IVY LANE

CORPORATION

EMPLOYEE BENEFIT GUIDE

2017

DISCLAIMER

The intent of this summary is to briefly highlight your benefits and NOT to replace your insurance

contracts or booklets. The information has been compiled into summary form to outline the

benefits offered by your company.

If this benefit summary does not address your specific benefit questions, please refer to the

Customer Service Contact page of this booklet. This page will provide you with the information

you need to contact the specific insurance carriers and/or your Human Resources Department for

additional assistance.

The information provided in this summary is for comparative purposes only. Actual claims paid

are subject to the specific terms and conditions of each contract. This benefit summary does not

constitute a contract.

The information in this booklet is proprietary. Please do not copy or distribute to others.

Contained within this document is your annual Medicare Part D notice as required by the Centers for Medicare

& Medicaid. Please see the table of contents for page number.

Customer Service Contact Information 1

Holmes Murphy Contacts 1

Eligibility 3

2017 Premiums 4

Medical Insurance – UHC JYV $750 Deductible 5

Medical Insurance – UHC JYR $1,500 Deductible 6

Medical Insurance – UHC JY3 $2,000 Deductible 7

Medical Insurance – UHC KX8 $5,000 Deductible with Copays 8

Medical Insurance – UHC GPM $5,000 Deductible 9

Rally 10

My Nurseline 11

Virtual Visits 12

Health Savings Account (HSA) Administration 13

Dental Insurance 14

Dental Mobile App 15

Vision Insurance 16

Flexible Spending Accounts 17

Basic Life / Accidental Death & Dismemberment 19

Short Term Disability Insurance 21

Long Term Disability Insurance 22

MetLife Critical Illness 23

MetLife Accident 25

LifeLock Identity Protection 27

Medicare Part D Notice – Creditable Coverage 29

HIPAA Special Enrollment Notice 31

Women’s Health & Cancer Rights Act of 1998 31

EPIC Hearing 32

Enrollment Forms 33

TABLE OF CONTENTS

1

CUSTOMER SERVICE CONTACT INFORMATION

Refer to this list when you need to contact one of your benefit vendors. For general information contact

Human Resources.

MEDICAL:

United Healthcare

(800) 669-1830

www.uhc.com

DENTAL:

MetLife

(800) 942-0854

www.metlife.com

VISION:

Avesis

(800) 828-9341

www.avesis.com

FLEXIBLE SPENDING ACCOUNTS (FSA):

Kabel Business Services

(515) 224-9400

www.kabelbiz.com

LIFE/AD&D / SHORT-TERM DISABILITY / LONG-TERM DISABILITY:

MetLife

(800) 858-6506

www.metlife.com

For additional assistance, please contact:

HOLMES MURPHY & ASSOCIATES:

Alesha Carroll

(800) 247-7756, ext. 2360

acarroll@holmesmurphy.com

MEDICARE:

Eric Kiser

(515) 223-7033

ekiser@holmesmurphy.com

1

2

ACTION ITEMS FOR OPEN ENROLLMENT

Medical

There have been NO changes to medical plan designs or offerings for 2017.

2017 medical rates have increased from 2016.

If you are not making any changes, NO action is necessary.

If you would like to make a change, add, or drop a dependent, please complete the UHC

application on page 37.

Dental

There have been NO changes to the dental plan for 2017.

2017 dental rates have increased from 2016.

If you are not making any changes, NO action is necessary.

If you would like to make a change, add, or drop a dependent, please complete the MetLife

application on page 41.

Vision

There have been NO changes to the vision plan or rates for 2017.

If you are not making any changes, NO action is necessary.

If you would like to make a change, add, or drop a dependent, please complete the Avesis

application on page 51.

Flexible Spending Accounts

Flexible Spending Accounts will now be administered through Kabel Business Services.

If you wish to enroll in the FSA, you MUST complete the enrollment form on page 52.

Elections from last year WILL NOT roll over to this year.

Critical Illness/Accident Policies

The Company will no longer be paying for Aflac premiums through payroll deductions.

If you are enrolled in any Aflac Critical Illness or Accident policies, you must port those with Aflac

or enroll in the company sponsored MetLife Critical Illness and Accident policies.

If you are currently enrolled and are not making any changes, NO action is necessary.

If you wish to enroll, you must complete the MetLife application on page 45 or 48.

*All employees must complete the ERISA Electronic Disclosure Consent Form on

page 33 of this packet.*

2

3

WHO IS ELIGIBLE?

If you are a full-time employee (working 30 or more hours per week) you are eligible to enroll in the

benefits described in this guide. The waiting period for new hires is the first of the month following 60

days of employment. You will need to elect your benefits during this 60 day time period for them to be

effective.

HOW TO ENROLL The first step is to review your current benefit elections. Verify your personal information and make any

changes if necessary. Make your benefit elections. Once you have made your elections, you will not be able

to change them until the next open enrollment period unless you have a qualified change in status. Please

make your elections by completing the enrollment forms found in the back of this booklet and returning

them to Human Resources.

WHEN TO ENROLL The open enrollment period runs January 6, 2017 through January 13, 2017. The benefits you elect during

open enrollment will be effective from February 1, 2017 through January 31, 2018.

HOW TO MAKE CHANGES Unless you have a qualified change in status, you cannot make changes to the benefits you elect until the

next open enrollment period. Qualified changes in status include: marriage, divorce, legal separation,

domestic partnership status change, birth or adoption of a child, change in child’s dependent status, death

of spouse, child or other qualified dependent, change in residence due to an employment transfer for you,

your spouse or domestic partner, commencement or termination of adoption proceedings, or change in

spouse’s or domestic partners benefits or employment status, reduction in hours, or marketplace open

enrollment. See HIPAA Special Enrollment Rights later in this packet for notification requirements

3

4

2017 SEMI-MONTHLY (24) PREMIUMS

Coverage Semi-Monthly Deduction

Medical

UHC JYV - $750 Deductible

Single: $93.71

Employee/Spouse: $323.27

Employee/Child(ren): $240.77

Family: $478.33

UHC JYR - $1,500 Deductible

Single: $74.71

Employee/Spouse: $282.38

Employee/Child(ren): $207.49

Family: $423.15

UHC JY3 - $2,000 Deductible

Single: $57.18

Employee/Spouse: $244.66

Employee/Child(ren): $176.78

Family: $372.25

UHC KX8 - $5,000 Deductible with Copays

Single: $49.29

Employee/Spouse: $227.68

Employee/Child(ren): $162.95

Family:

UHC GPM - $5,000 Deductible

Single:

Employee/Spouse:

Employee/Child(ren):

Family:

$349.34

$25.41

$176.29

$121.12

$279.99

Dental

Single: $16.43

Employee/Spouse: $34.37

Employee/Child(ren): $38.63

Family: $60.69

Vision

Single:

Employee/Spouse:

Employee/Child(ren):

Family:

$3.44

$6.64

$6.64

$9.72

Voluntary Life & STD 100%

Basic Life & LTD Company Paid

Flexible Spending Account 100%

4

5

MEDICAL INSURANCE

United Healthcare

Medical Plan JYV with RX Plan G4 - $750 Deductible

This chart gives a side-by-side look at the amounts you pay when you use in-network and out-of-network

providers. For a complete listing of providers, visit www.uhc.com/find-a-physician, and enter the desired

search criteria.

Plan Feature In-Network Out-of-Network(1,2)

Deductible – Embedded(3)

$750 single

$1,500 family

$1,000 single

$2,000 family

Coinsurance 20% 40%

Out-of-Pocket Maximum $2,250 single

$4,500 family

$3,000 single

$6,000 family

Office Visit $20 copayment Deductible, 40% coinsurance

Specialist Visit $40 copayment Deductible, 40% coinsurance

Preventive Care Services Copayment waived,

covered at 100% Not Covered

Urgent Care $50 copayment Deductible, 40% coinsurance

Emergency Room $100 copayment $100 copayment

Facility Services Deductible, 20% coinsurance Deductible, 40% coinsurance

Outpatient Services Deductible, 20% coinsurance Deductible, 40% coinsurance

Mental Health & Substance Abuse Services

Inpatient / Outpatient Deductible, 20% coinsurance Deductible, 40% coinsurance

Office Visit $20 copayment Deductible, 40% coinsurance

Retail Prescription Drug Coverage(4,5)

(Up to 31-day supply)

$100 Single/$300 Family Deductible (waived for Tier 1)

$10 Tier 1 / $30 Tier 2 / $50 Tier 3

EMPLOYEE COST Semi-Monthly (24/year)

Employee $93.71

Employee/Spouse $323.27

Employee/Child(ren) $240.77

Family $478.33

(1) For out-of-network providers, the member may incur some charges above usual, customary and reasonable, which are the

responsibility of the member and do not apply to the out-of-pocket maximum.

(2) In and out-of-network deductibles and out-of-pocket maximums do not apply to each other.

(3) Member has benefits when single deductible is met. Entire family has benefits when family deductible is met.

(4) When members purchase Tier 2 and Tier 3 drugs when there is a Tier 1 drug available, they will pay the Tier 2 or Tier 3

copayment plus the difference between the Tier 1 and the Tier 2 or Tier 3 drug.

(5) When members purchase prescriptions from a non-participating pharmacy, he/she may be required to manually file the

claim with the carrier; plus he/she may incur additional costs above the maximum allowed amount.

5

6

MEDICAL INSURANCE

United Healthcare

Medical Plan JYR with RX Plan G4 - $1,500 Deductible

This chart gives a side-by-side look at the amounts you pay when you use in-network and out-of-network

providers. For a complete listing of providers, visit www.uhc.com/find-a-physician, and enter the desired

search criteria.

Plan Feature In-Network Out-of-Network(1,2)

Deductible – Embedded(3)

$1,500 single

$3,000 family

$2,000 single

$4,000 family

Coinsurance 20% 30%

Out-of-Pocket Maximum $3,000 single

$6,000 family

$4,000 single

$8,000 family

Office Visit $20 copayment Deductible, 30% coinsurance

Specialist Visit $50 copayment Deductible, 30% coinsurance

Preventive Care Services Copayment waived,

covered at 100% Not Covered

Urgent Care $50 copayment Deductible, 30% coinsurance

Emergency Room $200 copayment $200 copayment

Facility Services Deductible, 20% coinsurance Deductible, 30% coinsurance

Outpatient Services Deductible, 20% coinsurance Deductible, 30% coinsurance

Mental Health & Substance Abuse Services

Inpatient / Outpatient Deductible, 20% coinsurance Deductible, 30% coinsurance

Office Visit $20 copayment Deductible, 30% coinsurance

Retail Prescription Drug Coverage(4,5)

(Up to 31-day supply)

$100 Single/$300 Family Deductible (waived for Tier 1)

$10 Tier 1 / $30 Tier 2 / $50 Tier 3

EMPLOYEE COST Semi-Monthly (24/year)

Employee $74.71

Employee/Spouse $282.38

Employee/Child(ren) $207.49

Family $423.15

(1) For out-of-network providers, the member may incur some charges above usual, customary and reasonable, which are the

responsibility of the member and do not apply to the out-of-pocket maximum.

(2) In and out-of-network deductibles and out-of-pocket maximums do not apply to each other.

(3) Member has benefits when single deductible is met. Entire family has benefits when family deductible is met.

(4) When members purchase Tier 2 and Tier 3 drugs when there is a Tier 1 drug available, they will pay the Tier 2 or Tier 3

copayment plus the difference between the Tier 1 and the Tier 2 or Tier 3 drug.

(5) When members purchase prescriptions from a non-participating pharmacy, he/she may be required to manually file the

claim with the carrier; plus he/she may incur additional costs above the maximum allowed amount.

6

7

MEDICAL INSURANCE

United Healthcare

Medical Plan JY3 with RX Plan G4 - $2,000 Deductible

This chart gives a side-by-side look at the amounts you pay when you use in-network and out-of-network

providers. For a complete listing of providers, visit www.uhc.com/find-a-physician, and enter the desired

search criteria.

Plan Feature In-Network Out-of-Network(1,2)

Deductible – Embedded(3)

$2,000 single

$4,000 family

$2,500 single

$5,000 family

Coinsurance 20% 30%

Out-of-Pocket Maximum $6,000 single

$12,000 family

$6,000 single

$12,000 family

Office Visit $30 copayment Deductible, 30% coinsurance

Specialist Visit $50 copayment Deductible, 30% coinsurance

Preventive Care Services Copayment waived,

covered at 100% Not Covered

Urgent Care $75 copayment Deductible, 30% coinsurance

Emergency Room $200 copayment $200 copayment

Facility Services Deductible, 20% coinsurance Deductible, 30% coinsurance

Outpatient Services Deductible, 20% coinsurance Deductible, 30% coinsurance

Mental Health & Substance Abuse Services

Inpatient / Outpatient Deductible, 20% coinsurance Deductible, 30% coinsurance

Office Visit $30 copayment Deductible, 30% coinsurance

Retail Prescription Drug Coverage(4,5)

(Up to 31-day supply)

$100 Single/$300 Family Deductible (waived for Tier 1)

$10 Tier 1 / $30 Tier 2 / $50 Tier 3

EMPLOYEE COST Semi-Monthly (24/year)

Employee $57.18

Employee/Spouse $244.66

Employee/Child(ren) $176.78

Family $372.25

(1) For out-of-network providers, the member may incur some charges above usual, customary and reasonable, which are the

responsibility of the member and do not apply to the out-of-pocket maximum.

(2) In and out-of-network deductibles and out-of-pocket maximums do not apply to each other.

(3) Member has benefits when single deductible is met. Entire family has benefits when family deductible is met.

(4) When members purchase Tier 2 and Tier 3 drugs when there is a Tier 1 drug available, they will pay the Tier 2 or Tier 3

copayment plus the difference between the Tier 1 and the Tier 2 or Tier 3 drug.

(5) When members purchase prescriptions from a non-participating pharmacy, he/she may be required to manually file the

claim with the carrier; plus he/she may incur additional costs above the maximum allowed amount.

7

8

MEDICAL INSURANCE

United Healthcare

Medical Plan KX8 with RX Plan G4 - $5,000 Deductible with Copays

This chart gives a side-by-side look at the amounts you pay when you use in-network and out-of-network

providers. For a complete listing of providers, visit www.uhc.com/find-a-physician, and enter the desired

search criteria.

Plan Feature In-Network Out-of-Network(1,2)

Deductible – Embedded(3)

$5,000 single

$10,000 family

$6,000 single

$12,000 family

Coinsurance 0% 30%

Out-of-Pocket Maximum $5,000 single

$10,000 family

$10,000 single

$20,000 family

Office Visit $25 copayment Deductible, 30% coinsurance

Specialist Visit $50 copayment Deductible, 30% coinsurance

Preventive Care Services Copayment waived, covered

at 100% Not Covered

Urgent Care $50 copayment Deductible, 30% coinsurance

Emergency Room $175 copayment $175 copayment

Facility Services Deductible, 0% coinsurance Deductible, 30% coinsurance

Outpatient Services Deductible, 0% coinsurance Deductible, 30% coinsurance

Mental Health & Substance Abuse Services

Inpatient / Outpatient Deductible, 0% coinsurance Deductible, 30% coinsurance

Office Visit $25 copayment Deductible, 30% coinsurance

Retail Prescription Drug Coverage(4,5)

(Up to 31-day supply)

$100 Single/$300 Family Deductible (waived for Tier 1)

$10 Tier 1 / $30 Tier 2 / $50 Tier 3

EMPLOYEE COST Semi-Monthly (24/year)

Employee $49.29

Employee/Spouse $227.68

Employee/Child(ren) $162.95

Family $349.34

(1) For out-of-network providers, the member may incur some charges above usual, customary and reasonable, which are the

responsibility of the member and do not apply to the out-of-pocket maximum.

(2) In and out-of-network deductibles and out-of-pocket maximums do not apply to each other.

(3) Member has benefits when single deductible is met. Entire family has benefits when family deductible is met.

(4) When members purchase Tier 2 and Tier 3 drugs when there is a Tier 1 drug available, they will pay the Tier 2 or Tier 3

copayment plus the difference between the Tier 1 and the Tier 2 or Tier 3 drug.

(5) When members purchase prescriptions from a non-participating pharmacy, he/she may be required to manually file the claim

with the carrier; plus he/she may incur additional costs above the maximum allowed amount.

8

9

MEDICAL INSURANCE

United Healthcare

Medical Plan HSA GPM with RX Plan MM - $5,000 Deductible

This chart gives a side-by-side look at the amounts you pay when you use in-network and out-of-network

providers. For a complete listing of providers, visit www.uhc.com/find-a-physician, and enter the desired

search criteria.

Plan Feature In-Network Out-of-Network(1,2)

Deductible – Embedded(3)

$5,000 single

$10,000 family

$5,000 single

$10,000 family

Coinsurance 0% 30%

Out-of-Pocket Maximum $5,000 single

$10,000 family

$10,000 single

$20,000 family

Office Visit Deductible, 0% coinsurance Deductible, 30% coinsurance

Specialist Visit Deductible, 0% coinsurance Deductible, 30% coinsurance

Preventive Care Services Copayment waived, covered

at 100% Not Covered

Urgent Care Deductible, 0% coinsurance Deductible, 30% coinsurance

Emergency Room Deductible, 0% coinsurance Deductible, 0% coinsurance

Facility Services Deductible, 0% coinsurance Deductible, 30% coinsurance

Outpatient Services Deductible, 0% coinsurance Deductible, 30% coinsurance

Mental Health & Substance Abuse Services

Inpatient / Outpatient Deductible, 0% coinsurance Deductible, 30% coinsurance

Office Visit Deductible, 0% coinsurance Deductible, 30% coinsurance

Retail Prescription Drug Coverage(4)

(Up to 31-day supply) Deductible, 0% coinsurance

EMPLOYEE COST Semi-Monthly (24/year)

Employee $25.41

Employee/Spouse $176.29

Employee/Child(ren) $121.12

Family $279.99

(1) For out-of-network providers, the member may incur some charges above usual, customary and reasonable, which are the

responsibility of the member and do not apply to the out-of-pocket maximum.

(2) In and out-of-network deductibles and out-of-pocket maximums do not apply to each other.

(3) Member has benefits when single deductible is met. Entire family has benefits when family deductible is met.

(4) When members purchase prescriptions from a non-participating pharmacy, he/she may be required to manually file the claim

with the carrier; plus he/she may incur additional costs above the maximum allowed amount.

9

Rally Health provides health and well-being information and support as part of your health plan. It does not provide medical advice or other health services, and is not a substitute for your doctor’s care. If you have specific health care needs, consult an appropriate health care professional. Participation in the health survey is voluntary. Your responses will be kept confidential in accordance with the law and will only be used to provide health and wellness recommendations or conduct other plan activities. Your Health Age is based on self-disclosed information, including any applicable biometric screening data.

All trademarks are the property of their respective owners. Insurance coverage provided by or through UnitedHealthcare Insurance Company or its affiliates. Administrative services provided by United HealthCare Services, Inc. or their affiliates.

© 2015 United HealthCare Services, Inc. All rights reserved. 48355-062015

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Rally is available at no additional cost to you, as part of your health plan benefits.

Register today at myuhc.com®.FIND YOUR MISSION TODAY.

10

When you have a health concern, it can be difficult and time-consuming to find the information you need. myNurseLine can help you make informed health care decisions with telephone and online access to experienced registered nurses.

Your health advocateOne toll-free number connects you with a registered nurse who will take the time to understand what is going on with your health and provide personalized information just for you. And this is all available 24 hours a day, seven days a week, at no additional cost to you as part of your benefits.

myNurseLine also gives you access to an audio health information library. Choose from more than 1,100 health and well-being topics, with 600 messages available in Spanish. Services are available to translate 140 languages and for callers with hearing impairments.

Experience you can rely onmyNurseLine nurses have an average of 15 years clinical nursing experience. They are an excellent resource when you need help choosing care, managing a chronic condition, understanding treatment options and more.

Your one-stop source Whether you have a baby with a 102 temperature at midnight or need help managing your diabetes, myNurseLine is the one source to help you with the answers you need.

Not sure if you need a doctor, urgent care clinic or just some good health advice? One call to myNurseLine may help you get information about the care and services you need. So, think of myNurseLine as your one-stop resource to help you make informed health care decisions every day.To talk with a myNurseLine nurse, call the Customer Care number on the back of your health plan ID card, or visit myuhc.com®.

The myNurseLineSM, Care Coordination Nurse, and Cancer Nurse Advocate services are for informational purposes only, and should not be used for emergency or urgent care situations. In an emergency, call 911 or go to the nearest emergency room. Nurses cannot diagnose problems or recommend specific treatment and are not a substitute for your doctor’s care. These services are not an insurance program and may be discontinued at any time. They are included as part of your health plan.

Insurance coverage provided by or through UnitedHealthcare Insurance Company or its affiliates. Administrative services provided by United HealthCare Services, Inc. or their affiliates.

100-3501 2/13 Consumer © 2013 United HealthCare Services, Inc.

myNurseLineSM

My health, my questions, myNurseLine.

myNurseLine is here to help you: Chat with a nurse live on myuhc.com

Understand your symptoms

Decide where to go for care

Learn more about a diagnosis

Explore treatment options

Understand medications

Find a doctor, hospital, or specialist and check if a doctor is in your network and is accepting new patients.

11

* Prescription services may not be available in all states. Access to virtual visits and prescription services may not be available in all states or for all groups. Go to myuhc.com for more information about availability of virtual visits and prescription services. Always refer to your plan documents for your specific coverage. Virtual visits are not an insurance product, health care provider or a health plan. Virtual visits are an internet based service provided by contracted UnitedHealthcare providers that allow members to select and interact with independent physicians and other health care providers. It is the member’s responsibility to select health care professionals. Care decisions are between the consumer and physician. Virtual visits are not intended to address emergency or life-threatening medical conditions and should not be used in those circumstances. Services may not be available at all times or in all locations. Members have cost share responsibility and all claims are adjudicated according to the terms of the member’s benefit plan. Payment for virtual visit services does not cover pharmacy charges; members must pay for prescriptions (if any) separately.Insurance coverage provided by or through UnitedHealthcare Insurance Company or its affiliates. Administrative services provided by United HealthCare Services, Inc. or their affiliates.MT-1027900.0 6/16 © 2016 United HealthCare Services, Inc. 16-2211 100-16667

Use virtual visits when: • Your doctor is not available • You become ill while traveling • You are considering visiting a hospital

emergency room for a non-emergency health condition

Not good for: • Anything requiring an exam or test• Complex or chronic conditions • Injuries requiring bandaging or

sprains/ broken bones

When you don’t feel well, or your child is sick, the last thing you want to do is leave the comfort of home to sit in a waiting room. Now, you don’t have to.

A virtual visit lets you see and talk to a doctor from your mobile device or computer without an appointment. Most visits take about 10-15 minutes and doctors can write a prescription*, if needed, that you can pick up at your local pharmacy. And, it’s part of your health benefits.

Conditions commonly treated through a virtual visitDoctors can diagnose and treat a wide range of non-emergency medical conditions, including:

• Bladder infection/ Urinary tract infection

• Bronchitis• Cold/flu

• Diarrhea• Fever• Migraine/headaches • Pink eye

• Rash• Sinus problems• Sore throat

• Stomach ache

To learn more, login to myuhc.com

Access virtual visitsLog in to myuhc.com® and choose from provider sites where you can register for a virtual visit. After registering and requesting a visit you will pay your portion of the service costs according to your medical plan, and then you will enter a virtual waiting room. During your visit you will be able to talk to a doctor about your health concerns, symptoms and treatment options.

Virtual VisitsGet access to care online. Any where. Any time.

12

13

HEALTH SAVINGS ACCOUNT (HSA) ADMINISTRATION

HSA Overview

Who is eligible?

1) Anyone covered under a qualified High Deductible Health Plan (HDHP) on the first day of the

month, but not covered under any other medical plan.

2) Anyone not enrolled in Medicare. Note: an actively at-work employee who is older than 65 may

not enroll in an HSA unless he/she has waived Medicare.

3) When enrolled in an HSA, member and spouse (if applicable) may only participate in a “limited-

purpose” flexible spending account.

4) Anyone not claimed as a dependent on another person’s tax return.

Is there a limit on the amount that can be contributed per year?

$3,400 for an individual plan, $6,750 for a family plan for 2017. These numbers are indexed annually by

the Treasury Department. In addition, there is a $1,000 catch-up contribution allowed for individuals 55

and older.

What are the advantages of enrolling in a HSA?

1) Monies go in tax-free.

2) Monies grow tax-free.

3) Monies come out tax-free if spent on qualified medical expenses.

4) Unspent monies roll over year to year, grow, and earn interest.

5) The account owner decides whether to use the HSA dollars for current expenses, or to save them

for future expenses.

6) The account is portable.

What expenses are eligible for reimbursement?

Internal Revenue Code Section 213(d) medical expenses for the employee and qualified dependents

(even if the dependents are not on the employee’s HDHP); COBRA premiums; qualified long-term care

expenses; retiree medical premiums to employer-sponsored medical coverage (if age 65 or older);

Medicare Parts B & D premiums, but not Medicare supplement premiums.

What if funds are used for non-qualified expenses?

Distributions for an account owner under age 65 are subject to income tax plus a 20% penalty.

Distributions for an account owner 65 and older are subject to income tax only.

For more details:

Check out www.irs.gov for more details.

13

14

DENTAL INSURANCE MetLife

This chart gives a side-by-side look at the amounts you pay when you use in-network and out-of-network

providers.

Type of Service In-Network Out-of-Network(1)

Deductible $50 single

$150 family

$50 single

$150 family

Diagnostic & Preventive Services Deductible waived, covered at

100%

Deductible waived, covered at

100%

Routine & Restorative Services Deductible, 20% coinsurance Deductible, 20% coinsurance

Major Services Deductible, 50% coinsurance Deductible, 50% coinsurance

Orthodontia

(Covers children up to age 19) Deductible, 50% coinsurance Deductible, 50% coinsurance

Plan Maximum

$2,000 per calendar year for Diagnostic & Preventive, Routine

& Restorative, and Major Services

Per insured person

$1,000 per lifetime for Orthodontia

Per dependent child

EMPLOYEE COST Semi-Monthly (24/year)

Employee $16.43

Employee/Spouse $34.37

Employee/Child(ren) $38.63

Family $60.69

(1) Out-of-Network benefits are reimbursed based on Reasonable & Customary charge. Reasonable & Customary is based on the

lowest the dentist’s actual charge or charge of most dentists in the area for the same or similar services.

ID CARD INFORMATION

14

Viewing your dental plan just got easier with the MetLife Mobile App.1

You can: Find a dentist

View your plan summary and claims

View your ID card

It’s easy! Search “MetLife” at iTunes App Store or Google Play to download the App. Search our network of thousands of dentists and specialists to find a provider near you. Or log-in to MyBenefits to access your plan information.1 It’s available 24 hours a day, seven days a week. 1 Certain features of the MetLife Mobile App are not available for all MetLife Dental plans. Before using the MetLife Mobile App, you must register at www.metlife.com/mybenefits from a computer. Registration cannot be done from your mobile device. Like most group benefit programs, benefit programs offered by MetLife and its affiliates contain certain exclusions, exceptions, waiting periods, reductions, limitations and terms for keeping them in force. Please contact MetLife or your plan administrator for complete details.

L0216456127[exp0417][All States][DC,GU,MP,PR,VI] © 2016 METLIFE, INC. PEANUTS © 2016 Peanuts Worldwide

Dental information available through the MetLife Mobile App

Group Dental

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VISION INSURANCE Avesis

This chart gives a side-by-side look at the amounts you pay when you use in-network and out-of-network

providers.

Type of Service In-Network Out-of-Network

Vision Exam $10 copayment Reimbursed up to $45

Lenses

Standard Single Vision $10 copayment Reimbursed up to $30

Standard Bifocal $10 copayment Reimbursed up to $50

Standard Trifocal $10 copayment Reimbursed up to $65

Standard Lenticular $10 copayment Reimbursed up to $80

Frames $50 Wholesale Allowance Reimbursed up to $70

Contact Lenses(1)

Elective Reimbursed up to $130 Reimbursed up to $105

Medically Necessary $10 copayment Reimbursed up to $210

Benefit Frequency

Vision Exam every 12 months

Spectacle Lenses every 12 months

Frames every 24 months

Contact Lenses every 12 months

EMPLOYEE COST Semi-Monthly (24/year)

Employee $3.44

Employee/Spouse $6.64

Employee/Child(ren) $6.64

Family $9.72

(1) Contacts are in lieu of frames or spectacles.

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FLEXIBLE SPENDING ACCOUNTS (FSA) Kabel Business Services

FSAs provide you with an important tax advantage that can help you pay health care and dependent care

expenses on a pre-tax basis. By anticipating your family’s health care and dependent care costs for the next

year, you can actually lower your taxable income.

Plan Overview

Pre-Tax Premium Benefits

This plan allows you to fund several of your premium contributions with pre-tax dollars and to fund either

a Health Care Reimbursement Account and/or Dependent Care Reimbursement Account. Your

contributions are deducted from your gross wages before FICA, Federal and State taxes are deducted.

You save money because you are taxed at a reduced income level. Your taxes are calculated after your

premiums and reimbursement account monies are deducted from your gross wages.

Health Care Reimbursement Accounts

This plan allows you to defer pre-tax dollars into a Health Care Reimbursement Account to pay for certain

IRS-approved medical care expenses not covered by your insurance plan with pre-tax dollars. Some

examples include:

Deductible, coinsurance and copayments

Over the counter medications – with prescription

Dental services and orthodontia

Vision services, including contact lenses, contact lens solution, eye exams and eyeglasses

Hearing services, including hearing aids and batteries

Medical Care Maximum: $2,600

Dependent Care Reimbursement Accounts

This plan allows you to defer pre-tax dollars into a Dependent Care Reimbursement Account. You may

request reimbursement as you incur expenses to provide day care for qualified dependents: children

under age 13, or an older disabled dependent child, or a disabled adult.

Dependent Care Maximums: $5,000 if married filing jointly or head of household;

$2,500 if married filing single.

Plan Provisions

Please Note: Your election in the Arona Corporation Section 125 Flexible Benefit Plan is irrevocable for

the entire plan year (February 1st through January 31

st) without a qualifying change in status (i.e. birth,

adoption, divorce, job status change, etc.) Please be advised that any unused FSA monies will be forfeited

back to the Plan at the end of the plan year.

Extension

Your flex plan has a 2.5 month extension of time (at the end of the 12 month flex plan year), in which you

may incur eligible flex expenses.

Claim Submission

Claims may be filed by mailing, faxing, or online. Please be aware that your plan has a 90 day run out

period, after the end of the plan, where you may still file claims. Remember that the expense, however,

must have been incurred during the plan year.

Claim Processing

Claims are processed on a daily basis. Reimbursements may be automatically deposited into your

checking account or mailed to you in the form of a check.

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FLEXIBLE SPENDING ACCOUNTS

How do Flexible Spending Accounts Work?

Flexible Spending Accounts (FSAs) are like personal bank accounts. They allow you to set aside money for

healthcare and/or dependent care expenses on a pre-tax basis. You can enroll in a Healthcare FSA and/or a

Dependent Day Care FSA. Your election will cover you from your enrollment date through the end of the

plan year unless you have a change in family status.

You can elect to have a portion of your salary withheld on a pre-tax basis for health or dependent care

expenses you incur during the plan year. The funds will be placed into an account to be used during the

year. If you contribute to both FSAs, you cannot use amounts contributed to one account to pay expenses

eligible for payment from another account. For example, you cannot pay medical expenses from your

Dependent Day Care FSA.

Health Care FSA

During annual enrollment you may elect to contribute monies into the Health Care FSA during the coming

plan year. The amount you elect to set aside will be deducted from your paycheck in equal installments

during the plan year.

Eligible health care expenses include copayments, deductibles, coinsurance, certain orthodontic procedures

and other health-related expenses incurred by you or a family member. In addition, over-the-counter

medicines are eligible for reimbursement with a prescription.

Dependent Care FSA

You can contribute up to $5,000 each year to the Dependent Day Care FSA to pay for dependent care

expenses. The amount you elect to set aside will be deducted from your paycheck in equal installments

during the coming year.

Eligible expenses are only those incurred for the care of a child under 13 years of age (or a disabled child

older than age 13) who qualifies as your dependent for tax purposes; or, anyone you can claim as a

dependent, such as an elderly parent or disabled spouse.

Use It Or Lose It

It is very important that you estimate accurately when determining how much to contribute to either FSA.

FSAs can provide significant tax advantages for employees when the contributions are made on a pre-tax

basis. For this reason the IRS requires that you use all of the money in your account(s) during the plan year.

Any money remaining in your account(s) at the end of the plan year will be forfeited.

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19

BASIC LIFE / ACCIDENTAL DEATH & DISMEMBERMENT MetLife

Your employer provides full-time employees with Basic Life/Accidental Death and Dismemberment

coverage, and pays the full cost of this benefit. Contact your Human Resources department to update your

beneficiary information.

Plan Overview

Basic Life Benefit Amount

$15,000

Accidental Death Benefit

Amount is the same as the Basic Life amount.

Waiver of Premium

Life insurance continues for totally disabled employees without payment of premium if:

Disability begins while the employee is insured;

Disability begins prior to age 60 and terminates at age 65;

Proof of disability is given to Carrier, prior to the end of the Disability Elimination Period;

Proof of continued disability is verified periodically, according to the terms of the contract.

Living Care Benefits

If you have a qualifying medical condition, you may apply for an accelerated benefit to receive a portion

of your life insurance once during your lifetime.

Conversion

Must apply for conversion within 31 days of termination of policy.

Age Reduction

Benefit reduces by 35% at Age 65;

Benefit reduces by 50% at Age 70.

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VOLUNTARY TERM LIFE INSURANCE MetLife

Employees who want to supplement their group life insurance benefits may purchase additional coverage.

When you enroll yourself, you may also elect coverage on your dependents in this benefit. You pay the full

cost through payroll deductions.

Voluntary Coverage Amounts

Employee may elect up to 5 times his/her annual salary

Minimum: $10,000

Maximum: $500,000

Multiples of: $10,000

Spouse

Minimum: $5,000

Maximum: $100,000

Multiples of: $5,000

Child(ren)

Minimum: $1,000

Maximum: $10,000

Increments: $1,000, $2,000, $4,000, $5,000, $10,000

Guarantee Issue Amounts(1)

Employee: $100,000

Spouse: $25,000

Child(ren): All amounts

Accidental Death Benefit

Amount is the same as the Voluntary Coverage Amount for employee only.

Waiver of Premium

Life insurance continues for totally disabled employees without payment of premium if:

Disability begins while the employee is insured;

Disability begins prior to age 60 and terminates at age 65;

Proof of disability is given to Carrier, prior to the end of the Disability Elimination Period;

Proof of continued disability is verified periodically, according to the terms of the contract.

Portability

Apply for within 31 days of termination.

Age Reduction Schedule

At age:

70

75

80

85

90

Benefits reduce to:

65%

45%

30%

20%

15% (1)

The levels of Guarantee Issue (GI) coverage are available for employees & family members when the employee is

initially eligible. At later annual enrollment periods, all applications for coverage are subject to approval by the carrier.

Monthly Cost for Each $1,000 of Employee & Spouse Life/AD&D Insurance Coverage

Age <30 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70+

Life $0.092 $0.101 $0.112 $0.154 $0.227 $0.343 $0.520 $0.760 $1.273 $2.380 Children $0.288 per $1,000

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VOLUNTARY SHORT TERM DISABILITY INSURANCE MetLife

Employees may purchase short term disability income benefits and pay the full cost of the benefit. In the

event you become disabled from a non-work-related injury or sickness, disability income benefits are

provided as a source of income. You are not eligible to receive short-term disability benefits if you are

receiving workers’ compensation benefits.

Plan Overview

Benefits Begin 8th day for disability due to Injury

8th day for disability due to Sickness

Benefit Amount 60% of weekly earnings

Maximum Benefit Amount $1,000 per week

Maximum Benefit Period 26 weeks

Pre-existing Condition Waiting Period Not applicable

To determine your monthly premium, refer to the chart below. Please note, the maximum benefit amount

cannot exceed 60% of your gross weekly earnings or $1,000, whichever is less (rounded down to the next

$50 increment). To calculate what your monthly election may be, use the following formula:

Yearly Salary x .60 = Maximum Allowance / 12 (round down to the nearest $50)

Example: $24,960 x .60 = $14,976

$14,976 / 52 = $288

Weekly Benefit would be $250

Monthly Premium Chart

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LONG TERM DISABILITY INSURANCE MetLife

Your employer provides full-time employees with long term disability income benefits, and pays the full cost

of this coverage. In the event you become disabled, disability income benefits are provided as a source of

income.

Plan Overview

Elimination Period 180 days

Benefit Amount 50% of monthly earnings

Maximum Benefit Amount $5,000 per month

Maximum Benefit Period Varies based on the age disability occurs. Refer to your summary

plan description for details.

Definition of Disability 2 years own occupation

Survivor Benefit 3 months

Zero Day Residual

Zero day residual stipulates that full-time or part-time work in

which the employee is performing all of the material duties of his

or her regular, or some other occupation, will not interrupt the

qualifying (elimination) period, or the period of disability.

Pre-Existing Condition Waiting Period

3/12 applies to all employees covered less than 12 months. In the

event of a claim, the carrier will review information from 3 months

prior to the employee being insured on this plan; if the disabling

condition had been treated or diagnosed, there would be no LTD

benefits for the first 12 months. After that time, benefits will be

payable according to the terms of the contract.

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COVERAGE OPTIONS

Critical Illness Insurance

Eligible Individual Initial Benefit Requirements

Employee Initial Benefit Amount of $15,000 or $30,000

Coverage is guaranteed provided you are actively at work.3

Spouse 100% of the employee’s Initial Benefit

Coverage is guaranteed provided the employee is actively at work and the spouse/domestic partner is not subject to a medical restriction as set forth on the enrollment form and in the Certificate.3

Dependent Child(ren)2* 100% of the employee’s Initial Benefit

Coverage is guaranteed provided the employee is actively at work and the dependent is not subject to a medical restriction as set forth on the enrollment form and in the Certificate.3

BENEFIT PAYMENT Your Initial Benefit provides a lump-sum payment upon the first diagnosis of a Covered Condition. Your plan pays a Recurrence Benefit4 equal to the Initial Benefit for the following Covered Conditions: Heart Attack, Stroke, Coronary Artery Bypass Graft, Full Benefit Cancer and Partial Benefit Cancer. A Recurrence Benefit is only available if an Initial Benefit has been paid for the Covered Condition. There is a Benefit Suspension Period between Recurrences. The maximum amount that you can receive through your Critical Illness Insurance plan is called the Total Benefit and is [3] times the amount of your Initial Benefit. Please refer to the table below for the percentage benefit amount for each Covered Condition.

Covered Conditions Initial Benefit Recurrence Benefit

Full Benefit Cancer5 100% of Initial Benefit 100% of Initial Benefit

Partial Benefit Cancer5 25% of Initial Benefit 25% of Initial Benefit

Heart Attack 100% of Initial Benefit 100% of Initial Benefit

Stroke5 100% of Initial Benefit 100% of Initial Benefit

Coronary Artery Bypass Graft6 100% of Initial Benefit 100% of Initial Benefit

Kidney Failure 100% of Initial Benefit Not applicable

Alzheimer’s Disease7 100% of Initial Benefit Not applicable

Major Organ Transplant Benefit 100% of Initial Benefit Not applicable

22 Listed Conditions8 25% of Initial Benefit Not applicable

MetLife Critical Illness Insurance Plan Summary

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Example of Initial & Recurrence Benefit Payments The example below illustrates an employee who elected an Initial Benefit of $15,000 and has a Total Benefit of 3 times the Initial Benefit Amount or $45,000.

Illness – Covered Condition Payment Total Benefit Remaining

Heart Attack – first diagnosis Initial Benefit payment of $15,000 or

100%. ($30,000)

Heart Attack – second diagnosis, two years later Recurrence Benefit payment of $15,000

or 100% ($15,000)

Kidney Failure – first diagnosis, three years later Initial Benefit payment of $15,000 or

100% ($0)

SUPPLEMENTAL BENEFITS MetLife provides coverage for the Supplemental Benefits listed below. This coverage would be in addition to the Total Benefit Amount payable for the previously mentioned Covered Conditions.

Health Screening Benefit9 After your coverage has been in effect for thirty days, MetLife will provide an annual benefit of $50 or $100* per calendar year for taking one of the eligible screening/prevention measures. MetLife will pay only one health screening benefit per covered person per calendar year. For a complete list of eligible screening/prevention measures, please refer to the Disclosure Statement/Outline of Coverage. *The Health Screening Benefit amount depends upon the Initial Benefit Amount selected. Employees would receive a $50 benefit with the $15,000 initial benefit amount or a $100 benefit with the $30,000 Initial Benefit Amount.

QUESTIONS & ANSWERS

Who is eligible to enroll? Regular active full-time employees who are actively at work along with their spouse and dependent children can enroll for MetLife Critical Illness Insurance coverage.3

How do I pay for coverage? Coverage is paid through convenient payroll deduction.

If I Leave the Company, Can I Keep My Coverage? 10 Under certain circumstances, you can take your coverage with you if you leave. You must make a request in writing within a specified period after you leave your employer. You must also continue to pay premiums to keep the coverage in force. Who do I call for assistance? Please call MetLife at 1-855-564-6638 and speak with a benefits consultant.

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ACCIDENT INSURANCE BENEFITS

With MetLife, you’ll have a choice of 2 comprehensive plans which provide payments in addition to any other insurance payments you may receive. Here are just some of the covered events/services.

Benefit Type1

Low Plan MetLife Accident Insurance Pays YOU

High Plan MetLife Accident Insurance Pays YOU

Injuries

Fractures2 $50 – $3,0002 $100 – $6,0002

Dislocations2 $50 – $3,0002 $100 – $6,0002

Second and Third Degree Burns $50 – $5,000 $100 – $10,000

Concussions $200 $400

Cuts/Lacerations $25 – $200 $50 – $400

Eye Injuries $200 $300

Medical Services & Treatment1

Ambulance $200 – $750 $300 – $1,000

Emergency Care $25 – $50 $50 – $100

Non-Emergency Care $25 $50

Physician Follow-Up $50 $75

Therapy Services (including physical therapy) $15 $25

Medical Testing Benefit $100 $200

Medical Appliances $50 – $500 $100 – $1,000

Inpatient Surgery $100 – $1,000 $200 – $2,000

Hospital3 Coverage (Accident)

Admission $500 – $1,000 per accident $1,000 – $2,000 per accident Confinement (non-ICU confinement paid for up to 365 days. ICU confinement paid for 30 days)

$100 (non-ICU) – $200 (ICU) a day $200 (non-ICU) – $400 (ICU) a day

Inpatient Rehab (paid per accident) $100 a day, up to 15 days $200 a day, up to 15 days

Hospital Coverage (Sickness)4

Admission (payable 1 x per calendar year) $150 (non-ICU) – $300 (ICU) $150 (non-ICU) – $300 (ICU)

Confinement (paid per sickness)

$100 (non-ICU) – $200 (ICU) Payable up to 30 days per sickness

$100 (non-ICU) – $200 (ICU) Payable up to 30 days per sickness

MetLife Accident Insurance Plan Summary

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Benefit Type1

Low Plan MetLife Accident Insurance Pays YOU

High Plan MetLife Accident Insurance Pays YOU

Accidental Death Employee receives 100% of amount shown, spouse receives 50% and children receive 20% of amount shown.

$25,000 $75,000 for common carrier5

$50,000 $150,000 for common carrier5

Dismemberment, Loss & Paralysis

Dismemberment, Loss & Paralysis $250 – $10,000 per injury $500 - $50,000 per injury

BENEFIT PAYMENT EXAMPLE

QUESTIONS & ANSWERS

Who is eligible to enroll for this accident coverage? You are eligible to enroll yourself and your eligible family members!9 You need to enroll during your Enrollment Period and be actively at work for your coverage to be effective. How do I pay for my accident coverage? Premiums will be conveniently paid through payroll deduction, so you don’t have to worry about writing a check or missing a payment. What happens if my employment status changes? Can I take my coverage with me? Yes, you can take your coverage with you. You will need to continue to pay your premiums to keep your coverage in force. Your coverage will only end if you stop paying your premium or if your employer offers you similar coverage with a different insurance carrier. Who do I call for assistance? Please call MetLife at 1-855-564-6638 and speak with a benefits consultant.

Covered Event1 Benefit Amount8

Ambulance (ground) $300

Emergency Care $100

Physician Follow-Up ($75 x 2) $150

Medical Testing $200

Concussion $400

Broken Tooth (repaired by crown) $200

Benefits paid by MetLife Group Accident Insurance

$1,350

Kathy’s daughter, Molly, plays soccer on the varsity high school team. During a recent game, she collided with an opposing player, was knocked unconscious and taken to the local emergency room by ambulance for treatment. The ER doctor diagnosed a concussion and a broken tooth. He ordered a CT scan to check for facial fractures too, since Molly’s face was very swollen. Molly was released to her primary care physician for follow-up treatment, and her dentist repaired her broken tooth with a crown. Depending on her health insurance, Kathy’s out-of-pocket costs could run into hundreds of dollars to cover expenses like insurance co-payments and deductibles. MetLife Group Accident Insurance payments can be used to help

cover these unexpected costs.

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ENROLL IN PROACTIVEIDENTITY THEFT PROTECTION.

Protecting Your PersonalInformation is Our Top PriorityLifeLock helps safeguard your finances, credit & good name.

LifeLock Identity Theft Protection® detects your personal information in applications for credit and services within our extensive network.† We monitor over a trillion data points, including those for new credit cards, wireless services, retail credit, mortgages, auto and payday loans. You can respond immediately to confirm if the activity is fraudulent with our proprietary Not Me® verification technology. If identity fraud does occur, our Certified Resolution Specialists are available to personally manage your case from beginning to end.

†Network does not cover all transactions.‡The benefits under the Service Guarantee are provided under a Master Insurance Policy underwritten by State National Insurance Company. As this is only a summary please see the actual policy for applicable terms and restrictions at LifeLock.com/legal

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†Network does not cover all transactions and scope may vary.†† This information is required to receive LifeLock alerts.* Must agree to the terms and conditions available at LifeLock.com/terms. ‡ actual policy for applicable terms and restrictions at LifeLock.com. Copyright © 2013, LifeLock. All Rights Reserved. LifeLock, the LockMan Icon and “Relentlessly Protecting Your Identity” are registered trademarks of LifeLock, Inc.

service is limited to employees and their eligible dependents.

Choose the LifeLock Service That’s Right for You

LifeLock Identity The� ProtectionLifeLock® identity the� protection helps proactively safeguard your personal information and alerts you of potential threats.†

LifeLock UltimateLifeLock Ultimate™ service is the most comprehensive identity the� protection service ever created and even includes monitoring of new and existing checking and savings accounts.†

How to enroll: 1. Learn more & enroll online at:

2. Provide the name, Social Security number, dateof birth, address , email and phone number foryou and each dependent you wish to enroll.††

3. Select your level of coverage.*

4. Your LifeLock coverage will begin on the 1stof the month following the success�l completion of your enrollment.

5. You will receive a welcome email �om LifeLockwith instructions on how to take �ll advantageof your LifeLock membership.

Enroll in LifeLock service during open enrollment and secure your personal information.

Plan Options LifeLock Identity LifeLock Ultimate

Employee Only [18 and over] $4.25 $10.63

Employee + Spouse $8.50 $21.25

Employee + Children** $7.44 $15.41

Employee + Family** $11.69 $26.03

LifeLock Service Payroll Deduction Pricing –

THE NECESSARY, VOLUNTARY BENEFIT

Service Features LifeLock Identity The� Protection LifeLock Ultimate

Proactive Protection Credit Application Alerts† Non-Credit Alerts† Lost Wallet Protection

Black Market Website Surveillance

Award-Winning Member Service 24/7/365 $1 Million Total Service Guarantee‡ Alias Name and Address Monitoring Court Records Scanning File-Sharing Network Searches

Checking and Savings Account Application Alerts† Bank Account Takeover Alerts† Enhanced Credit Application Alerts† Online Annual Credit Reports and Scores Monthly Credit Score Tracking Priority Award-Winning Member Service 24/7/365

Special Employee Bene�t Rate

Starting as low as

$4.25per pay period***

http://arona.excelsiorenroll.com

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29

IMPORTANT NOTICE FROM ARONA CORPORATION ABOUT YOUR

PRESCRIPTION DRUG COVERAGE AND MEDICARE

Please read this notice carefully and keep it where you can find it. This notice has information about your

current prescription drug coverage with Arona Corporation and about your options under Medicare’s

prescription drug coverage. This information can help you decide whether or not you want to join a Medicare

drug plan. If you are considering joining, you should compare your current coverage, including which drugs

are covered at what cost, with the coverage and costs of the plans offering Medicare prescription drug

coverage in your area. Information about where you can get help to make decisions about your prescription

drug coverage is at the end of this notice.

There are two important things you need to know about your current coverage and Medicare’s prescription

drug coverage:

1. Medicare prescription drug coverage became available in 2006 to everyone with Medicare. You can

get this coverage if you join a Medicare Prescription Drug Plan or join a Medicare Advantage Plan (like

an HMO or PPO) that offers prescription drug coverage. All Medicare drug plans provide at least a

standard level of coverage set by Medicare. Some plans may also offer more coverage for a higher

monthly premium.

2. Arona Corporation has determined that the prescription drug coverage offered by all plans is, on

average for all plan participants, expected to pay out as much as standard Medicare prescription drug

coverage pays and is therefore considered Creditable Coverage. Because your existing coverage is

Creditable Coverage, you can keep this coverage and not pay a higher premium (a penalty) if you later

decide to join a Medicare drug plan.

When Can You Join A Medicare Drug Plan?

You can join a Medicare drug plan when you first become eligible for Medicare and each year from October

15th

to December 7th

.

However, if you lose your current creditable prescription drug coverage, through no fault of your own, you will

also be eligible for a two (2) month Special Enrollment Period (SEP) to join a Medicare drug plan.

What Happens To Your Current Coverage If You Decide to Join A Medicare Drug Plan?

If you decide to join a Medicare drug plan, your current Arona Corporation coverage will not be affected. Your

current coverage pays for other health expenses in addition to prescription drugs. If you enroll in a Medicare

prescription drug plan, you and your eligible dependents will still be eligible to receive all of your current health

and prescription drug benefits.

If you do decide to join a Medicare drug plan and drop your current Arona Corporation coverage, be aware

that you and your dependents may not be able to get this coverage back.

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When Will You Pay A Higher Premium (Penalty) To Join A Medicare Drug Plan?

You should also know that if you drop or lose your current coverage with Arona Corporation and don’t join a

Medicare drug plan within 63 continuous days after your current coverage ends, you may pay a higher

premium (a penalty) to join a Medicare drug plan later.

If you go 63 continuous days or longer without creditable prescription drug coverage, your monthly premium

may go up by at least 1% of the Medicare base beneficiary premium per month for every month that you did

not have that coverage. For example, if you go nineteen months without creditable coverage, your premium

may consistently be at least 19% higher than the Medicare base beneficiary premium. You may have to pay

this higher premium (a penalty) as long as you have Medicare prescription drug coverage. In addition, you

may have to wait until the following November to join.

For More Information About This Notice Or Your Current Prescription Drug Coverage…

Contact the person listed below for further information. NOTE: You’ll get this notice each year. You will also

get it before the next period you can join a Medicare drug plan, and if this coverage through Arona

Corporation changes. You also may request a copy of this notice at any time.

For More Information About Your Options Under Medicare Prescription Drug Coverage…

More detailed information about Medicare plans that offer prescription drug coverage is in the “Medicare &

You” handbook. You’ll get a copy of the handbook in the mail every year from Medicare. You may also be

contacted directly by Medicare drug plans.

For more information about Medicare prescription drug coverage:

• Visit www.medicare.gov

• Call your State Health Insurance Assistance Program (see the inside back cover of your copy

of the “Medicare & You” handbook for their telephone number) for personalized help

• Call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048.

If you have limited income and resources, extra help paying for Medicare prescription drug coverage is

available. For information about this extra help, visit Social Security on the web at www.socialsecurity.gov, or

call them at 1-800-772-1213 (TTY 1-800-325-0778).

Remember: Keep this Creditable Coverage notice. If you decide to join one of the Medicare drug plans,

you may be required to provide a copy of this notice when you join to show whether or not you have

maintained creditable coverage and, therefore, whether or not you are required to pay a higher

premium (a penalty).

Date: 02/01/2017

Name of Entity/Sender: Arona Corporation

Contact--Position/Office: Amy Linn, Director of Human Resources

Address: 1001 Grand Avenue, West Des Moines, IA 50265

Phone Number: (515) 225-9029

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HIPAA SPECIAL ENROLLMENT NOTICE

This notice is being provided to insure that you understand your right to apply for group health insurance coverage. You

should read this notice even if you plan to waive coverage at this time.

Loss of Other Coverage (including Medicaid and State Child Health Coverage)

If you are declining coverage for yourself or your dependents (including spouse) because of other health insurance or

group health plan coverage, you may be able to enroll yourself and your dependents in this plan if you or your

dependents lose eligibility for that other coverage (or if the employer stops contributing toward your or your

dependents’ other coverage). However, you must request enrollment within 30 days after you or your dependents’ other

coverage ends (or after the employer stops contributing toward the other coverage. Some plans may allow longer than

30 days, so please refer to your plan documents for your specific plan details.

Example: You waived coverage because you were covered under a plan offered by your spouse’s employer.

Your spouse terminates employment. If you notify your employer within 30 days of the date coverage ends,

you and your eligible dependents may apply for coverage under this health plan.

Marriage, Birth or Adoption

If you have a new dependent as a result of marriage, birth, adoption or placement for adoption, you may be able to

enroll yourself and your dependents. However, you must request enrollment within 30 days after the marriage, birth, or

placement for adoption. Some plans may allow longer than 30 days, so please refer to your plan documents for your

specific plan details.

Example: When you were hired, you were single and chose not to elect health insurance benefits. One year

later, you marry. You and your eligible dependents are entitled to enroll in this group health plan. However,

you must apply within 30 days from the date of your marriage.

Medicaid or State Child Health Coverage

If you or your dependents lose eligibility for coverage under Medicaid or State Child Health Coverage Program (CHIP) or

become eligible for a premium assistance subsidy under Medicaid or CHIP, you may be able to enroll yourself and your

dependents. You must request enrollment within 60 days of the loss of Medicaid or CHIP or the determination of

eligibility for a premium assistance subsidy.

Example: When you are hired, your children received health coverage under CHIP and you did not enroll them

in this health plan. Because of changes in your income, your children are no longer eligible for CHIP coverage.

You may enroll them in this group health plan if you apply within 60 days of the date of their loss of CHIP

coverage.

WOMEN’S HEALTH & CANCER RIGHTS ACT OF 1998

In October 1998, Congress enacted the Women’s Health and Cancer Rights Act of 1998. This notice explains some

important provisions of the Act. Please review this information carefully.

As specified in the Women’s Health and Cancer Rights Act, a plan participant or beneficiary who elects breast

reconstruction in connection with a mastectomy is also entitled to the following benefits:

Reconstruction of the breast on which the mastectomy was performed;

Surgery and reconstruction of the other breast to produce a symmetrical appearance; and

Prosthesis and treatment of physical complications at all stages of the mastectomy, including lymph edemas.

Health plans must determine the manner of coverage in consultation with the attending physician and the patient.

Coverage for breast reconstruction and related services may be subject to deductibles and coinsurance amounts that are

consistent with those that apply to other benefits under this plan.

31

39

1/1/2011

Call 1(866) 956.5400

To activate your plan

Benefits.

32

CONSENT TO RECEIVE ELECTRONIC ERISA DISCLOSURES:

**ALL EMPLOYEES MUST COMPLETE AND RETURN TO HUMAN RESOURCES**

Name: ____________________________________________________________ Email: ______________________________________________________

Employee Address: ___________________________________________ City: ________________________ State: _________ Zip: _____________

I understand that:

1. The following documents and/or notices may be provided to me electronically:

Summary Plan Descriptions

Summaries of Material Modifications

Summary Annual Reports

COBRA Notices

Summary of Benefits Coverage

Notice of Health Insurance Marketplace Coverage Options

CHIPRA Notices

2. I may provide notice of a revised email address or revoke my consent at any time without charge by notifying

Human Resources at (515) 225-9029.

3. I am entitled to request and obtain a paper copy of any electronically furnished document free of charge by

contacting Human Resources at (515) 225-9029.

4. In order to access information provided electronically, I must have:

A computer with Internet access

An email account that allows me to send and receive emails

Microsoft Word or Adobe Acrobat Reader

I consent to receive these documents electronically.

I DO NOT consent to receive these documents electronically.

Signature: _____________________________________________________________ Date: _________________________________

33

2017 Benefit Election Form

Employee Name: _____________________________________ Business Entity: __________________ Store Number: _________________

Make your elections by checking the appropriate box for each benefit at your desired coverage level. Please list all

dependents and which coverages they will be enrolled in (M, D, V, VL) on the back side. Premium amounts shown are per

pay period deduction amount. Benefit deductions are taken on the first two paychecks of every month, twenty-four (24)

times per year.

MEDICAL INSURANCE

United Healthcare Plan JYV - $750 Deductible United Healthcare Plan JYR - $1,500 Deductible

Single $93.71 Single $74.71

Employee/Spouse $323.17 Employee/Spouse $282.38

Employee/Child(ren) $240.77 Employee/Child(ren) $207.49

Family $478.33 Family $423.15

United Healthcare Plan JY3 - $2,000 Deductible United Healthcare Plan GPM - $5,000 Deductible

Single $57.18 Single $25.41

Employee/Spouse $244.66 Employee/Spouse $176.29

Employee/Child(ren) $176.78 Employee/Child(ren) $121.12

Family $372.25 Family $279.99

United Healthcare Plan KX8 - $5,000 Deductible with Copays

Single $49.29

Employee/Spouse $227.68

Employee/Child(ren) $162.95

Family $349.34

I decline medical insurance for 2017.

DENTAL INSURANCE

Single $16.43 I decline dental coverage for 2017.

Employee/Spouse $34.37

Employee/Child(ren) $38.63

Family $60.69

VISION INSURANCE

Single $3.44 I decline vision coverage for 2017.

Employee/Spouse $6.64

Employee/Child(ren) $6.64

Family $9.72

VOLUNTARY LIFE INSURANCE

I wish to apply for the Voluntary Life Insurance Plan for 2017.

Employee Amount: _____________________

Spouse Amount: _____________________

Dependent Amount: _____________________ Note: Guarantee Issue amount is $100,000 for employees and $25,000 for spouses. If you are electing over this amount, you must provide Evidence of

Insurability. If you were previously eligible and did not elect Voluntary Life Insurance, you must provide Evidence of Insurability regardless of amount

elected.

I decline to apply for the Voluntary Life Insurance Plan for 2017.

34

VOLUNTARY SHORT-TERM DISABILITY INSURANCE

I wish to apply for the Voluntary Short-Term Disability Plan for 2017.

Employee Amount: _____________________

(please enter amount requested in multiple of $50, no greater than 60% of salary)

I decline to apply for the Voluntary Short-Term Disability Plan for 2017.

CRITICAL ILLNESS

I wish to enroll in Critical Illness for 2017.

Amount of Coverage: $15,000 $30,000

I decline to enroll in Critical Illness for 2017.

Single

Employee/Spouse

Employee/Child(ren)

Family

ACCIDENT

HIGH PLAN LOW PLAN

Single $11.22 Single $5.87

Employee/Spouse $17.40 Employee/Spouse $9.11

Employee/Child(ren) $20.28 Employee/Child(ren) $10.63

Family $27.02 Family $14.16

I decline to enroll in Accident Coverage for 2017.

LIFELOCK IDENTITY PROTECTION

I wish to enroll in LifeLock Identity Theft Protection for 2017. Single

Plan Selection: Base Plan Ultimate Plan Employee/Spouse

Employee/Child(ren)

I decline to enroll in LifeLock Identity Theft Protection for 2017. Family

FLEXIBLE SPENDING ACCOUNT

I wish to enroll in the Flexible Spending Account for 2017.

Healthcare Annual Amount: _____________________ (annual maximum of $2,600)

Dependent Care Annual Amount: ____________________ (annual maximum of $5,000)

I decline to enroll in the Flexible Spending Account for 2017.

HEALTH SAVINGS ACCOUNT

I wish to enroll in the Health Savings Account for 2017.

Annual Amount: _____________________

combined total contribution cannot exceed $6,750. If you are enrolled in the FSA, you may not put money into an HSA.

I decline to enroll in the Health Savings Account for 2017.

35

Note: Maximum amount for Single is $3,400. Maximum amount for Family is $6,750. If you have a spouse who is also contributing to an HSA, your

Please list all dependents and indicate which coverages they will be enrolled in.

Name Relationship Coverage

___________________________________________________ _________________________ ____________________________________________________

___________________________________________________ _________________________ ____________________________________________________

___________________________________________________ _________________________ ____________________________________________________

___________________________________________________ _________________________ ____________________________________________________

___________________________________________________ _________________________ ____________________________________________________

___________________________________________________ _________________________ ____________________________________________________

___________________________________________________ _________________________ ____________________________________________________

___________________________________________________ _________________________ ____________________________________________________

___________________________________________________ _________________________ ____________________________________________________

** Please Note: You will automatically be enrolled in the Company Paid Life Insurance and Long-Term Disability.

You do not need to take any action to enroll in these benefits.

Please list a beneficiary for your employer paid Life Insurance and/or Voluntary Life Insurance.

Name: _________________________________________________________________ Relationship: _________________________________________

Phone: ________________________ Address: ______________________________________________________________________________________

PLEASE READ CAREFULLY BEFORE SIGNING THIS FORM:

I have indicated my benefit preferences on this and other benefit enrollment forms for the 2017 Plan Year. I understand

that these changes will remain in effect until 1/31/2018, unless there is a change in my family status as defined in the

plans. I authorize the Company to reduce my earnings by the amount of these elections or to take deductions for the

after tax elections. I authorize the Company to keep these elections in effect for any subsequent years, unless I provide

specific written notification in accordance with plan enrollment provisions.

Print Name: ______________________________________________ Date: ______________________________

Signature: ______________________________________________

36

Last Name First Name MI Social Security Number Home PhoneWork Phone

Address Apt # City State Zip Code Email Address

Date of Birth Sex Physician* (First & Last Name) / Physician’s ID Number Primary Care Dentist Number*/ / �� M �� F

Marital Status Race – Check all that apply (Optional)**�� Single �� Married �� American Indian/Alaska Native �� Asian �� Black/African-American �� Hispanic/Latino �� Divorced �� Widowed �� Native Hawaiian/Pacific Islander �� White �� Other–Please specify ___________________________

A. Employee Information

Enrollment Application/Change/Cancellation Request

■■ Address Change■■ Name Change

Date of Change____ /___ /____

■■ Enroll ■■ Cancel ■■ ChangeTo Be Completed By Employer

ATTENTION EMPLOYER REPRESENTATIVE: To ensure accurate processing of application, 1) please review all sections and confirm theemployee completed the appropriate information, 2) complete the information in this section and 3) provide your signature andtoday’s date. If the employee is waiving coverage, do not submit the application but retain it for your records.

Company Name Group # Department #

Plan Variation Reporting Code Benefit Level/Class Code, if applicableMedical ______ Vision ______ Medical ______ Vision ______ Life/AD&D ______ Suppl. Life ______Dental ______ Life ______ Dental ______ Life ______ Spouse Life ______ Suppl. AD&D ______

■■ New Enrollment/Additions: (Check one)

Date of Hire ___ /___ /___ Requested Date of Coverage ___ /___ /___■■ New Hire ■■ Status Change (PT to FT)■■ Return from Leave/Layoff ■■ Birth ■■ Marriage ■■ Adoption ■■ Court ordered dependent ■■ Other (describe) ________________________

■■ COBRA/State Continuation start date _______ stop date________■■ Annual Open Enrollment Requested Effective Date of Enrollment ___ /__ /___

■■ Cancellations: Last Date of Employment ___ /___ /___Requested Effective Date of Cancellation ___ /___ /___■■ Cancel all coverage ■■ Cancel all listed below – Section BReason: (check one)■■ Death ■■ Employee Terminated ■■ Divorce ■■ Moved out of service area■■ Dependent reached dependent max age ■■ Other (describe)____________________________

Signature ________________________________________________ Date ___________________

Employer Position_____________________________ Phone Number________________________

Employee Type ■■ Union ■■ Non-union ■■ Salaried ■■ Hourly ■■ Active ■■ Retire Date ______ ■■ COBRA/State Cont.

Coverage provided by "UnitedHealthcare and Affiliates"Medical coverage provided by UnitedHealthcare Insurance Company, UnitedHealthcare of the Midlands, Inc.(HMO), UnitedHealthcare InsuranceCompany of the River Valley, or UnitedHealthcare Plan of the River Valley, Inc. (HMO)Dental coverage provided by UnitedHealthcare Insurance Company or Unimerica Insurance CompanyLife Insurance coverage provided by UnitedHealthcare Insurance Company or Unimerica Insurance CompanyVision coverage provided by UnitedHealthcare Insurance Company or Unimerica Insurance Company

*IMPORTANT: Please see employer representative as some plans require a Primary Physician (Primary Care) and/or a Primary Care Dentist(PCD) selection.

**Data collected will be used only to help communicate with enrollees and inform them of specific programs to enhance their well-being andnot for eligibility or claim payment determination.

Page 1 of 4LG.EE.10.IA 7/10 250-3766 7/10

�� Unimerica Insurance Company�� UnitedHealthcare Insurance Company�� UnitedHealthcare of the Midlands, Inc.�� UnitedHealthcare Insurance Company of the River Valley�� UnitedHealthcare Plan of the River Valley, Inc.

37

List All Enrolling/Changing/Cancelling (Attach sheet if necessary)

Last Name First Name MI Sex Relationship** Birthdate Full Time Physician*(First and Last Name)Social Security Number Student*** Physician’s ID Number

Spouse

Primary Care Dentist Number*

Dependent

Primary Care Dentist Number*

Dependent

Primary Care Dentist Number*

Dependent

Primary Care Dentist Number*

Dependent

Primary Care Dentist Number*

* IMPORTANT: Please see employer representative as some plans require a Primary Physician (Primary Care) and/or a Primary Care Dentist (PCD) selection.

** For some cases, such as Qualified Medical Child Support, additional documentation may be required. Please see employer representative for more information.

*** Please see employer representative for student status qualifications.**** Data collected will be used only to help communicate with enrollees and inform them of specific programs to enhance their well-being

and not for eligibility or claim payment determination.

B. Family Information

M

F

M

F

M

F

M

F

M

F

Please check all that apply. Benefit offerings are dependent upon employer selection. Dual Option Plan

Person Medical Dental Vision Life/Amount Sup Life Sup AD&D STD LTD SelectedEmployee ■■ ■■ ■■ ■■ $____________ ■■ ■■ ■■ ■■

Spouse ■■ ■■ ■■ ■■

Dependents ■■ ■■ ■■ ■■

Salary __________ Required only if LifePlan based on salary

Life Insurance Beneficiary’s Full Name and Address Relationship

C. Product Selection

Checkappropriatebox

�� Enroll�� Cancel�� Change

�� Enroll�� Cancel�� Change

�� Enroll�� Cancel�� Change

�� Enroll�� Cancel�� Change

�� Enroll�� Cancel�� Change

Race – Check all that apply (Optional)***�� American Indian/Alaska Native �� Asian �� Black/African-American �� Hispanic/Latino�� Native Hawaiian/Pacific Islander �� White �� Other–Please specify _____________________

Race – Check all that apply (Optional)***�� American Indian/Alaska Native �� Asian �� Black/African-American �� Hispanic/Latino�� Native Hawaiian/Pacific Islander �� White �� Other–Please specify _____________________

Race – Check all that apply (Optional)***�� American Indian/Alaska Native �� Asian �� Black/African-American �� Hispanic/Latino�� Native Hawaiian/Pacific Islander �� White �� Other–Please specify _____________________

Race – Check all that apply (Optional)* **�� American Indian/Alaska Native �� Asian �� Black/African-American �� Hispanic/Latino�� Native Hawaiian/Pacific Islander �� White �� Other–Please specify _____________________

Race – Check all that apply (Optional)***�� American Indian/Alaska Native �� Asian �� Black/African-American �� Hispanic/Latino�� Native Hawaiian/Pacific Islander �� White �� Other–Please specify _____________________

Page 2 of 4 250-3766 7/10

�� Yes

�� No

�� Yes

�� No

�� Yes

�� No

�� Yes

�� No

38

F. Signature

Date Employee Signature for all applying and waiving Spouse Signature (if applying for coverage)

Primary Language Spoken ■■ English ■■ Spanish ■■ Other ________________________________

I confirm that the information I have provided on this form is complete and accurate. I understand that the health benefit plan that I have selected provides reimbursement for certain medical costs, which are more fully describedin the current Certificate of Coverage. I understand there may be instances where treatment decisions made by my physician or me or medicalexpenses which I have incurred may not be covered by my health benefit plan.

I understand that information collected in connection with administration of the benefit plan may be used to bring to my attention healthproducts or services that might be valuable to me and otherwise as permitted by law. I understand that you may combine that information withother information so that it is no longer individually identifiable and use it for commercial and other purposes.

I acknowledge that I have received the “Important Information” statement which is included on the back of this form.

Medicare – Employee Information: If enrolled in Medicare, please attach a copy of your Medicare ID card.�� Enrolled in Part A: Effective Date _____________ �� Ineligible for Part A* �� Not Enrolled in Part A (chose not to enroll)�� Enrolled in Part B: Effective Date _____________ �� Ineligible for Part B* �� Not Enrolled in Part B (chose not to enroll)�� Enrolled in Part D: Effective Date _____________ �� Ineligible for Part D* �� Not Enrolled in Part D (chose not to enroll)Reason for Medicare eligibility: �� Over 65 �� Kidney Disease �� Disabled �� Disabled but actively at work

Medicare – Spouse/Dependent Name: ____________________________________________�� Enrolled in Part A: Effective Date _____________ �� Ineligible for Part A* �� Not Enrolled in Part A (chose not to enroll)�� Enrolled in Part B: Effective Date _____________ �� Ineligible for Part B* �� Not Enrolled in Part B (chose not to enroll)�� Enrolled in Part D: Effective Date _____________ �� Ineligible for Part D* �� Not Enrolled in Part D (chose not to enroll)Reason for Medicare eligibility: �� Over 65 �� Kidney Disease �� Disabled �� Disabled but actively at work*Only check “Ineligible” if you have received documentation from your Social Security benefits that indicate that you are not eligible for Medicare.

E. Waiver of Coverage

I decline coverage for:�� Myself �� Spouse�� Dependent Children�� Myself and all dependents

Declining coverage due to existence of other coverage:�� Spouse’s Employer’s Plan �� Individual Plan�� Covered by Medicare �� Medicaid�� COBRA from Prior Employer �� VA Eligibility�� Tri-Care�� I (we) have no other coverage at this time�� Other ____________________________________

I understand that by waiving coverage at this time, I will not be allowed to participate unless I qualify at a special enrollment period or as a late enrollee, ifapplicable, or at the next open enrollment period. I acknowledge that I have received the “ImportantInformation” statementwhich is includedwith this form.

Employee Initials Date

On the day this coverage begins, will you, your spouse or any of your dependents be covered under any other medical health plan or policy,including another UnitedHealthcare plan or Medicare? �� YES (continue completing this section) �� NO (skip the rest of this section)

Name of other carrier ______________________________________________________

Other Group Medical Coverage Information Type Effective Date End Date Name and date of birth of policyholder (only list those covered by other plan) (B/S/F)* for other coverage

Spouse Name:

Dependent Name:

Dependent Name:

Dependent Name:

*B.Enter ‘B’ when this dependent is covered under both you and your spouse’s insurance plan (married)S.Enter ‘S’ if you are the parent awarded custody of this dependent and no other individual is required to pay for this dependent’s medical expenses.F. Enter ‘F’ if this dependent is covered by another individual (not a member of your household) required to pay for this dependent’s medical expenses.

D. Other Medical Coverage Information This section must be completed. (Attach sheet if necessary.)

250-3766 7/10Page 3 of 439

IMPORTANT INFORMATION

In order to make choices about your health care coverage and treatment, we believe that it is important for you to understand how yourplan operates and how it may affect you. In an ever-changing environment, the information can never be complete and we urge you tocontact us if, after enrollment, your Certificate of Coverage or other materials do not answer your questions. Further information is availableat www.myuhc.com or at the toll-free Customer Care number located on the back of your identification card or on other plan materials.

1. We do not provide health care services or make treatment decisions. We help finance and/or administer the health benefit plan in whichyou are enrolled. That means:

• We make decisions about whether the health benefit plan you chose will reimburse you for care that you may receive.

• We do not decide what care you need or will receive. You and your provider make those decisions.

2. We may enter into arrangements where another entity carries out some of our duties, but those entities must operate consistently withour commitment to your plan.

3. We may use individually identifiable information about you to identify for you (and you alone) procedures, products, and services thatyou may find valuable.

4. We contract with networks of physicians and other providers. Our credentialing process confirms public information about theproviders’ licenses and other credentials, but does not assure the quality of the services provided.

5. Physicians and other providers in our networks are independent contractors and are not our employees or agents. We do not controlnor do we have a right to control your provider’s treatment or plan.

6. We may enter into agreements with your physician or other provider to share in the cost savings that our approach may generate. Weencourage providers in our network to disclose the nature of those arrangements with you. If they do not, we encourage you to talk toyour provider about these arrangements.

7. We encourage physicians and other providers to talk with you about care you or your provider think might be valuable.

8. We will use individually identifiable information about you as permitted by law, including in our operations and in our research. We willuse anonymous data for commercial purposes including research.

I (we) request the indicated group coverage for myself and, if the plan provides, for my dependents. I authorize any required premiumcontributions to be deducted from earnings.

I (we) authorize all providers of health services or supplies and any of their representatives to give the following to the HMO/insurancecompany(ies): any available information about the health history, condition, or treatment of any persons named in this request. I (we)authorize the HMO/insurance company(ies) to use this information to determine eligibility for health coverage and eligibility for benefitsunder an existing policy.

I (we) also authorize the HMO/insurance company(ies) to give this information to its (their) representatives or to any other organization forthe reason notified above. I (we) agree that this authorization is valid for 24 months from the date below. I (we) know that I (we) have theright to ask for and to receive a copy of this authorization.

I understand that the Certificate of Coverage and other documents, notices, and communications regarding my health benefit plan may betransmitted electronically.

I (we) have not given the agent or any other persons any health information not included on the Request for Coverage. I (we) understandthat the HMO/insurance company(ies) is not bound by any statements I (we) have made to any agent or to any other persons, if thosestatements are not written or printed on this Request for Coverage and any attachments.

Statement of affirmation and authorization to obtain and disclose information in connection with eligibility for coverage.

250-3766 7/10Page 4 of 440

GEF02-1 ADM

SUBMISSION INSTRUCTIONS After completion, make a copy for your records and return the original to

MetLife Administration, P.O. Box 14593, Lexington, KY 40512-4593 Fax MetLife at 1-888-505-7446

Page 1 of 4 EF-XDP7731S-NW (08/15)

Metropolitan Life Insurance Company, New York, NY

ENROLLMENT • CHANGE FORM

GROUP CUSTOMER INFORMATION (To be Completed by the Recordkeeper) Name of Group Customer/Employer

Arona Corporation

Group Customer #

Division

Class

Dept Code

Date of Hire (MM/DD/YYYY)

Coverage Effective Date (MM/DD/YYYY)

Original COBRA Effective Date if applicable (MM/DD/YYYY)

COBRA Termination Date if applicable (MM/DD/YYYY)

YOUR ENROLLMENT INFORMATION (To be Completed by the Employee in blue or black ink) Name (First, Middle, Last)

Social Security #

– – Male Female

Single Married

Address (Street, City, State, Zip Code)

Date of Birth (MM/DD/YYYY)

Employee Retiree

Job Title:

Basic Annual Earnings:

$ Salaried Hourly

Hours Worked Per Week:

New Enrollment Change in Enrollment COBRA Continuation If due to a Qualifying Event, enter date (MM/DD/YYYY)

I have read my enrollment materials and I request coverage for the benefits for which I am or may become eligible. I understand the amounts of insurance I request must comply with and are limited by the plan design described in my enrollment materials.

► If you are enrolling during the initial enrollment period, you must complete this Hospitalization question for Supplemental/Optional Life, Supplemental/Optional Dependent Spouse Life and Supplemental/Optional Dependent Child Life.

Have you been Hospitalized as defined below (not including well-baby delivery) in the past 90 days?

Employee

Yes No

Spouse

Yes No

Child(ren)

Yes No

If a Proposed Insured has been Hospitalized within the last 90 days a Statement of Health must be completed for the person to whom the “yes” applies. Hospitalized means admission for inpatient care in a hospital; receipt of care in a hospice facility, intermediate care facility, or long term care facility; or receipt of the following treatment wherever performed: chemotherapy, radiation therapy, or dialysis.

► If you are enrolling after the initial enrollment period, you must complete a Statement of Health form for all amounts you are requesting except amounts of Voluntary Short Term Disability Benefits.

Term Life and Accidental Death & Dismemberment (AD&D) Insurance

Basic Life 1 and AD&D (Core)

Supplemental/Optional Life 1 and AD&D (Buy up) Enter amount requested $

Supplemental/Optional Dependent Spouse 2 Life 1,3 and AD&D (Buy up) Enter amount requested $

Supplemental/Optional Dependent Child Life 3 and AD&D (Buy up) Enter amount requested $

1 Life Insurance may include an Accelerated Benefits Option under which a terminally ill insured can accelerate a portion of his or her life insurance amount. An interest and expense charge may be deducted from the accelerated payment. Receipt of accelerated benefits may affect eligibility for public assistance.

2 For purposes of Life Insurance for Vermont and Washington State residents, Spouse includes your registered Domestic Partner if you and your Domestic Partner if you and your Domestic Partner are registered as domestic partners, civil union partners or reciprocal beneficiaries with a government agency or office where such registration is available.

3 Amounts will be subject to state limits, if applicable.

41

GEF09-1 FW Page 2 of 4 EF-XDP7731S-NW (08/15)

Disability Income Insurance

Voluntary Short Term Disability Benefits Enter amount requested in a multiple of $50. $

Long Term Disability Benefits

Dental Insurance

Select your level of coverage

Employee Only

Employee + Spouse 1

Employee + Child(ren)

Employee + Spouse 1 + Child(ren)

Dependent Information

If you are applying for coverage for your Spouse and/or Child(ren), please provide the information requested below:

Name of your Spouse (First, Middle, Last) Date of Birth (MM/DD/YYYY)

Male Female

Name(s) of your Child(ren) (First, Middle, Last) Date of Birth (MM/DD/YYYY)

Male Female

Male Female

Male Female

Male Female

Check here if you need more lines. Provide the additional information on a separate piece of paper and return it with your enrollment form.

1 For purposes of Dental Insurance for California, Vermont and Washington State residents, Spouse includes your registered Domestic Partner if you and your Domestic Partner if you and your Domestic Partner are registered as domestic partners, civil union partners or reciprocal beneficiaries with a government agency or office where such registration is available.

GEF02-1 ADM

FRAUD WARNINGS Before signing this enrollment form, please read the warning for the state where you reside and for the state where the contract under which you are applying for coverage was issued.

Alabama, Arkansas, District of Columbia, Louisiana, Massachusetts, New Mexico, Ohio, Rhode Island and West Virginia: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.

Colorado: It is unlawful to knowingly provide false, incomplete or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies.

Florida: Any person who knowingly and with intent to injure, defraud or deceive any insurance company files a statement of claim or an application containing any false, incomplete or misleading information is guilty of a felony of the third degree.

Kentucky: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime.

Maine, Tennessee and Washington: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties may include imprisonment, fines or a denial of insurance benefits.

Maryland: Any person who knowingly or willfully presents a false or fraudulent claim for payment of a loss or benefit or who knowingly or willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.

42

GEF09-1 DEC Page 3 of 4 EF-XDP7731S-NW (08/15)

New Jersey: Any person who files an application containing any false or misleading information is subject to criminal and civil penalties.

New York (only applies to Accident and Health Benefits): Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation.

Oklahoma: WARNING: 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.

Oregon: Any person who knowingly presents a materially false statement in an application for insurance may be guilty of a criminal offense and may be subject to penalties under state law.

Puerto Rico: Any person who knowingly and with the intention to defraud includes false information in an application for insurance or files, assists or abets in the filing of a fraudulent claim to obtain payment of a loss or other benefit, or files more than one claim for the same loss or damage, commits a felony and if found guilty shall be punished for each violation with a fine of no less than five thousand dollars ($5,000), not to exceed ten thousand dollars ($10,000); or imprisoned for a fixed term of three (3) years, or both. If aggravating circumstances exist, the fixed jail term may be increased to a maximum of five (5) years; and if mitigating circumstances are present, the jail term may be reduced to a minimum of two (2) years.

Vermont: Any person who knowingly presents a false statement in an application for insurance may be guilty of a criminal offense and subject to penalties under state law.

Virginia: Any person who, with the intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application of files a claim containing a false or deceptive statement may have violated the state law.

Pennsylvania and all other states: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties.

GEF09-1 FW

BENEFICIARY DESIGNATION FOR EMPLOYEE INSURANCE I designate the following person(s) as primary beneficiary(ies) for any amount payable upon my death for the MetLife insurance coverage applied for in this enrollment form. With such designation any previous designation of a beneficiary for such coverage is hereby revoked. I understand I have the right to change this designation at any time. I also understand that unless otherwise specified in the group insurance certificate, insurance due upon the death of a Dependent is payable to the Employee.

Check if you need more space for additional beneficiaries and attach a separate page. Include all beneficiary information, and sign/date the page.

Full Name (First, Middle, Last)

Social Security #

Date of Birth (Mo./Day/Yr.)

Relationship

Share %

Address (Street, City, State, Zip)

Phone #

Full Name (First, Middle, Last)

Social Security #

Date of Birth (Mo./Day/Yr.)

Relationship

Share %

Address (Street, City, State, Zip)

Phone #

Full Name (First, Middle, Last)

Social Security #

Date of Birth (Mo./Day/Yr.)

Relationship

Share %

Address (Street, City, State, Zip)

Phone #

Payment will be made in equal shares or all to the survivor unless otherwise indicated. TOTAL: 100%

If all the primary beneficiary(ies) die before me, I designate as contingent beneficiary(ies): Full Name (First, Middle, Last)

Social Security #

Date of Birth (Mo./Day/Yr.)

Relationship

Share %

Address (Street, City, State, Zip)

Phone #

Full Name (First, Middle, Last)

Social Security #

Date of Birth (Mo./Day/Yr.)

Relationship

Share %

Address (Street, City, State, Zip)

Phone #

Payment will be made in equal shares or all to the survivor unless otherwise indicated. TOTAL: 100%

43

GEF09-1 DEC Page 4 of 4 EF-XDP7731S-NW (08/15)

DECLARATIONS AND SIGNATURE By signing below, I acknowledge:

1. I have read this enrollment form and declare that all information I have given is true and complete to the best of my knowledge and belief.

2. I declare that I am actively at work on the date I am enrolling and, if I am enrolling for any contributory life insurance, that I was actively at work for at least 20 hours during the 7 calendar days preceding my date of enrollment. I understand that if I am not actively at work on the scheduled effective date of insurance, such insurance will not take effect until I return to active work.

3. I understand that, on the date dependent insurance for a person is scheduled to take effect, the dependent must not be confined at home under a physician’s care, receiving or applying for disability benefits from any source, or Hospitalized. If the dependent does not meet this requirement on such date, the insurance will take effect on the date the dependent is no longer confined, receiving or applying for disability benefits from any source, or Hospitalized.

4. I understand that if I do not enroll for life or disability coverage (other than Voluntary Short Term Disability coverage) during the initial enrollment period, or if I do not enroll for the maximum amount of coverage for which I am eligible, evidence of insurability satisfactory to MetLife may be required to enroll for or increase such coverage after the initial enrollment period has expired. Coverage will not take effect, or it will be limited, until notice is received that MetLife has approved the coverage or increase. I understand that if I do not enroll for Voluntary Short Term Disability coverage during the initial enrollment period, or if I do not enroll for the maximum amount of coverage for which I am eligible, coverage will be limited if I enroll for or increase such coverage after the initial enrollment period has expired. I also understand that if I do not enroll for dental coverage during the initial enrollment period, a waiting period may be required before I can enroll for such coverage after the initial enrollment period has expired.

5. I authorize my employer to deduct the required contributions from my earnings for my coverage. This authorization applies to such coverage until I rescind it in writing.

6. I affirmatively decline coverage for any benefits for which I am eligible which I do not request on this enrollment form.

7. I have read the Beneficiary Designation section provided in this enrollment form and I have made a designation if I so choose.

8. I have read the applicable Fraud Warning(s) provided in this enrollment form.

Signature of Employee Print Name Date Signed (MM/DD/YYYY)

Sign Here

44

GEF02-1 ADM SUBMISSION INSTRUCTIONS After completion, make a copy for your records and return the original to your Employer. Page 1 of 3 EF-ST966S-NW (08/15)

Metropolitan Life Insurance Company, New York, NY

ENROLLMENT • CHANGE FORM

GROUP CUSTOMER INFORMATION (To be Completed by the Recordkeeper) Name of Group Customer/Employer

Group Customer #

Division

Class

Dept Code

Date of Hire (MM/DD/YYYY)

Coverage Effective Date (MM/DD/YYYY)

YOUR ENROLLMENT INFORMATION (To be Completed by the Employee in blue or black ink) Name (First, Middle, Last)

Social Security #

– –

Male

Female

Single

Married

Address (Street, City, State, Zip Code)

Date of Birth (MM/DD/YYYY)

Phone #

Email Address

Job Title:

Hours Worked Per Week:

New Enrollment Change in Enrollment If due to a Qualifying Event, enter date (MM/DD/YYYY)

I have read my enrollment materials and I request coverage for the benefits for which I am or may become eligible. I understand the amounts of insurance I request must comply with and are limited by the plan design described in my enrollment materials. I have received and read a copy of the Outline of Coverage or other disclosure document for the Critical Illness Insurance. In certain states, this coverage may be referred to as Critical Illness Insurance, Specified Disease Insurance, Limited Benefit Insurance or Limited Benefit Critical Illness Insurance.

Critical Illness Insurance

First select your option Then select your level of coverage

$15,000 Employee Only

$30,000 Employee + Spouse/Domestic Partner 1

Employee + Child(ren)

Employee + Spouse/Domestic Partner 1 + Child(ren)

Dependent Information

If you are applying for coverage for your Spouse/Domestic Partner and/or Child(ren), please provide the information requested below:

Name of your Spouse/Domestic Partner (First, Middle, Last) Date of Birth (MM/DD/YYYY)

Male Female

Name(s) of your Child(ren) (First, Middle, Last) Date of Birth (MM/DD/YYYY)

Male Female

Male Female

Male Female

Male Female

Check here if you need more lines. Provide the additional information on a separate piece of paper and return it with your enrollment form.

1 Domestic Partner includes your registered Domestic Partner if you and your Domestic Partner are registered as domestic partners, civil union partners or reciprocal beneficiaries with a government agency or office where such registration is available. It also includes your non-registered Domestic Partner in whom you have an insurable interest. By enrolling such Domestic Partner for coverage and signing this enrollment form, you are attesting to your insurable interest.

Smoking Status Information

Have you smoked cigarettes, pipes or cigars or used tobacco in any form in the past 1 year? Employee

Yes No

45

GEF09-1 FW Page 2 of 3 EF-ST966S-NW (08/15)

FRAUD WARNINGS

Before signing this enrollment form, please read the warning for the state where you reside and for the state where the contract under which you are applying for coverage was issued.

Alabama, Arkansas, District of Columbia, Louisiana, Massachusetts, New Mexico, Ohio, Rhode Island and West Virginia: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.

Colorado: It is unlawful to knowingly provide false, incomplete or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies.

Florida: Any person who knowingly and with intent to injure, defraud or deceive any insurance company files a statement of claim or an application containing any false, incomplete or misleading information is guilty of a felony of the third degree.

Kentucky: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime.

Maine, Tennessee and Washington: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties may include imprisonment, fines or a denial of insurance benefits.

Maryland: Any person who knowingly or willfully presents a false or fraudulent claim for payment of a loss or benefit or who knowingly or willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.

New Jersey: Any person who files an application containing any false or misleading information is subject to criminal and civil penalties.

New York (only applies to Accident and Health Benefits): Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation.

Oklahoma: WARNING: 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.

Oregon: Any person who knowingly presents a materially false statement in an application for insurance may be guilty of a criminal offense and may be subject to penalties under state law.

Puerto Rico: Any person who knowingly and with the intention to defraud includes false information in an application for insurance or files, assists or abets in the filing of a fraudulent claim to obtain payment of a loss or other benefit, or files more than one claim for the same loss or damage, commits a felony and if found guilty shall be punished for each violation with a fine of no less than five thousand dollars ($5,000), not to exceed ten thousand dollars ($10,000); or imprisoned for a fixed term of three (3) years, or both. If aggravating circumstances exist, the fixed jail term may be increased to a maximum of five (5) years; and if mitigating circumstances are present, the jail term may be reduced to a minimum of two (2) years.

Vermont: Any person who knowingly presents a false statement in an application for insurance may be guilty of a criminal offense and subject to penalties under state law.

Virginia: Any person who, with the intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application of files a claim containing a false or deceptive statement may have violated the state law.

Pennsylvania and all other states: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties.

46

GEF09-1 DEC Page 3 of 3 EF-ST966S-NW (08/15)

BENEFICIARY DESIGNATION FOR EMPLOYEE INSURANCE I designate the following person(s) as primary beneficiary(ies) for any amount payable upon my death for the MetLife insurance coverage applied for in this enrollment form. With such designation any previous designation of a beneficiary for such coverage is hereby revoked. I understand I have the right to change this designation at any time. I also understand that unless otherwise specified in the group insurance certificate, insurance due upon the death of a Dependent is payable to the Employee.

Check if you need more space for additional beneficiaries and attach a separate page. Include all beneficiary information, and sign/date the page.

Full Name (First, Middle, Last)

Social Security #

Date of Birth (Mo./Day/Yr.)

Relationship

Share %

Address (Street, City, State, Zip)

Phone #

Full Name (First, Middle, Last)

Social Security #

Date of Birth (Mo./Day/Yr.)

Relationship

Share %

Address (Street, City, State, Zip)

Phone #

Full Name (First, Middle, Last)

Social Security #

Date of Birth (Mo./Day/Yr.)

Relationship

Share %

Address (Street, City, State, Zip)

Phone #

Payment will be made in equal shares or all to the survivor unless otherwise indicated. TOTAL: 100%

If all the primary beneficiary(ies) die before me, I designate as contingent beneficiary(ies): Full Name (First, Middle, Last)

Social Security #

Date of Birth (Mo./Day/Yr.)

Relationship

Share %

Address (Street, City, State, Zip)

Phone #

Full Name (First, Middle, Last)

Social Security #

Date of Birth (Mo./Day/Yr.)

Relationship

Share %

Address (Street, City, State, Zip)

Phone #

Payment will be made in equal shares or all to the survivor unless otherwise indicated. TOTAL: 100%

DECLARATIONS AND SIGNATURE By signing below, I acknowledge:

1. I have read this enrollment form and declare that all information I have given is true and complete to the best of my knowledge and belief.

2. I declare that I am actively at work on the date I am enrolling. I understand that if I am not actively at work on the scheduled effective date of insurance, such insurance will not take effect until I return to active work.

3. I understand that, on the date dependent insurance for a person is scheduled to take effect, the dependent must not be confined at home under a physician’s care, receiving or applying for disability benefits from any source, or Hospitalized. If the dependent does not meet this requirement on such date, the insurance will take effect on the date the dependent is no longer confined, receiving or applying for disability benefits from any source, or Hospitalized. Hospitalized means admission for inpatient care in a hospital; receipt of care in a hospice facility, intermediate care facility, or long term care facility; or receipt of the following treatment wherever performed: chemotherapy, radiation therapy, or dialysis.

4. I authorize my employer to deduct the required contributions from my earnings for my coverage. This authorization applies to such coverage until I rescind it in writing.

5. I affirmatively decline coverage for any benefits for which I am eligible which I do not request on this enrollment form.

6. I have read the Beneficiary Designation section provided in this enrollment form and I have made a designation if I so choose.

7. I have read the applicable Fraud Warning(s) provided in this enrollment form.

Signature of Employee Print Name Date Signed (MM/DD/YYYY)

Sign Here

47

GEF02-1 ADM SUBMISSION INSTRUCTIONS After completion, make a copy for your records and return the original to your Employer. Page 1 of 3 EF-ST936S-NW (08/15)

Metropolitan Life Insurance Company, New York, NY

ENROLLMENT • CHANGE FORM

GROUP CUSTOMER INFORMATION (To be Completed by the Recordkeeper) Name of Group Customer/Employer

Group Customer #

Division

Class

Dept Code

Date of Hire (MM/DD/YYYY)

Coverage Effective Date (MM/DD/YYYY)

YOUR ENROLLMENT INFORMATION (To be Completed by the Employee in blue or black ink) Name (First, Middle, Last)

Social Security #

– –

Male

Female

Single

Married

Address (Street, City, State, Zip Code)

Date of Birth (MM/DD/YYYY)

Phone #

Email Address:

Job Title:

Hours Worked Per Week:

New Enrollment Change in Enrollment If due to a Qualifying Event, enter date (MM/DD/YYYY)

I have read my enrollment materials and I request coverage for the benefits for which I am or may become eligible. I understand the amounts of insurance I request must comply with and are limited by the plan design described in my enrollment materials. I have received and read a copy of the Outline of Coverage or other disclosure document for the Accident Insurance.

Accident Insurance

First select your option Then select your level of coverage

Low Plan Employee Only

High Plan Employee + Spouse/Domestic Partner 1

Employee + Child(ren)

Employee + Spouse/Domestic Partner 1 + Child(ren)

Dependent Information

If you are applying for coverage for your Spouse/Domestic Partner and/or Child(ren), please provide the information requested below:

Name of your Spouse/Domestic Partner (First, Middle, Last) Date of Birth (MM/DD/YYYY)

Male Female

Name(s) of your Child(ren) (First, Middle, Last) Date of Birth (MM/DD/YYYY)

Male Female

Male Female

Male Female

Male Female

Check here if you need more lines. Provide the additional information on a separate piece of paper and return it with your enrollment form.

1 Domestic Partner includes your registered Domestic Partner if you and your Domestic Partner are registered as domestic partners, civil union partners or reciprocal beneficiaries with a government agency or office where such registration is available. It also includes your non-registered Domestic Partner in whom you have an insurable interest. By enrolling such Domestic Partner for coverage and signing this enrollment form, you are attesting to your insurable interest.

48

GEF09-1 FW Page 2 of 3 EF-ST936S-NW (08/15)

FRAUD WARNINGS

Before signing this enrollment form, please read the warning for the state where you reside and for the state where the contract under which you are applying for coverage was issued.

Alabama, Arkansas, District of Columbia, Louisiana, Massachusetts, New Mexico, Ohio, Rhode Island and West Virginia: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.

Colorado: It is unlawful to knowingly provide false, incomplete or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies.

Florida: Any person who knowingly and with intent to injure, defraud or deceive any insurance company files a statement of claim or an application containing any false, incomplete or misleading information is guilty of a felony of the third degree.

Kentucky: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime.

Maine, Tennessee and Washington: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties may include imprisonment, fines or a denial of insurance benefits.

Maryland: Any person who knowingly or willfully presents a false or fraudulent claim for payment of a loss or benefit or who knowingly or willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.

New Jersey: Any person who files an application containing any false or misleading information is subject to criminal and civil penalties.

New York (only applies to Accident and Health Benefits): Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation.

Oklahoma: WARNING: 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.

Oregon: Any person who knowingly presents a materially false statement in an application for insurance may be guilty of a criminal offense and may be subject to penalties under state law.

Puerto Rico: Any person who knowingly and with the intention to defraud includes false information in an application for insurance or files, assists or abets in the filing of a fraudulent claim to obtain payment of a loss or other benefit, or files more than one claim for the same loss or damage, commits a felony and if found guilty shall be punished for each violation with a fine of no less than five thousand dollars ($5,000), not to exceed ten thousand dollars ($10,000); or imprisoned for a fixed term of three (3) years, or both. If aggravating circumstances exist, the fixed jail term may be increased to a maximum of five (5) years; and if mitigating circumstances are present, the jail term may be reduced to a minimum of two (2) years.

Vermont: Any person who knowingly presents a false statement in an application for insurance may be guilty of a criminal offense and subject to penalties under state law.

Virginia: Any person who, with the intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application of files a claim containing a false or deceptive statement may have violated the state law.

Pennsylvania and all other states: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties.

49

GEF09-1 DEC Page 3 of 3 EF-ST936S-NW (08/15)

DECLARATIONS AND SIGNATURE By signing below, I acknowledge:

1. I have read this enrollment form and declare that all information I have given is true and complete to the best of my knowledge and belief.

2. I declare that I am actively at work on the date I am enrolling. I understand that if I am not actively at work on the scheduled effective date of insurance, such insurance will not take effect until I return to active work.

3. I understand that, on the date dependent insurance for a person is scheduled to take effect, the dependent must not be confined at home under a physician’s care, receiving or applying for disability benefits from any source, or Hospitalized. If the dependent does not meet this requirement on such date, the insurance will take effect on the date the dependent is no longer confined, receiving or applying for disability benefits from any source, or Hospitalized. Hospitalized means admission for inpatient care in a hospital; receipt of care in a hospice facility, intermediate care facility, or long term care facility; or receipt of the following treatment wherever performed: chemotherapy, radiation therapy, or dialysis.

4. I authorize my employer to deduct the required contributions from my earnings for my coverage. This authorization applies to such coverage until I rescind it in writing.

5. I affirmatively decline coverage for any benefits for which I am eligible which I do not request on this enrollment form.

6. I have read the applicable Fraud Warning(s) provided in this enrollment form.

Signature of Employee Print Name Date Signed (MM/DD/YYYY)

Sign Here

50

TO BE COMPLETED BY THE EMPLOYEEEmployee Last Name Employee First Name MI

Date of Birth Social Security Number Sex

Street Address Apartment No.

City State Zip Code

TO BE COMPLETED BY THE EMPLOYER

New Enrollment AddDependent(s)

ChangeAddress PhoneName COBRA

Cancel CoveragePolicy HolderDependent(s)

Reason for Change Employment StatusQualifying Event: (PLEASE STATE) ___________________________________________

Requested Effective Date Date of Employment

AVESIS ADVANTAGE VISION CARE EMPLOYEE ENROLLMENT FORMUnderwritten by Fidelity Security Life Insurance Company Kansas City, Missouri Policy No. VC-16/VC-23

MACY C. O’BRIEN SCHOOL DISTRICT #90 & PINAL COUNTY SPECIAL EDUCATION12345-123401900

I authorize deductions from my earnings at the required contributions towards the cost of the coverage.I certify that I am eligible to participate and that the above information is correct.

Signature Date

A-00713 M-9004/M-9059By signing above, I understand that I must remain enrolled during the Benefit Plan period.

Dependent Name Date of Birth

Spouse /Domestic Partner

Child

Child

Child

Child

Child

Child

Male Female

Do you wish to cover your eligible dependents? Yes NoIf yes, complete the following:

I would like to cover additional eligible dependents (PLEASE LIST ON A SECOND ENROLLMENT FORM)

--//

-

//

//

//

//

//

//

//

//

PLEASE PRINT LEGIBLY

//06/09

//

FIRST LAST

51

Cafeteria / Flex Plan Enrollment Form 1454 30th Street, Suite 105 West Des Moines, IA 50266 Phone 515-224-9400 or 800-300-9691 Fax 515-224-9256 www.kabelbiz.com

Company Name (Employer) _________________________________________________________________________________

Employee Information

_____________________________________________________ _____________________________________________________ ____________ Last Name First Name Middle Initial __________________________________________ _____________________________ ______________________________________________ Social Security Number Date of Birth Email Address ____________________________________________________________________ ______________________________________________ Address City __________________________ ________________________________ State Zip Code

Enrollment Information

_____ New _____ Renewal Effective Date _________________________________ First Payroll Deduction Date _____________________

Unreimbursed Medical

Annual amount of Unreimbursed Medical $ ______________ (Divided by # of Payroll Periods) _________ = Per Payroll Deduction ____________________ Please check the one that applies to your situation Regular Flex Plan Limited Purpose Flex Plan (If you or your Spouse have an HSA.)

Dependent Care

Annual amount of Dependent Care $ ______________ (Divided by # of Payroll Periods) _________ = Per Payroll Deduction ____________________

Authorization: I certify the above information to be true to the best of my knowledge and that the children on whom I will be claiming dependent expenses or child care either reside with me in a parent child relationship or are legally dependent on me for their support. I agree to have my compensation reduced by the deduction amount(s) stated above. I understand that any amounts remaining in my account(s) not used for qualified expenses incurred during the plan year will be forfeited in accordance with current plan provisions and tax laws. I further understand that the Flexible Compensation deduction(s) will be in effect for the entire plan year and cannot be revoked unless I experience a change in my family status or termination of employment. Signature ___________________________________________________________ Date ________________________________________

I decline to participate in the Flex Spending account Signature ____________________________________

Direct Deposit (Attach a blank voided check if you select Direct Deposit and are a new participant.) AUTHORIZATION AGREEMENT FOR AUTOMATIC DEPOSITS (ACH CREDITS) I hereby authorize KABEL BUSINESS SERVICES to initiate credit entries and to initiate, if necessary, debit entries and adjustments for any credit entries in error to my account indicated on the attached voided check. This authority is to remain in full force and effect until KABEL BUSINESS SERVICES has received written notice from me of its termination in such time and in such manner as to afford KABEL BUSINESS SERVICES and DEPOSITORY a reasonable opportunity to act on it. Signature ____________________________________________________________ Date ________________________________________

52