(Signature of Employer/Applicant)

(Title) (Date)This is to certify that I, the undersigned agent, have truly and accurately recorded on this application form the information supplied.

(Signature of Agent/Broker) (Date)

Print Agent/Broker’s Name License No.

FOR HOME OFFICE USE

Accepted by Administrator Effective:

By:

(Title) (Date)

Form # 95078 REV. 2/17

FRAUD WARNING: (Not Applicable in AZ, FL, MD, OR, VA): Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or a statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits (in TX, may be committing) a fraudu-lent insurance act, which is a crime and subjects (in KS, which may be determined by a court of law to be a crime which subjects) such person to criminal and civil penalties.FRAUD WARNING: (FL only): Any person who knowingly and with intent to injure, defraud or deceive any insurer files a statement of claim or an application containing any false, incomplete or misleading information is guilty of a felony of the third degree.

Plan: M A Deductible: M $100 Lifetime Annual Maximum: M $1,000

M B M $50 Annual M $1,500

Deductible and Annual Maximum are: M Contract Year M Calendar YearOrthodontia: M Yes M No

Dental Cents®

Alabama 357-358 C 352, 365-366, 369 B All Others A

Alaska H Arkansas 722, 727, 729 C All Others A

Delaware 197 D 198 E All Others B

District of Columbia H

Florida 331-332, 341 G 326, 339, 342, 349 E 320, 323-325 D 329-330, 333-334 D 338, 344 C 321-322, 327-328 B 336-337, 347 B All Others A

Georgia 300, 303, 311 F 301-302 E 305-306, 308-309 C 307, 310, 312-314 B 316-319, 398 B All Others A

Idaho 837 E 833, 835-836, 838 D All Others C

Illinois 600, 602 G 601, 603, 606-608 F 604-605 E 610-611, 627 D 609, 613-618 C 612, 619, 623, 629 B All Others A

Indiana 462 E 460-461 D 463-469, 473, 479 D 470, 472, 474-478 C All Others B

Iowa 500-503, 509 D 504-505, 508 C 510-520, 522-528 C All Others B

Kansas 662 D 660-661, 672 C 664-668 B All Others A

Kentucky A

Louisiana 701, 706 D All Others C

Maine 039-041 H 042 G All Others F

Maryland 208-209 E 207, 214 D 206, 215, 219 C 212, 216-218 B All Others A

Massachusetts 013-026 H 010-011, 027 G All Others E

Michigan 480-483 D 484-485 C 491 B All Others A

Minnesota 554, 556-560, 563-564 F All Others E

Mississippi B

Missouri 631 D 630, 633, 640-641 C 658 B All Others A

Montana 591, 598 E All Others D

Nebraska A

Nevada 893, 898 F 894-897 E All Others A

New Hampshire H

North Carolina 282 E 271, 276 D 270, 274, 277 C 281, 286-289 C 272, 275 B 278-280, 284-285 B All Others A

North Dakota 581 E All Others C

Ohio 430-432 D 441-443, 452 D 433-436, 440, 446-447 C 450-451, 454, 458 C 444-445, 448-449 B 453, 455-456 B All Others A

Oklahoma 730, 739, 740-741 B All Others A Oregon C

Pennsylvania 191 E 190, 193 D 172, 176 C 183, 189, 194 C 175, 180-181, 196 B All Others A

Rhode Island 028 F All Others G

South Carolina 292, 294-296 B 298-299 B All Others A

South Dakota C

Tennessee 372 C All Others B

Texas 752-753, 770-772 D 786-787, 790-792 D 750-751, 760-761, 773 C 754-759, 762-765 B 768-769, 774-780 B 788-789, 793-797 B All Others A

Vermont 054 G All Others F

Virginia 201, 220-223 B All Others A Washington 980-981 E All Others C

West Virginia 247-249, 258-259, 266 C 250-257, 261, 267 B All Others A

Wisconsin 537 F 539, 543-544 E 547, 549 E 530-535, 538 D 541-542, 546 D All Others C

Wyoming C

Area Table (By First 3 Digits of ZIP Code)

95076 REV. 10/17

P.O. Box 100102Columbia, SC 29202-3102

Arrive at final rates for the group by:

A. Determining the group’s plan, annual maximum adjustment, deductible adjustment, rate area, SIC factor and orthodontia rate (if applicable), using charts included;

B. Then determine the monthly base rates for the group’s desired plan on the enclosed Rate Sheet and complete the Rate Formula at the bottom of the Rate Sheet.

Complete the Employer Participation Application. If Takeover from a previous dental carrier, please submit:

A. A copy of the previous insurance carrier’s most recent billing statement;

B. A certificate or letter of acceptance from the previous insurance carrier that shows the effective date of the policy; and

C. A copy of the previous insurance carrier’s certificate, booklet or schedule of benefits.

Have an Employee Enrollment Card completed by each full-time employee.

Have the group’s check for one month’s premium made payable to: Companion Life Insurance Company.

Mail Rate Calculation, Employer Participation Application, Employee Enrollment Cards and the check to:

How To Enroll

1

2

3

4

5

Group MarketingCompanion Life Insurance Company

P.O. Box 100102Columbia, SC 29202-3102

If you have any questions, please call 800-753-0404 and ask for Group Marketing.

95076 REV. 10/17

Non-Discrimination Statement and Foreign Language Access We do not discriminate on the basis of race, color, national origin, disability, age, sex, gender identity, sexual orientation or health status in our health plans, when we enroll members or provide benefits. If you or someone you’re assisting is disabled and needs interpretation assistance, help is available at the contact number posted on our website or listed in the materials included with this notice. Free language interpretation support is available for those who cannot read or speak English by calling one of the appropriate numbers listed below. If you think we have not provided these services or have discriminated in any way, you can file a grievance online at contact@hcrcompliance.com or by calling our Compliance area at 1-800-832-9686 or the U.S. Department of Health and Human Services, Office for Civil Rights at 1-800-368-1019 or 1-800-537-7697 (TDD). Si usted, o alguien a quien usted está ayudando, tiene preguntas acerca de este plan de salud, tiene derecho a obtener ayuda e información en su idioma sin costo alguno. Para hablar con un intérprete, llame al 1-844-396-0183. (Spanish) 如果您，或是您正在協助的對象，有關於本健康計畫方面的問題，您有權利免費以您的母語得到幫助和訊

息。洽詢一位翻譯員，請撥電話 [在此插入數字 1-844-396-0188。 (Chinese) Nếu quý vị, hoặc là người mà quý vị đang giúp đỡ, có những câu hỏi quan tâm về chương trình sức khỏe này, quý vị sẽ được giúp đở với các thông tin bằng ngôn ngữ của quý vị miễn phí. Để nói chuyện với một thông dịch viên, xin gọi 1-844-389-4838 (Vietnamese) 이 건보험에 관하여 궁금한 사항 혹은 질문이 있으시면 1-844-396-0187 로 연락주십시오. 귀하의 비용 부담없이 한국어로 도와드립니다. PC 명조 (Korean) Kung ikaw, o ang iyong tinutulungan, ay may mga katanungan tungkol sa planong pangkalusugang ito, may karapatan ka na makakuha ng tulong at impormasyon sa iyong wika nang walang gastos. Upang makausap ang isang tagasalin, tumawag sa 1-844-389-4839 . (Tagalog) Если у Вас или лица, которому вы помогаете, имеются вопросы по поводу Вашего плана медицинского обслуживания, то Вы имеете право на бесплатное получение помощи и информации на русском языке. Для разговора с переводчиком позвоните по телефону 1-844-389-4840. (Russian)

فلدیك الحق في الحصول على المساعدة والمعلومات ،خطة الصحة ھذه إن كان لدیك أو لدى شخص تساعده أسئلة بخصوص 1-844-396-0189 (Arabic) للتحدث مع مترجم اتصل ب .الضروریة بلغتك من دون ایة تكلفة

Si ou menm oswa yon moun w ap ede gen kesyon konsènan plan sante sa a, se dwa w pou resevwa asistans ak enfòmasyon nan lang ou pale a, san ou pa gen pou peye pou sa. Pou pale avèk yon entèprèt, rele nan 1-844-398-6232. (French/Haitian Creole) Si vous, ou quelqu'un que vous êtes en train d’aider, a des questions à propos de ce plan médical, vous avez le droit d'obtenir de l'aide et l'information dans votre langue à aucun coût. Pour parler à un interprète, appelez 1-844-396-0190 . (French) Jeśli Ty lub osoba, której pomagasz, macie pytania odnośnie planu ubezpieczenia zdrowotnego, masz prawo do uzyskania bezpłatnej informacji i pomocy we własnym języku. Aby porozmawiać z tłumaczem, zadzwoń pod numer 1-844-396-0186. (Polish) Se você, ou alguém a quem você está ajudando, tem perguntas sobre este plano de saúde, você tem o direito de obter ajuda e informação em seu idioma e sem custos. Para falar com um intérprete, ligue para 1-844-396-0182. (Portuguese) Se tu o qualcuno che stai aiutando avete domande su questo piano sanitario, hai il diritto di ottenere aiuto e informazioni nella tua lingua gratuitamente. Per parlare con un interprete, puoi chiamare 1-844-396-0184. (Italian) あなた、またはあなたがお世話をされている方が、この健康保険 についてご質問がございましたら、ご

希望の言語でサポートを受けたり、情報を入手したりすることができます。料金はかかりません。通訳

とお話される場合、1-844-396-0185 までお電話ください。 (Japanese) Falls Sie oder jemand, dem Sie helfen, Fragen zu diesem Krankenversicherungsplan haben bzw. hat, haben Sie das Recht, kostenlose Hilfe und Informationen in Ihrer Sprache zu erhalten. Um mit einem Dolmetscher zu sprechen, rufen Sie bitte die Nummer 1-844-396-0191 an. (German)

ی بھداشتی این برنامھ یاگر شما یا فردی کھ بھ او کمک می کنید سؤالاتی در بارهداشتھ باشید، حق این را دارید کھ کمک و اطلاعات بھ زبان خود را بھ طور رایگان

تماس حاصل 6233-398-844-1 یدریافت کنید. برای صحبت کردن با مترجم، لطفاً با شماره (Persian-Farsi) نمایید.